Developing clinical decision support within a commercial electronic health record system to improve antimicrobial prescribing in the neonatal ICU.

OBJECTIVE: To develop and implement a clinical decision support (CDS) tool to improve antibiotic prescribing in neonatal intensive care units (NICUs) and to evaluate user acceptance of the CDS tool. METHODS: Following sociotechnical analysis of NICU prescribing processes, a CDS tool for empiric and targeted antimicrobial therapy for healthcare-associated infections (HAIs) was developed and incorporated into a commercial electronic health record (EHR) in two NICUs. User logs were reviewed and NICU prescribers were surveyed for their perceptions of the CDS tool. RESULTS: The CDS tool aggregated selected laboratory results, including culture results, to make treatment recommendations for common clinical scenarios. From July 2010 to May 2012, 1,303 CDS activations for 452 patients occurred representing 22% of patients prescribed antibiotics during this period. While NICU clinicians viewed two culture results per tool activation, prescribing recommendations were viewed during only 15% of activations. Most (63%) survey respondents were aware of the CDS tool, but fewer (37%) used it during their most recent NICU rotation. Respondents considered the most useful features to be summarized culture results (43%) and antibiotic recommendations (48%). DISCUSSION: During the study period, the CDS tool functionality was hindered by EHR upgrades, implementation of a new laboratory information system, and changes to antimicrobial testing methodologies. Loss of functionality may have reduced viewing antibiotic recommendations. In contrast, viewing culture results was frequently performed, likely because this feature was perceived as useful and functionality was preserved. CONCLUSION: To improve CDS tool visibility and usefulness, we recommend early user and information technology team involvement which would facilitate use and mitigate implementation challenges.

Clinician preferences for verbal communication compared to EHR documentation in the ICU.

BACKGROUND: Effective communication is essential to safe and efficient patient care. Additionally, many health information technology (HIT) developments, innovations, and standards aim to implement processes to improve data quality and integrity of electronic health records (EHR) for the purpose of clinical information exchange and communication. OBJECTIVE: We aimed to understand the current patterns and perceptions of communication of common goals in the ICU using the distributed cognition and clinical communication space theoretical frameworks. METHODS: We conducted a focus group and 5 interviews with ICU clinicians and observed 59.5 hours of interdisciplinary ICU morning rounds. RESULTS: Clinicians used an EHR system, which included electronic documentation and computerized provider order entry (CPOE), and paper artifacts for documentation; yet, preferred the verbal communication space as a method of information exchange because they perceived that the documentation was often not updated or efficient for information retrieval. These perceptions that the EHR is a "shift behind" may lead to a further reliance on verbal information exchange, which is a valuable clinical communication activity, yet, is subject to information loss. CONCLUSIONS: Electronic documentation tools that, in real time, capture information that is currently verbally communicated may increase the effectiveness of communication.