When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record.
BMJ quality & safety
Impact of problem-based charting on the utilization and accuracy of the electronic problem list
JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION
2018; 25 (5): 548?54
The Impact of Big Data on the Physician
GUIDE TO BIG DATA APPLICATIONS
2018; 26: 415?48
Discordance Between Apolipoprotein B and LDL-Cholesterol in Young Adults Predicts Coronary Artery Calcification The CARDIA Study
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
2016; 67 (2): 193?201
Order sets are widely used tools in the electronic health record (EHR) for improving healthcare quality. However, there is limited insight into how well they facilitate clinician workflow. We assessed four indicators based on order set usage patterns in the EHR that reflect potential misalignment between order set design and clinician workflow needs.We used data from the EHR on all orders of medication, laboratory, imaging and blood product items at an academic hospital and an itemset mining approach to extract orders that frequently co-occurred with order set use. We identified the following four indicators: infrequent ordering of order set items, rapid retraction of medication orders from order sets, additional a la carte ordering of items not included in order sets and a la carte ordering of items despite being listed in the order set.There was significant variability in workflow alignment across the 11?762 order set items used in the 77?421 inpatient encounters from 2014 to 2017. The median ordering rate was 4.1% (IQR 0.6%-18%) and median medication retraction rate was 4% (IQR 2%-10%). 143 (5%) medications were significantly less likely while 68 (3%) were significantly more likely to be retracted than if the same medication was ordered a la carte. 214 (39%) order sets were associated with least one additional item frequently ordered a la carte and 243 (45%) order sets contained at least one item that was instead more often ordered a la carte.Order sets often do not align with what clinicians need at the point of care. Quantitative insights from EHRs may inform how order sets can be optimised to facilitate clinician workflow.
View details for DOI 10.1136/bmjqs-2018-008968
View details for PubMedID 31164486
Validation of Test Performance and Clinical Time Zero for an Electronic Health Record Embedded Severe Sepsis Alert.
Applied clinical informatics
2016; 7 (2): 560-572
High levels of apolipoprotein B (apoB) have been shown to predict atherosclerotic cardiovascular disease (CVD) in adults even in the context of low levels of low-density lipoprotein cholesterol (LDL-C) or non-high-density lipoprotein cholesterol (non-HDL-C).This study aimed to quantify the associations between apoB and the discordance between apoB and LDL-C or non-HDL-C in young adults and measured coronary artery calcium (CAC) in midlife.Data were derived from a multicenter cohort study of young adults recruited at ages 18 to 30 years. All participants with complete baseline CVD risk factor data, including apoB and year 25 (Y25) CAC score, were entered into this study. Presence of CAC was defined as having a positive, nonzero Agatston score as determined by computed tomography. Baseline apoB values were divided into tertiles of 4 mutually exclusive concordant/discordant groups, based on median apoB and LDL-C or non-HDL-C.Analysis included 2,794 participants (mean age: 25 ± 3.6 years; body mass index: 24.5 ± 5 kg/m(2); and 44.4% male). Mean lipid values were as follows: total cholesterol: 177.3 ± 33.1 mg/dl; LDL-C: 109.9 ± 31.1 mg/dl; non-HDL-C: 124.0 ± 33.5 mg/dl; HDL-C: 53 ± 12.8 mg/dl; and apoB: 90.7 ± 24 mg/dl; median triglycerides were 61 mg/dl. Compared with the lowest apoB tertile, higher odds of developing Y25 CAC were seen in the middle (odds ratio [OR]: 1.53) and high (OR: 2.28) tertiles based on traditional risk factor-adjusted models. High apoB and low LDL-C or non-HDL-C discordance was also associated with Y25 CAC in adjusted models (OR: 1.55 and OR: 1.45, respectively).These data suggest a dose-response association between apoB in young adults and the presence of midlife CAC independent of baseline traditional CVD risk factors.
View details for DOI 10.1016/j.jacc.2015.10.055
View details for Web of Science ID 000368114400011
View details for PubMedID 26791067
Dietary vitamin K intake and anticoagulation control during the initiation phase of warfarin therapy: A prospective cohort study
THROMBOSIS AND HAEMOSTASIS
2013; 110 (1): 195?96
Increasing use of EHRs has generated interest in the potential of computerized clinical decision support to improve treatment of sepsis. Electronic sepsis alerts have had mixed results due to poor test characteristics, the inability to detect sepsis in a timely fashion and the use of outside software limiting widespread adoption. We describe the development, evaluation and validation of an accurate and timely severe sepsis alert with the potential to impact sepsis management.To develop, evaluate, and validate an accurate and timely severe sepsis alert embedded in a commercial EHR.The sepsis alert was developed by identifying the most common severe sepsis criteria among a cohort of patients with ICD 9 codes indicating a diagnosis of sepsis. This alert requires criteria in three categories: indicators of a systemic inflammatory response, evidence of suspected infection from physician orders, and markers of organ dysfunction. Chart review was used to evaluate test performance and the ability to detect clinical time zero, the point in time when a patient develops severe sepsis.Two physicians reviewed 100 positive cases and 75 negative cases. Based on this review, sensitivity was 74.5%, specificity was 86.0%, the positive predictive value was 50.3%, and the negative predictive value was 94.7%. The most common source of end-organ dysfunction was MAP less than 70 mm/Hg (59%). The alert was triggered at clinical time zero in 41% of cases and within three hours in 53.6% of cases. 96% of alerts triggered before a manual nurse screen.We are the first to report the time between a sepsis alert and physician chart-review clinical time zero. Incorporating physician orders in the alert criteria improves specificity while maintaining sensitivity, which is important to reduce alert fatigue. By leveraging standard EHR functionality, this alert could be implemented by other healthcare systems.
View details for DOI 10.4338/ACI-2015-11-RA-0159
View details for PubMedID 27437061
View details for PubMedCentralID PMC4941860