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1

Review paper: Computerized clinical decision support for prescribing: provision does not guarantee uptake  

Microsoft Academic Search

There is wide variability in the use and adoption of recommendations generated by computerized clinical decision support systems (CDSSs) despite the benefits they may bring to clinical practice. We conducted a systematic review to explore the barriers to, and facilitators of, CDSS uptake by physicians to guide prescribing decisions. We identified 58 studies by searching electronic databases (1990–2007). Factors impacting

Annette Moxey; Jane Robertson; David Newby; Isla Hains; Margaret Williamson; Sallie-Anne Pearson

2010-01-01

2

Improving Emergency Department Triage Classification with Computerized Clinical Decision Support at a Pediatric Hospital  

ERIC Educational Resources Information Center

Background: The Emergency Severity Index (ESI) is an emergency department (ED) triage classification system based on estimated patient-specific resource utilization. Rules for a computerized clinical decision support (CDS) system based on a patient's chief complaint were developed and tested using a stochastic model for predicting ESI scores.…

Kunisch, Joseph Martin

2012-01-01

3

Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study  

PubMed Central

Background The purpose of this study was to identify recommended practices for computerized clinical decision support (CDS) development and implementation and for knowledge management (KM) processes in ambulatory clinics and community hospitals using commercial or locally developed systems in the U.S. Methods Guided by the Multiple Perspectives Framework, the authors conducted ethnographic field studies at two community hospitals and five ambulatory clinic organizations across the U.S. Using a Rapid Assessment Process, a multidisciplinary research team: gathered preliminary assessment data; conducted on-site interviews, observations, and field surveys; analyzed data using both template and grounded methods; and developed universal themes. A panel of experts produced recommended practices. Results The team identified ten themes related to CDS and KM. These include: 1) workflow; 2) knowledge management; 3) data as a foundation for CDS; 4) user computer interaction; 5) measurement and metrics; 6) governance; 7) translation for collaboration; 8) the meaning of CDS; 9) roles of special, essential people; and 10) communication, training, and support. Experts developed recommendations about each theme. The original Multiple Perspectives framework was modified to make explicit a new theoretical construct, that of Translational Interaction. Conclusions These ten themes represent areas that need attention if a clinic or community hospital plans to implement and successfully utilize CDS. In addition, they have implications for workforce education, research, and national-level policy development. The Translational Interaction construct could guide future applied informatics research endeavors. PMID:22333210

2012-01-01

4

Review Paper: Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review  

Microsoft Academic Search

While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs.To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand

Gilad J. Kuperman; Anne M. Bobb; Thomas H. Payne; Anthony J. Avery; Tejal K. Gandhi; Gerard Burns; David C. Classen; David W. Bates

2007-01-01

5

Evaluation of a Computerized Diagnostic Decision Support System for Patients with Pneumonia : Study Design Considerations  

Microsoft Academic Search

Planning the clinical evaluation of a computerized decision support system requires a strategy that encompasses the different aspects of the clinical problem, the technical difficulties of software and hardware integration and implementation, the behavioral aspects of the targeted users, and the discip of study design. Although clinical information systems are becoming more widely available, only a few decision support systems

Dominik Aronsky; Karen J Chan; Peter J Haug

2001-01-01

6

Designing Computerized Decision Support That Works for Clinicians and Families  

PubMed Central

Evidence-based decision-making is central to the practice of pediatrics. Clinical trials and other biomedical research provide a foundation for this process, and practice guidelines, drawing from their results, inform the optimal management of an increasing number of childhood health problems. However, many clinicians fail to adhere to guidelines. Clinical decision support delivered using health information technology, often in the form of electronic health records, provides a tool to deliver evidence-based information to the point of care and has the potential to overcome barriers to evidence-based practice. An increasing literature now informs how these systems should be designed and implemented to most effectively improve outcomes in pediatrics. Through the examples of computerized physician order entry, as well as the impact of alerts at the point of care on immunization rates, the delivery of evidence-based asthma care, and the follow-up of children with attention deficit hyperactivity disorder, the following review addresses strategies for success in using these tools. The following review argues that, as decision support evolves, the clinician should no longer be the sole target of information and alerts. Through the Internet and other technologies, families are increasingly seeking health information and gathering input to guide health decisions. By enlisting clinical decision support systems to deliver evidence-based information to both clinicians and families, help families express their preferences and goals, and connect families to the medical home, clinical decision support may ultimately be most effective in improving outcomes. PMID:21315295

Fiks, Alexander G.

2011-01-01

7

Computerized decision support in adult and pediatric critical care  

PubMed Central

Computerized decision support (CDS) is the most advanced form of clinical decision support available and has evolved with innovative technologies to provide meaningful assistance to medical professionals. Critical care clinicians are in unique environments where vast amounts of data are collected on individual patients, and where expedient and accurate decisions are paramount to the delivery of quality healthcare. Many CDS tools are in use today among adult and pediatric intensive care units as diagnostic aides, safety alerts, computerized protocols, and automated recommendations for management. Some CDS use have significantly decreased adverse events and improved costs when carefully implemented and properly operated. CDS tools integrated into electronic health records are also valuable to researchers providing rapid identification of eligible patients, streamlining data-gathering and analysis, and providing cohorts for study of rare and chronic diseases through data-warehousing. Although the need for human judgment in the daily care of critically ill patients has limited the study and realization of meaningful improvements in overall patient outcomes, CDS tools continue to evolve and integrate into the daily workflow of clinicians, and will likely provide advancements over time. Through novel technologies, CDS tools have vast potential for progression and will significantly impact the field of critical care and clinical research in the future. PMID:24701413

Williams, Cydni N; Bratton, Susan L; Hirshberg, Eliotte L

2013-01-01

8

Clinical applications of computerized thermography  

NASA Technical Reports Server (NTRS)

Computerized or digital, thermography is a rapidly growing diagnostic imaging modality. It has superseded contact thermography and analog imaging thermography which do not allow effective quantization. Medical applications of digital thermography can be classified in two groups: static and dynamic imaging. They can also be classified into macro thermography (resolution greater than 1 mm) and micro thermography (resolution less than 100 microns). Both modalities allow a thermal resolution of 0.1 C. The diagnostic power of images produced by any of these modalities can be augmented by the use of digital image enhancement and image recognition procedures. Computerized thermography has been applied in neurology, cardiovascular and plastic surgery, rehabilitation and sports medicine, psychiatry, dermatology and ophthalmology. Examples of these applications are shown and their scope and limitations are discussed.

Anbar, Michael

1988-01-01

9

Computerized physician order entry and online decision support.  

PubMed

Computerized physician order entry (CPOE) and decision support systems (DSS) can reduce certain types of error but often slow clinicians and may increase other types of error. The net effect of these systems on an emergency department (ED) is unknown. The consensus participants combined published evidence with expert opinion to outline recommendations for success. These include seamless integration of CPOE and DSS into systems and workflow; ensuring access to Internet-based and other online support material in the clinical arena; designing systems specifically for the ED and measuring their impact to ensure an overall benefit; ensuring that CPOE systems provide error and interaction checking and facilitate weight- and physiology-based dosing; using interruptive alerts only for the highest-severity events; providing a simple, vendor-independent interface for institutional customization of CPOE alert thresholds; maximizing the use of automated systems and passive data capture; and ensuring the widespread availability of CPOE and DSS using secure wireless and portable technologies where appropriate. Decisions regarding CPOE and DSS in the ED should be guided by the ED chair or designee. Much of what is believed to be true regarding CPOE and DSS has not been adequately studied. Additional CPOE and DSS research is needed quickly, and this research should receive funding priority. DSS and CPOE hold great promise to improve patient care, but not all systems are equal. Evidence must guide these efforts, and the measured outcomes must consider the many factors of quality care. PMID:15528576

Handler, Jonathan A; Feied, Craig F; Coonan, Kevin; Vozenilek, John; Gillam, Michael; Peacock, Peter R; Sinert, Rich; Smith, Mark S

2004-11-01

10

Computerized system for medical decision in the perinatal period  

Microsoft Academic Search

The paper presents the motivations for the implementation of a computerized system operating in the field of medical decision, aimed at the reduction of the medical errors and the improvement of health status of the pregnant women and newborn babies. The proposed system is going to be available as an Internet accessible platform that will monitor the health status of

R. Antohi; C. Ogescu; F. Udrescu; M. Onofriescu; D. Bistriceanu; L. Stefan; S. Dumitru

2010-01-01

11

What can natural language processing do for clinical decision support?  

Microsoft Academic Search

Computerized clinical decision support (CDS) aims to aid decision making of health care providers and the public by providing easily accessible health-related information at the point and time it is needed. natural language processing (NLP) is instrumental in using free-text information to drive CDS, representing clinical knowledge and CDS interventions in standardized formats, and leveraging clinical narrative. The early innovative

Dina Demner-fushman; Wendy Webber Chapman; Clement J. Mcdonald

2009-01-01

12

Computerized clinical documentation system in the pediatric intensive care unit  

PubMed Central

Background To determine whether a computerized clinical documentation system (CDS): 1) decreased time spent charting and increased time spent in patient care; 2) decreased medication errors; 3) improved clinical decision making; 4) improved quality of documentation; and/or 5) improved shift to shift nursing continuity. Methods Before and after implementation of CDS, a time study involving nursing care, medication delivery, and normalization of serum calcium and potassium values was performed. In addition, an evaluation of completeness of documentation and a clinician survey of shift to shift reporting were also completed. This was a modified one group, pretest-posttest design. Results With the CDS there was: improved legibility and completeness of documentation, data with better accessibility and accuracy, no change in time spent in direct patient care or charting by nursing staff. Incidental observations from the study included improved management functions of our nurse manager; improved JCAHO documentation compliance; timely access to clinical data (labs, vitals, etc); a decrease in time and resource use for audits; improved reimbursement because of the ability to reconstruct lost charts; limited human data entry by automatic data logging; eliminated costs of printing forms. CDS cost was reasonable. Conclusions When compared to a paper chart, the CDS provided a more legible, compete, and accessible patient record without affecting time spent in direct patient care. The availability of the CDS improved shift to shift reporting. Other observations showed that the CDS improved management capabilities; helped physicians deliver care; improved reimbursement; limited data entry errors; and reduced costs. PMID:11604105

2001-01-01

13

Tight glycemic control and computerized decision-support systems: a systematic review  

Microsoft Academic Search

Objective  To identify and summarize characteristics of computerized decision-support systems (CDSS) for tight glycemic control (TGC)\\u000a and to review their effects on the quality of the TGC process in critically ill patients.\\u000a \\u000a \\u000a \\u000a Methods  We searched Medline (1950–2008) and included studies on critically ill adult patients that reported original data from a clinical\\u000a trial or observational study with a main objective of evaluating

Saeid Eslami; Ameen Abu-Hanna; Evert de Jonge; Nicolette F. de Keizer

2009-01-01

14

A Computerized Clinical Support System and Psychological Laboratory.  

ERIC Educational Resources Information Center

Advocating "holistic" medicine, this article details the benefits to be derived from using a computerized clinical support system in a psychological laboratory focusing on internal healing where the client/patient becomes a committed partner utilizing biofeedback equipment, gaming, and simulation to achieve self-understanding and self-control. (JC)

Cassel, Russell N.

1978-01-01

15

Evaluation of a Computerized Contraceptive Decision Aid for Adolescent Patients.  

ERIC Educational Resources Information Center

Discusses a computer-based contraceptive decision aid used with adolescent female family planning clinic patients (N=949). Results show improved short-term knowledge of and confidence in oral contraceptive (OC) efficacy. Higher OC knowledge after one year and fewer pregnancies were seen in one group. Findings suggest the usefulness of informatics…

Chewning, Betty; Mosena, Pat; Wilson, Dale; Erdman, Harold; Potthoff, Sandra; Murphy, Anita; Kuhnen, Kathleen Kennedy

1999-01-01

16

Physicians' Decisions to Override Computerized Drug Alerts in Primary Care  

Microsoft Academic Search

Background: Although computerized physician order entry reduces medication errors among inpatients, little is known about the use of this system in primary care. Methods: We calculated the override rate among 3481 consecutivealertsgeneratedat5adultprimarycareprac- tices that use a common computerized physician order entry system for prescription writing. For detailed re- view, we selected a random sample of 67 alerts in which physicians

Saul N. Weingart; Maria Toth; Daniel Z. Sands; Mark D. Aronson; Roger B. Davis; Russell S. Phillips

2003-01-01

17

Intraclass correlation metrics for the accuracy of algorithmic definitions in a computerized decision support system for supportive cancer care  

Microsoft Academic Search

As part of the development of a computerized clinical decision support system for anemia management in cancer patients, we\\u000a applied psychometric principles and techniques to assess the accuracy of the algorithmic operationalizations of a set of evidence-based\\u000a practice guidelines. In an iterative rating process, five medical and nursing experts rated 27 algorithmic sets derived from\\u000a 18 guidelines, the objective being

Matti Aapro; Ivo Abraham; Karen MacDonald; Pierre Soubeyran; Jan Foubert; Carsten Bokemeyer; Michael Muenzberg; Joanna Van Erps; Matthew Turner

2007-01-01

18

A Framework for Breast Cancer Prevention Using a Computerized Decision Aid  

Cancer.gov

A Framework for Breast Cancer Prevention Using a Computerized Decision Aid Elissa Ozanne, Ph.D. Kelly Adduci, M.P.H. Caroline Annis, M.S. Laura Esserman, M.D., M.B.A. Abstract Background Current prevention decision making typically uses the Gail,

19

Computerized Aid Improves Safety Decision Process for Survivors of Intimate Partner Violence  

ERIC Educational Resources Information Center

A computerized safety decision aid was developed and tested with Spanish or English-speaking abused women in shelters or domestic violence (DV) support groups (n = 90). The decision aid provides feedback about risk for lethal violence, options for safety, assistance with setting priorities for safety, and a safety plan personalized to the user.…

Glass, Nancy; Eden, Karen B.; Bloom, Tina; Perrin, Nancy

2010-01-01

20

Computerized Case History - an Effective Tool for Management of Patients and Clinical Trials  

Microsoft Academic Search

Monitoring diagnostic procedures, treatment protocols and clinical outcome are key issues in maintaining quality medical care and in evaluating clinical trials. For these purposes, a user-friendly computerized method for monitoring all available information about a patient is needed. Objective: To develop a real-time computerized data collection system for verification, analysis and storage of clinical information on an individual patient. Methods:

Nikita Shklovsky-Kordi; Boris Zingerman; Nikolay Rivkind; Saveli Goldberg; Scott Davis; Lyuba Varticovski; Marina Krol; Andrei Vorobiev; Ilia Serebriyskiy

21

Clinical Decision-Support Systems  

Microsoft Academic Search

Clinical decision-support systems (CDSS) apply best-known medical knowledge to patient data for the purpose of generating case-specific decision-support advice. CDSS forms the cornerstone of health informatics research and practice. It is an embedded concept in almost all major clinical information systems and plays an instrumental role in helping health care achieve its ultimate goal: providing high- quality patient care while,

Kai Zheng

22

A Computerized Decision Support Aid for Critical Care Novice Nursing1 , H. Michel  

E-print Network

A Computerized Decision Support Aid for Critical Care Novice Nursing1 P. Fortier , H. Michel , B The traditional health care model of a novice nurse interacting with a senior staff nurse in a mentoring role this information in real-time may leave less time to the nurse for actual patient care. In a perfect world

Michel, Howard E.

23

Using Bayesian Decision Theory to Design a Computerized Mastery Test  

Microsoft Academic Search

A theoretical framework for mastery testing based on item response theory and Bayesian deci sion theory is described. The idea of sequential testing is developed, with the goal of providing shorter tests for individuals who have clearly mastered (or clearly not mastered) a given subject and longer tests for those individuals for whom the mastery decision is not as clear-cut.

Charles Lewis; Kathleen Sheehan

1990-01-01

24

Computerized methods for the clinical interpretation of myocardial scintigrams  

SciTech Connect

Computer processing of medical images is mainly used in order to improve the image quality or to derive some quantitative data from the study. Clinical interpretation of the pictures is usually based on criteria which depend on the experience of the observer, who decides to establish a relationship between the results of the study and the clinical situation of the patient. Computerized classification techniques may overcome the operator variability and optimize the criteria which affect pictures to normal or various pathological classes. In order to test the ability of factorial discriminant analysis to interpret thallium-201 myocardial scintigrams, 207 studies (at rest = 95, after stress + redistribution = 50, after dipyridamole + redistribution = 62) performed in patients undergoing coronary angiography have been first evaluated using various criteria of increasing severity, according to a regional tracer uptake model with 10 territories. The receiver operating characteristics (ROC) curves demonstrated, that sensitivity and specificity varied in opposite directions, a high sensitivity (89% to 100%) being only achieved when accepting a lack of specificity (33% to 57%). Discriminant analysis, on the contrary, provided for each type of scintigraphic protocol a single optimal combination of sensitivity (74% to 87%) and specificity (92% to 100%).

Itti, R.; Benjelloun, L.; Benjelloun, H.; Rosenberg, S.; Laudet, M.

1985-05-01

25

Clinical Judgment and Decision Making  

Microsoft Academic Search

? Abstract When clinical psychologists make judgments, are they likely to be cor- rect or incorrect? The following topics are reviewed: (a) methodological,advances,in evaluating the validity of descriptions of personality and psychopathology, (b) recent findings on the cognitive processes of clinicians, and (c) the validity of judgments and utility of decisions made,by mental,health professionals. Results from research on clinical judgment,and

Howard N. Garb

2005-01-01

26

What can Natural Language Processing do for Clinical Decision Support?  

PubMed Central

Computerized Clinical Decision Support (CDS) aims to aid decision making of health care providers and the public by providing easily accessible health-related information at the point and time it is needed. Natural Language Processing (NLP) is instrumental in using free-text information to drive CDS, representing clinical knowledge and CDS interventions in standardized formats, and leveraging clinical narrative. The early innovative NLP research of clinical narrative was followed by a period of stable research conducted at the major clinical centers and a shift of mainstream interest to biomedical NLP. This review primarily focuses on the recently renewed interest in development of fundamental NLP methods and advances in the NLP systems for CDS. The current solutions to challenges posed by distinct sublanguages, intended user groups, and support goals are discussed. PMID:19683066

Demner-Fushman, Dina; Chapman, Wendy W.; McDonald, Clement J.

2009-01-01

27

Intraclass correlation metrics for the accuracy of algorithmic definitions in a computerized decision support system for supportive cancer care.  

PubMed

As part of the development of a computerized clinical decision support system for anemia management in cancer patients, we applied psychometric principles and techniques to assess the accuracy of the algorithmic operationalizations of a set of evidence-based practice guidelines. In an iterative rating process, five medical and nursing experts rated 27 algorithmic sets derived from 18 guidelines, the objective being an intraclass coefficient (ICC) exceeding 0.90. The first round of review yielded an ICC of 1.00 for 22 sets. After revision and resubmission to the expert panel, an ICC of 1.00 was obtained for the additional five sets. The evolving decision support system is based on algorithms that accurately specify evidence-based guidelines for anemia management in cancer patients. PMID:17393188

Aapro, Matti; Abraham, Ivo; MacDonald, Karen; Soubeyran, Pierre; Foubert, Jan; Bokemeyer, Carsten; Muenzberg, Michael; Van Erps, Joanna; Turner, Matthew

2007-11-01

28

Application of Computerized Polysomnographic Systems in Psychophysiology and Clinical Studies  

Microsoft Academic Search

The development of sleep medication, computer technologies, and microelectronics in the past decade brought about the creation of a new class of instruments for the diagnostics of sleep disorders, i.e., computerized polysomnographic systems. The application of the IBM PC PENTIUM using the MS Windows system for software development and standard hardware and software allows a user to economically supplement the

V. B. Dorokhov

2002-01-01

29

Computerized Physician Order Entry - effectiveness and efficiency of electronic medication ordering with decision support systems  

PubMed Central

Health political background Computerized physician order entry (CPOE) systems are software to electronically enter medication orders. They can be equipped with tools for decision support (CDS). In Germany, various vendors offer such systems for hospitals and physicians’ offices. These systems have mostly been developed during the last five to ten years. Scientific background CPOE-systems exist since the 1970’s. Usually, clinical decision support is integrated into the CPOE to avoid errors. Research questions This HTA-report aims to evaluate the effectiveness and efficiency of CPOE-/CDS-systems and their ethical, social and legal aspects. Methods The systematic literature search (27 international data bases) yielded 791 abstracts. Following a two-part selection process, twelve publications were included in the assessment. Results All reviews and studies included in the present report show that the use of CPOE-/CDS-systems can lead to a reduction of medication errors. Minor errors can be eliminated almost completely. The effect of CPOE-/CDS-systems on the rate of adverse drug events (ADE) is evaluated in only two primary studies with conflicting results. It is difficult to compare the results of economical studies because they evaluate different settings, interventions and time frames. In addition, the documentation often is not fully transparent. All four studies included measure costs and effects from the perspective of a hospital or hospital affiliation. Concerning social aspects, the literature points at changes regard competing interests of technology and humans that result from the implementation of CPOE-systems. The experience of institutions in which the implementation of CPOE-systems leads to problems showed that the importance of considering the socio-organisational context had partly been underestimated. Discussion CPOE-/CDS-systems are able to reduce the rate of medication errors when ordering medications. The adherence to guidelines, communication, patient care and personnel satisfaction can also be affected positively. However, the literature also reports negative effects, as through the use of CPOE-/CDS-systems new errors can be generated. This makes continuous revisions of the system, as well as data-updates necessary. Concerning the cost-benefit-ratio from the hospital perspective, the two qualitatively best economic studies show contradictory results. Therefore, a positive cost-benefit-ratio for individual hospitals cannot be assumed, particularly as the study results cannot be generalized. Conclusions If the implementation of CPOE-/CDS-systems is well planned and conducted, the system adapted to the needs of the institution and continuously reviewed, and data used are updated on a regular basis, the rate of medication ordering errors can be reduced considerably by using CPOE-/CDS-systems. However, it is not clear how this results in a reduction of ADE. Prospective, systematic multi-centre evaluation-studies with clear methodology are needed, which include an analysis of the user-friendliness and of social and technical aspects of the system. Such studies should evaluate the impact a CPOE-/CDS-system has on ADE-rates and mortality. A detailed description of the system used and of the hospital evaluated is essential. If possible, costs and cost effects should be surveyed and documented transparently. PMID:21289894

Sturzlinger, Heidi; Hiebinger, Cora; Pertl, Daniela; Traurig, Peter

2009-01-01

30

What Decision Analysis Can Offer the Clinical Decision Maker  

Microsoft Academic Search

Cognitive Continuum Theory can be used to explain why the relationship between research and practice is more problematic than is customarily assumed. The various possible sources of evidence for clinical decision making and the alternative approaches to such decision making can be located within the main modes of this continuum, each of which embodies a different balance of intuition and

Jack Dowie

1999-01-01

31

Clinic Function and Computerized Ambulatory Records: A Concurrent Study with Conventional Records  

PubMed Central

Controlled studies of computerized ambulatory information systems are rare. As part of an evaluation of the effects of COSTAR on clinic function, we divided our resident teaching clinic into a study group with access to COSTAR and a control group allowed access only to conventional medical records. We sampled staff attitudes toward use of the computer and did detailed time studies of clinic patient flow. Staff attitudes reflected a high degree of acceptance, favoring COSTAR over conventional records. This was primarily related to improvement in telephone management and demand care. House staff never became facile users of COSTAR because of infrequent clinic sessions. Clinics assigned to COSTAR experienced somewhat longer waiting times due to an increased workload and training effects. Installation of computerized records should prompt a careful evaluation of expected benefits.

Campbell, James R.; Givner, Nathaniel; Seelig, Charles B.; Patil, Kashinath; Wigton, Robert S.; Tape, Thomas G.

1988-01-01

32

An Introduction to Clinical Decision Support Systems  

Microsoft Academic Search

Library support of clinical decision making ranges from passive (traditional library collections of books and journals) to highly active (professional services, such as clinical medical librarians, LATCH, and informationists). Support of mobile computing resources and subscriptions to point-of-care services, such as UpToDate® and DynaMed®, moves libraries toward interactive resources to aid health care providers in their decisions about specific patient

Mary Moore; Kimberly A. Loper

2011-01-01

33

Grand challenges in clinical decision support  

Microsoft Academic Search

There is a pressing need for high-quality, effective means of designing, developing, presenting, implementing, evaluating, and main- taining all types of clinical decision support capabilities for clinicians, patients and consumers. Using an iterative, consensus-building process we identified a rank-ordered list of the top 10 grand challenges in clinical decision support. This list was created to educate and inspire researchers, developers,

Dean F. Sittig; Adam Wright; Jerome A. Osheroff; Blackford Middleton; Jonathan M. Teich; Joan S. Ash; Emily Campbell; David W. Bates

2008-01-01

34

Computerizing Clinical Pathways: Ontology-Based Modeling and Execution  

E-print Network

, Canada Abstract. Clinical Pathways (CP) stipulate an evidence-based patient care workflow for a specific that they can be executed at the point-of- care. We present our CP modeling approach that features. Introduction In Canada, the management of prostate cancer follows an integrated care approach involving

Abidi, Syed Sibte Raza

35

Computerized Examination: Application to the Clinical Biochemistry Laboratory  

ERIC Educational Resources Information Center

Explains a computer exam format used with pharmacy students in a clinical biochemistry laboratory course. Student attitudes were assessed. Students felt that their final grade reflected their comprehension, exam pratical facilitated learning, exam format fostered retention and the questions were appropriate. (GS)

Bachmann, Kenneth A.

1975-01-01

36

Effectiveness of Computerized Decision Support Systems Linked to Electronic Health Records: A Systematic Review and Meta-Analysis  

PubMed Central

We systematically reviewed randomized controlled trials (RCTs) assessing the effectiveness of computerized decision support systems (CDSSs) featuring rule- or algorithm-based software integrated with electronic health records (EHRs) and evidence-based knowledge. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Abstracts of Reviews of Effects. Information on system design, capabilities, acquisition, implementation context, and effects on mortality, morbidity, and economic outcomes were extracted. Twenty-eight RCTs were included. CDSS use did not affect mortality (16 trials, 37395 patients; 2282 deaths; risk ratio [RR]?=?0.96; 95% confidence interval [CI]?=?0.85, 1.08; I2?=?41%). A statistically significant effect was evident in the prevention of morbidity, any disease (9 RCTs; 13868 patients; RR?=?0.82; 95% CI?=?0.68, 0.99; I2?=?64%), but selective outcome reporting or publication bias cannot be excluded. We observed differences for costs and health service utilization, although these were often small in magnitude. Across clinical settings, new generation CDSSs integrated with EHRs do not affect mortality and might moderately improve morbidity outcomes. PMID:25322302

Kwag, Koren H.; Lytras, Theodore; Bertizzolo, Lorenzo; Brandt, Linn; Pecoraro, Valentina; Rigon, Giulio; Vaona, Alberto; Ruggiero, Francesca; Mangia, Massimo; Iorio, Alfonso; Kunnamo, Ilkka; Bonovas, Stefanos

2014-01-01

37

Effectiveness of computerized decision support systems linked to electronic health records: a systematic review and meta-analysis.  

PubMed

We systematically reviewed randomized controlled trials (RCTs) assessing the effectiveness of computerized decision support systems (CDSSs) featuring rule- or algorithm-based software integrated with electronic health records (EHRs) and evidence-based knowledge. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Abstracts of Reviews of Effects. Information on system design, capabilities, acquisition, implementation context, and effects on mortality, morbidity, and economic outcomes were extracted. Twenty-eight RCTs were included. CDSS use did not affect mortality (16 trials, 37395 patients; 2282 deaths; risk ratio [RR]?=?0.96; 95% confidence interval [CI]?=?0.85, 1.08; I(2)?=?41%). A statistically significant effect was evident in the prevention of morbidity, any disease (9 RCTs; 13868 patients; RR?=?0.82; 95% CI?=?0.68, 0.99; I(2)?=?64%), but selective outcome reporting or publication bias cannot be excluded. We observed differences for costs and health service utilization, although these were often small in magnitude. Across clinical settings, new generation CDSSs integrated with EHRs do not affect mortality and might moderately improve morbidity outcomes. PMID:25322302

Moja, Lorenzo; Kwag, Koren H; Lytras, Theodore; Bertizzolo, Lorenzo; Brandt, Linn; Pecoraro, Valentina; Rigon, Giulio; Vaona, Alberto; Ruggiero, Francesca; Mangia, Massimo; Iorio, Alfonso; Kunnamo, Ilkka; Bonovas, Stefanos

2014-12-01

38

Appropriateness and imaging utilization: "computerized provider order entry and decision support".  

PubMed

Modern imaging methods have been transformative in improving medical care. Cross-sectional imaging has largely eliminated the need for invasive "exploratory" surgery and is widely used to triage acutely ill patients. However, how to best use medical imaging with ongoing concerns related to overall costs and radiation risks remains controversial. Imaging saves lives, but overuse of imaging can add unnecessary costs to the health system and add to the radiation burden of the population. In this article, the American College of Radiology Appropriateness Criteria (ACRAC) are reviewed, while the Massachusetts General Hospital experience with a computerized physician (provider) order entry system and other approaches to utilization management are discussed. There are strong evidence-based indicators of appropriateness for a substantial percentage of common imaging applications and where this is the case, decision support systems based on ACRAC or other criteria can and should be used. Standardize health care delivery and elimination of wasteful practice variation can be achieved without the art of medicine being ignored or devalued. PMID:25107862

Thrall, James H

2014-09-01

39

Research Paper: Exploring Barriers and Facilitators to the Use of Computerized Clinical Reminders  

Microsoft Academic Search

ObjectiveEvidence-based practices in preventive care and chronic disease management are inconsistently implemented. Computerized clinical reminders (CRs) can improve compliance with these practices in outpatient settings. However, since clinician adherence to CR recommendations is quite variable and declines over time, we conducted observations to determine barriers and facilitators to the effective use of CRs.DesignWe conducted an observational study of nurses and

Jason J. Saleem; Emily S. Patterson; Laura G. Militello; Marta L. Render; Greg Orshansky; Steven M. Asch

2005-01-01

40

Is it appropriate, or ethical, to use health data collected for the purpose of direct patient care to develop computerized predictive decision support tools?  

PubMed

The increasing use of clinical decision support systems (CDSS) to assist clinicians in decision-making is pushing the limits of information technology. The emergence of Electronic Health Records (EHR) coupled with enriched health information standards such as HL7 CDA, SNOMED, ICD-10 and LOINC have provided a rich environment for massive data collection and analysis by healthcare providers. This immense increase in data collection has also provided a gateway for the application of various data mining techniques on clinical datasets so as to measure health status (i.e. function, comfort and likelihood of dying) of patients. In measuring health status, many clinicians have opted to use CDSS to assist in decision-making and enhance clinical experience. However, even as the use of CDSS in clinicians' office continues to grow, the question that remains in the minds of many patients and the general public is whether it is appropriate, or ethical, for researchers to use health data collected for the purpose of direct patient care to develop computerized predictive decision support tool. In this paper, a systematic review is used to highlight the relevant technical barriers and ethical issues surrounding the secondary use of health data in developing CDSS. PMID:19380924

Bonney, Wilfred

2009-01-01

41

Use of a Computerized Decision Aid for ADHD Diagnosis: A Randomized Controlled Trial  

PubMed Central

OBJECTIVE: To determine if implementing attention-deficit/hyperactivity disorder (ADHD) diagnosis and treatment guidelines in a clinical decision support system would result in better care, including higher rates of adherence to clinical care guidelines. METHODS: We conducted a cluster randomized controlled trial in which we compared diagnosis and management of ADHD in 6- to 12-year-olds after implementation of a computer decision support system in 4 practices. RESULTS: Eighty-four charts were reviewed. In the control group, the use of structured diagnostic assessments dropped from 50% in the baseline period to 38% in the intervention period. In the intervention group, however, it rose from 60% to 81%. This difference was statistically significant, even after controlling for age, gender, and race (odds ratio of structured diagnostic assessment in intervention group versus control group = 8.0, 95% confidence interval 1.6–40.6). Significant differences were also seen in the number of ADHD core symptoms noted at the time of diagnosis. Our study was not powered to detect changes in care and management, but the percent of patients who had documented medication adjustments, mental health referrals, and visits to mental health specialists were higher in the intervention group than the control. CONCLUSIONS: The introduction of a clinical decision support module resulted in higher quality of care with respect to ADHD diagnosis including a prospect for higher quality of ADHD management in children. Future work will examine how to further develop the ADHD module and add support for other chronic conditions. PMID:23958768

Bauer, Nerissa S.; Dugan, Tamara M.; Anand, Vibha; Saha, Chandan; Downs, Stephen M.

2013-01-01

42

Clinical Decision Support at Intermountain Healthcare  

Microsoft Academic Search

Decision support technologies are becoming increasingly available to medical practitioners. A variety of programs designed\\u000a to assist with drug dosing, health maintenance, diagnosis, and other clinically relevant healthcare decisions have been developed\\u000a for the medical workplace. Increasing ease of access to personal computers is partially responsible for this growth. More\\u000a important, however, is the growing dependency on computers to maintain

Peter J. Haug; Reed M. Gardner; R. Scott Evans; Beatriz H. Rocha; Roberto A. Rocha

43

Therapeutic decisions: assessing clinical fit.  

PubMed

Quality health care has been defined as the maximization of desired outcomes while minimizing undesirable consequences. Therefore, the optimal antimicrobial agent for a given clinical condition will be one that is the most rapidly effective, produces the least patient discomfort, results in minimal disruption of the patient's or hospital flora, and causes minimal dissatisfaction with the treatment program and its attendant costs. The clinical utility of antimicrobials is generally judged on the basis of in vitro activity, kinetic disposition, resistance trends, safety, and cost. Fluoroquinolones possess characteristics in each of these areas; for example, broad, potent gram-negative spectrum coupled with excellent oral absorption and tissue penetration, and relative safety and reduced cost compared with parenteral therapy. Drawbacks include the emergence of resistance among certain bacteria, particularly staphylococci and Pseudomonas aeruginosa, drug interactions that may compromise efficacy, and greater cost than other potentially useful oral antimicrobial agents. Indications for the agents' use can be categorized as appropriate (gram-negative osteomyelitis, complicated urinary tract infection, prostatitis, certain sexually transmitted diseases, bacterial gastroenteritis), potential (gastrointestinal tract decontamination in granulocytopenic patients, exacerbations of chronic obstructive pulmonary disease, nosocomial pneumonia and bacteremia, eradication of certain bacterial carrier states), or inappropriate (community-acquired pulmonary infections, especially aspiration pneumonitis, serious gram-positive infections, uncomplicated urinary tract infection, surgical prophylaxis except prostatic surgery). Gram-negative osteomyelitis serves as a model to demonstrate the fluoroquinolones as agents for quality health care. Current and future investigations should focus on the cost effectiveness and cost utility of the agents. PMID:8474933

Barriere, S L

1993-01-01

44

The Effect of Level of Patient Acuity, Critical Care Experience, and ACLS Certification on Clinical Decision Making: Implications for Computer Decision Support Systems  

PubMed Central

This study examined the effect of patient acuity, critical care experience, and ACLS certification on clinical decision making. Each subject (N=68) completed two computerized clinical simulations. Ventricular tachycardia (VT) represented the high acuity situation and atrial flutter (AF) the lower acuity situation. Clinical decision making was measured by proficiency score, patient outcome (cure/die), and amount of data collected. In the AF simulation, proficiency scores were higher (p=.000), more dysrhythmias were cured (p<.005), and more data were collected (p=.040) than in the VT simulation. Experienced and inexperienced nurses did not differ on proficiency score, however, inexperienced nurses collected more data (p=.048) and cured fewer atrial flutter simulations (p=.04). ACLS certified nurses had higher proficiency scores (p=.033) and collected less data (p=.048). Clinical decision making on two simulations was affected by patient acuity, critical care experience, and ACLS certification. These findings have implications for the design and implementation of clinical decision support systems.

Henry, Suzanne Bakken

1990-01-01

45

Clinical decision rules: how to use them  

Microsoft Academic Search

The first of this pair of papers outlined what a clinical decision rule is and how one should be created. This section examines how to use a rule, by checking that it is likely to work (examining how it has been validated), understanding what the various numbers that tell us about “accuracy” mean, and considers some practical aspects of how

B Phillips

2010-01-01

46

A Hierarchical Computer Network: An Alternative Approach to Clinical Laboratory Computerization in a Large Hospital  

PubMed Central

Computerized data handling is recognized as an essential aspect of the modern clinical laboratory in medium and large sized hospitals. However, most currently installed proprietary or “turnkey” systems are often hardware/software-constrained and based on outmoded design concepts which seriously limit the use of the laboratory computer system as an effective patient care, research, and management tool. These short-comings are particularly serious in the large university teaching hospital. Recent improvements in the price/performance ratio for computer hardware, the availability of specialized high-level applications-oriented languages, and advances in data communications have permitted development of powerful computer networks which are economically feasible in the large hospital setting. An operational three-tiered hierarchical network for clinical laboratory data processing is described. The integration of the clinical laboratory data processing function into overall institutional information processing, details of the computer system configuration, and the benefits realized are discussed.

Miller, Robert E.; Steinbach, Glen L.; Dayhoff, Ruth E.

1980-01-01

47

Clinical systems  

Microsoft Academic Search

The computerization of clinical care is needed for several reasons. Paper records cannot efficiently support new models of care, clinical governance, or clinical decision-making; and they are not always available. The British Government's strategy for computerizing the NHS in England is embodied in the National Programme for Information Technology (NPfIT). Modern, patient-centric, electronic patient record systems that incorporate clinical decision-support

Anthony P Madden

2004-01-01

48

Computerized scintigraphic technique for the evaluation of adult respiratory distress syndrome: initial clinical trials  

SciTech Connect

Eleven patients with suspected adult respiratory distress syndrome (ARDS) and five control patients were studied using a computerized gamma imaging and analysis technique and /sup 99m/Tc-labeled human serum albumin. The heart and right lung were imaged, lung:heart ratio was plotted vs. time, and a linear regression was fitted to the data points displayed. The slope of this fit was termed the ''slope index.'' An index value of 2 standard deviations greater than the control mean was considered positive. Radiographs from the six positive studies revealed typical diffuse air-space disease. Radiographs from two of the five negative studies demonstrated air-space consolidation. Both of these patients had elevated pulmonary capillary wedge pressure, cardiomegaly, and clinical course consistent with cardiogenic pulmonary edema. These preliminary data demonstrated a good correlation between positive slope index and clinical ARDS.

Tatum, J.L.; Burke, T.S.; Sugerman, H.T.; Strash, A.M.; Hirsch, J.I.; Fratkin, M.J.

1982-04-01

49

Computerized scintigraphic technique for the evaluation of adult respiratory distress syndrome: initial clinical trials  

SciTech Connect

Eleven patients with suspected adult respiratory distress syndrome (ARDS) and five control patients were studied using a computerized gamma imaging and analysis technique and 99mTc-labeled human serum albumin. The heart and right lung were imaged, lung:heart ratio was plotted vs. time, and a linear regression was fitted to the data points displayed. The slope of this fit was termed the ''slope index.'' An index value of 2 standard deviations greater than the control mean was considered positive. Radiographs from the six positive studies revealed typical diffuse air-space disease. Radiographs from two of the five negative studies demonstrated air-space consolidation. Both of these patients had elevated pulmonary capillary wedge pressure, cardiomegaly, and clinical course consistent with cardiogenic pulmonary edema. These preliminary data demonstrated a good correlation between positive slope index and clinical ARDS.

Tatum, J.L.; Burke, T.S.; Sugerman, H.J.; Strash, A.M.; Hirsch, J.I.; Fratkin, M.J.

1982-04-01

50

Clinical decision making on extensive molar restorations.  

PubMed

SUMMARY Extensive loss of posterior tooth substance, which traditionally was restored with amalgam or indirect restorations, is more commonly being restored with resin-based composite restorations. Using a questionnaire, we aimed to survey dentists' clinical decision making when restoring extensive defects in posterior molar teeth. The questionnaire, which included questions on background information from the dentists, clinical cases with treatment options, and general questions about restoring extensive posterior defects, was sent to 476 dentists. The response rate was 59%. Multiple logistic regressions were used to investigate the different associations. Most of the respondents preferred a direct composite restoration when one cusp was missing, while indirect restorations were most preferred when replacing three or four cusps. Younger dentists and dentists working in the private sector had a greater tendency to choose an indirect technique compared with older colleagues. Generally, the most important influencing factor in clinical decision making was the amount of remaining tooth substance. Factors that appeared to be less important were dental advertisements, use of fluoride, and dietary habits. Female dentists perceived factors such as oral hygiene, patient requests, and economy to be more important than did their male colleagues. PMID:24828135

Laegreid, T; Gjerdet, Nr; Johansson, A; Johansson, A-K

2014-01-01

51

Ontology Engineering to Model Clinical Pathways: Towards the Computerization and Execution of Clinical Pathways  

Microsoft Academic Search

Clinical pathways translate evidence-based recommendations into locally practicable, process-specific algorithms that reduce practice variations and optimize quality of care. Our objective was to abstract practice-oriented knowledge from a cohort of real clinical pathways and represent this knowledge as a clinical pathway ontology. We employed a four step methodology: (1) knowledge source identification and classification of clinical pathways according to variations

Katrina F. Hurley; Syed Sibte Raza Abidi

2007-01-01

52

Clinical Decision Support: Effectiveness in Improving Quality Processes and Clinical Outcomes and Factors That May Influence Success  

PubMed Central

The use of electronic health records has skyrocketed following the 2009 HITECH Act, which provides financial incentives to health care providers for the “meaningful use” of electronic medical record systems. An important component of the “Meaningful Use” legislation is the integration of Clinical Decision Support Systems (CDSS) into the computerized record, providing up-to-date medical knowledge and evidence-based guidance to the physician at the point of care. As reimbursement is increasingly tied to process and clinical outcomes, CDSS will be integral to future medical practice. Studies of CDSS indicate improvement in preventive services, appropriate care, and clinical and cost outcomes with strong evidence for CDSS effectiveness in process measures. Increasing provider adherence to CDSS recommendations is essential in improving CDSS effectiveness, and factors that influence adherence are currently under study. PMID:24910564

Murphy, Elizabeth V.

2014-01-01

53

Clinical decision-making and pediatric bipolar disorder.  

E-print Network

?? Clinical decision-making in mental health could greatly benefit from evidence-based decision tools, particularly in diagnosing challenging, high-stakes conditions such as pediatric bipolar disorder. The… (more)

Jenkins, Melissa M.

2010-01-01

54

The Computerized Medical Record as a Tool for Clinical Governance in Australian Primary Care  

PubMed Central

Background Computerized medical records (CMR) are used in most Australian general practices. Although CMRs have the capacity to amalgamate and provide data to the clinician about their standard of care, there is little research on the way in which they may be used to support clinical governance: the process of ensuring quality and accountability that incorporates the obligation that patients are treated according to best evidence. Objective The objective of this study was to explore the capability, capacity, and acceptability of CMRs to support clinical governance. Methods We conducted a realist review of the role of seven CMR systems in implementing clinical governance, developing a four-level maturity model for the CMR. We took Australian primary care as the context, CMR to be the mechanism, and looked at outcomes for individual patients, localities, and for the population in terms of known evidence-based surrogates or true outcome measures. Results The lack of standardization of CMRs makes national and international benchmarking challenging. The use of the CMR was largely at level two of our maturity model, indicating a relatively simple system in which most of the process takes place outside of the CMR, and which has little capacity to support benchmarking, practice comparisons, and population-level activities. Although national standards for coding and projects for record access are proposed, they are not operationalized. Conclusions The current CMR systems can support clinical governance activities; however, unless the standardization and data quality issues are addressed, it will not be possible for current systems to work at higher levels. PMID:23939340

Phillips, Christine; Hall, Sally; Travaglia, Joanne

2013-01-01

55

Designing an automated clinical decision support system to match clinical practice guidelines for opioid therapy for chronic pain  

PubMed Central

Background Opioid prescribing for chronic pain is common and controversial, but recommended clinical practices are followed inconsistently in many clinical settings. Strategies for increasing adherence to clinical practice guideline recommendations are needed to increase effectiveness and reduce negative consequences of opioid prescribing in chronic pain patients. Methods Here we describe the process and outcomes of a project to operationalize the 2003 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Non-Cancer Pain into a computerized decision support system (DSS) to encourage good opioid prescribing practices during primary care visits. We based the DSS on the existing ATHENA-DSS. We used an iterative process of design, testing, and revision of the DSS by a diverse team including guideline authors, medical informatics experts, clinical content experts, and end-users to convert the written clinical practice guideline into a computable algorithm to generate patient-specific recommendations for care based upon existing information in the electronic medical record (EMR), and a set of clinical tools. Results The iterative revision process identified numerous and varied problems with the initially designed system despite diverse expert participation in the design process. The process of operationalizing the guideline identified areas in which the guideline was vague, left decisions to clinical judgment, or required clarification of detail to insure safe clinical implementation. The revisions led to workable solutions to problems, defined the limits of the DSS and its utility in clinical practice, improved integration into clinical workflow, and improved the clarity and accuracy of system recommendations and tools. Conclusions Use of this iterative process led to development of a multifunctional DSS that met the approval of the clinical practice guideline authors, content experts, and clinicians involved in testing. The process and experiences described provide a model for development of other DSSs that translate written guidelines into actionable, real-time clinical recommendations. PMID:20385018

2010-01-01

56

Clinical knowledge management at scale: fulfilling the promise of pervasive  

E-print Network

Clinical knowledge management at scale: fulfilling the promise of pervasive computerized clinical. Corporate Manager Clinical Knowledge Management and Decision Support, Clinical Informatics Research and application results 2. Clinical Knowledge Management System Typical knowledge engineering processes

Gabrieli, John

57

'Too much, too late': mixed methods multi-channel video recording study of computerized decision support systems and GP prescribing  

PubMed Central

Objective Computerized decision support systems (CDSS) are commonly deployed to support prescribing, although over-riding of alerts by prescribers remains a concern. We aimed to understand how general practitioners (GPs) interact with prescribing CDSS in order to inform deliberation on how better to support prescribing decisions in primary care. Materials and methods Quantitative and qualitative analysis of interactions between GPs, patients, and computer systems using multi-channel video recordings of 112 primary care consultations with eight GPs in three UK practices. Results 132 prescriptions were issued in the course of 73 of the consultations, of which 81 (61%) attracted at least one alert. Of the total of 117 alerts, only three resulted in the GP checking, but not altering, the prescription. CDSS provided information and safety alerts at the point of generating a prescription. This was ‘too much, too late’ as the majority of the ‘work’ of prescribing occurred prior to using the computer. By the time an alert appeared, the GP had formulated the problem(s), potentially spent several minutes considering, explaining, negotiating, and reaching agreement with the patient about the proposed treatment, and had possibly given instructions and printed an information leaflet. Discussion CDSS alerts do not coincide with the prescribing workflow throughout the whole GP consultation. Current systems interrupt to correct decisions that have already been taken, rather than assisting formulation of the management plan. Conclusions CDSS are likely to be more acceptable and effective if the prescribing support is provided much earlier in the process of generating a prescription. PMID:23470696

Hayward, James; Thomson, Fionagh; Milne, Heather; Buckingham, Susan; Sheikh, Aziz; Fernando, Bernard; Cresswell, Kathrin; Williams, Robin; Pinnock, Hilary

2013-01-01

58

Clinical decision support: progress and opportunities  

PubMed Central

In 2005, the American Medical Informatics Association undertook a set of activities relating to clinical decision support (CDS), with support from the office of the national coordinator and the Agency for Healthcare Research and Quality. They culminated in the release of the roadmap for national action on CDS in 2006. This article assesses progress toward the short-term goals within the roadmap, and recommends activities to continue to improve CDS adoption throughout the United States. The report finds that considerable progress has been made in the past four?years, although significant work remains. Healthcare quality organizations are increasingly recognizing the role of health information technology in improving care, multi-site CDS demonstration projects are under way, and there are growing incentives for adoption. Specific recommendations include: (1) designating a national entity to coordinate CDS work and collaboration; (2) developing approaches to monitor and track CDS adoption and use; (3) defining and funding a CDS research agenda; and (4) updating the CDS ‘critical path’. PMID:20819850

Cohn, Wendy F; Bloomrosen, Meryl; Detmer, Don E

2010-01-01

59

Evaluating informatics applications - clinical decision support systems literature review  

Microsoft Academic Search

This paper reviews clinical decision support systems (CDSS) literature, with a focus on evaluation. The literature indicates a general consensus that clinical decision support systems are thought to have the potential to improve care. Evidence is more equivocal for guidelines and for systems to aid physicians with diagnosis. There also is general consensus that a variety of systems are little

Bonnie Kaplan

2001-01-01

60

Clinical Decision Support Systems Governance and the Pharmacy Department  

PubMed Central

The Meaningful Use criteria include a variety of core requirements that all electronic health record systems must demonstrate. An increasing level of functionality from clinical decision support systems is one of those requirements. In this article, we discuss general and specific aspects of clinical decision support systems, including potential roles for pharmacy in governance. PMID:24421527

Fox, Brent I.; Felkey, Bill G.

2013-01-01

61

Reducing Diagnostic Error with Computer-Based Clinical Decision Support  

ERIC Educational Resources Information Center

Information technology approaches to delivering diagnostic clinical decision support (CDS) are the subject of the papers to follow in the proceedings. These will address the history of CDS and present day approaches (Miller), evaluation of diagnostic CDS methods (Friedman), and the role of clinical documentation in supporting diagnostic decision

Greenes, Robert A.

2009-01-01

62

Incorporation of clinical data into a computerized method for the assessment of mammographic breast lesions  

NASA Astrophysics Data System (ADS)

We previously developed a computerized method to classify mammographic masses as benign or malignant. In this method, mammographic features that are similar to the ones used by radiologists are automatically extracted to characterize a mass lesion. These features are then merged by an artificial neural network (ANN), which yields an estimated likelihood of malignancy for each mass. The performance of the method was evaluated on an independent database consisting of 110 cases (60 benign and 50 malignant cases). The method achieved an Az of 0.91 from round-robin analysis in the task of differentiating between benign and malignant masses using the computer-extracted features only. As the most important clinical risk factor for breast cancer, age achieved a performance level (Az equals 0.79) similar to that (Az equals 0.77 and 0.80) of the computer-extracted spiculation features, which are the most important indicators for malignancy of a mass, in differentiating between the malignant and benign cases. In this study, age is included as an additional input feature to the ANN. The performance of the scheme (Az equals 0.93) is improved when age is included. However, the improvement is not found to be statistically significant. Our results indicated that age may be a strong feature in predicting malignancy of a mass. For this database, however, the inclusion of age may not have a strong impact on the determination of the likelihood for a mammographic mass lesion when the major mammographic characteristics (e.g., spiculation) of a mass are accurately extracted and analyzed along with other features using an artificial neural network.

Huo, Zhimin; Giger, Maryellen L.

2000-06-01

63

Electronic information and clinical decision support for prescribing: state of play in Australian general practice  

PubMed Central

Background. Investments in eHealth worldwide have been mirrored in Australia, with >90% of general practices computerized. Recent eHealth incentives promote the use of up to date electronic information sources relevant to general practice with flexibility in mode of access. Objective. To determine GPs’ access to and use of electronic information sources and computerized clinical decision support systems (CDSSs) for prescribing. Methods. Semi-structured interviews were conducted with 18 experienced GPs and nine GP trainees in New South Wales, Australia in 2008. A thematic analysis of interview transcripts was undertaken. Results. Information needs varied with clinical experience, and people resources (specialists, GP peers and supervisors for trainees) were often preferred over written formats. Experienced GPs used a small number of electronic resources and accessed them infrequently. Familiarity from training and early clinical practice and easy access were dominant influences on resource use. Practice time constraints meant relevant information needed to be readily accessible during consultations, requiring integration or direct access from prescribing software. Quality of electronic resource content was assumed and cost a barrier for some GPs. Conclusions. The current Australian practice incentives do not prescribe which information resources GPs should use. Without integration into practice computing systems, uptake and routine use seem unlikely. CDSS developments must recognize the time pressures of practice, preference for integration and cost concerns. Minimum standards are required to ensure that high-quality information resources are integrated and regularly updated. Without standards, the anticipated benefits of computerization on patient safety and health outcomes will be uncertain. PMID:21109619

Robertson, Jane; Moxey, Annette J; Newby, David A; Gillies, Malcolm B; Williamson, Margaret; Pearson, Sallie-Anne

2011-01-01

64

The Effect of Computerized Physician Order Entry and Decision Support System on Medication Errors in the Neonatal Ward: Experiences from an Iranian Teaching Hospital  

Microsoft Academic Search

Medication dosing errors are frequent in neonatal wards. In an Iranian neonatal ward, a 7.5 months study was designed in three\\u000a periods to compare the effect of Computerized Physician Order Entry (CPOE) without and with decision support functionalities in reducing non-intercepted medication dosing errors in antibiotics and anticonvulsants.\\u000a Before intervention (Period 1), error rate was 53%, which did not significantly change

Alireza Kazemi; Johan Ellenius; Faramarz Pourasghar; Shahram Tofighi; Aref Salehi; Ali Amanati; Uno G. H. Fors

2011-01-01

65

Provider perceptions of colorectal cancer screening clinical decision support at three benchmark institutions.  

PubMed

Implementation of computerized clinical decision support (CDS), and its integration into workflow has not reached its potential. To better understand the use of CDS for colorectal cancer (CRC) screening at benchmark institutions for health information technology (HIT), we conducted direct observation, including opportunistic interviews of primary care providers, as well as key informant interviews and focus groups, to document current challenges to CRC screening and follow-up at clinics affiliated with the Veterans Heath Administration, Regenstrief Institute, and Partners HealthCare System. Analysis revealed six common barriers across institutions from the primary care providers' perspective: receiving and documenting "outside" exam results, inaccuracy of the CDS, compliance issues, poor usability, lack of coordination between primary care and gastroenterology, and the need to attend to more urgent patient issues. Strategies should be developed to enhance current HIT to address these challenges and better support primary care providers and staff. PMID:20351917

Saleem, Jason J; Militello, Laura G; Arbuckle, Nicole; Flanagan, Mindy; Haggstrom, David A; Linder, Jeffrey A; Doebbeling, Bradley N

2009-01-01

66

How Doctors and Patients Discuss Routine Clinical Decisions  

PubMed Central

OBJECTIVE To characterize the informed consent process in routine, primary care office practice. DESIGN Cross-sectional, descriptive evaluation of audiotaped encounters. SETTING Offices of primary care physicians in Portland, Oregon. PARTICIPANTS Internists (54%) and family physicians (46%), and their patients. MEASUREMENTS AND MAIN RESULTS Audiotapes of primary care office visits from a previous study of doctor-patient communication were coded for the number and type of clinical decisions made. The discussion between doctor and patient was scored according to six criteria for informed decision making: description of the nature of the decision, discussion of alternatives, discussion of risks and benefits, discussion of related uncertainties, assessment of the patient’s understanding and elicitation of the patient’s preference. Discussions leading to decisions included fewer than two of the six described elements of informed decision making (mean 1.23, median 1.0), most frequent of these was description of the nature of the decision (83% of discussion). Discussion of risks and benefits was less frequent (9%), and assessment of understanding was rare (2%). Discussions of management decisions were generally more substantive than discussions of diagnostic decisions (p = .05). CONCLUSIONS Discussions leading to clinical decisions in these primary care settings did not fulfill the criteria considered integral to informed decision making. Physicians frequently described the nature of the decision, less frequently discussed risks and benefits, and rarely assessed the patient’s understanding of the decision. PMID:9192250

Braddock, Clarence H; Fihn, Stephan D; Levinson, Wendy; Jonsen, Albert R; Pearlman, Robert A

1997-01-01

67

JOURNAL CLUB: Requiring Clinical Justification to Override Repeat Imaging Decision Support: Impact on CT Use.  

PubMed

OBJECTIVE. The purpose of this study was to determine the impact of requiring clinical justification to override decision support alerts on repeat use of CT. SUBJECTS AND METHODS. This before and after intervention study was conducted at a 793-bed tertiary hospital with computerized physician order entry and clinical decision support systems. When a CT order is placed, decision support alerts the orderer if the patient's same body part has undergone CT within the past 90 days. The study cohort included all 28,420 CT orders triggering a repeat alert in 2010. The intervention required clinical justification, selected from a predetermined menu, to override repeat CT decision support alerts to place a CT order; otherwise the order could not be placed and was dropped. The primary outcome, dropped repeat CT orders, was analyzed using three methods: chi-square tests to compare proportions dropped before and after intervention; multiple logistic regression tests to control for orderer, care setting, and patient factors; and statistical process control for temporal trends. RESULTS. The repeat CT order drop rate had an absolute increase of 1.4%; 6.1% (682/11,230) before to 7.5% (1290/17,190) after intervention, which was a 23% relative change (7.5 - 6.1) / 6.1 × 100 = 23%; p < 0.0001). Orders were dropped more often after intervention (odds ratio, 1.3; 95% CI, 1.1-1.4; p < 0.0001). Statistical control analysis supported the association between the increase in the drop rate with intervention rather than underlying trends. CONCLUSION. Adding a requirement for clinical justification to override alerts modestly but significantly improves the impact of repeat CT decision support (23% relative change), with the overall effect of preventing one in 13 repeat CT orders. PMID:25341162

O'Connor, Stacy D; Sodickson, Aaron D; Ip, Ivan K; Raja, Ali S; Healey, Michael J; Schneider, Louise I; Khorasani, Ramin

2014-11-01

68

Clinical decision support for imaging in the era of the Patient Protection and Affordable Care Act.  

PubMed

Imaging clinical decision support (CDS) systems provide evidence for or against imaging procedures ordered within a computerized physician order entry system at the time of the image order. Depending on the pertinent clinical history provided by the ordering clinician, CDS systems can optimize imaging by educating providers on appropriate image order entry and by alerting providers to the results of prior, potentially relevant imaging procedures, thereby reducing redundant imaging. The American Recovery and Reinvestment Act (ARRA) has expedited the adoption of computerized physician order entry and CDS systems in health care through the creation of financial incentives and penalties to promote the "meaningful use" of health IT. Meaningful use represents the latest logical next step in a long chain of legislation promoting the areas of appropriate imaging utilization, accurate reporting, and IT. It is uncertain if large-scale implementation of imaging CDS will lead to improved health care quality, as seen in smaller settings, or to improved patient outcomes. However, imaging CDS enables the correlation of existing imaging evidence with outcome measures, including morbidity, mortality, and short-term imaging-relevant management outcomes (eg, biopsy, chemotherapy). The purposes of this article are to review the legislative sequence relevant to imaging CDS and to give guidance to radiology practices focused on quality and financial performance improvement during this time of accelerating regulatory change. PMID:23206649

Zafar, Hanna M; Mills, Angela M; Khorasani, Ramin; Langlotz, Curtis P

2012-12-01

69

Impact of Computerized Physician Order Entry on Clinical Practice in a Newborn Intensive Care Unit  

Microsoft Academic Search

OBJECTIVE: To study the impact of computerized physician order entry (CPOE) on selected neonatal intensive care unit (NICU) practices.DESIGN: Retrospective review.SETTING: Nursing units in an academic health system where CPOE has been implemented in adult services since 2000 and in the NICU since 2002.STUDY POPULATION: Data from 111 very-low-birth-weight (VLBW) infants born consecutively within 6 months before and 100 VLBW

Leandro Cordero; Lynn Kuehn; Rajee R Kumar; Hagop S Mekhjian

2004-01-01

70

A Framework and Model for Evaluating Clinical Decision Support Architectures  

PubMed Central

In this paper, we develop a four-phase model for evaluating architectures for clinical decision support that focuses on: defining a set of desirable features for a decision support architecture; building a proof-of-concept prototype; demonstrating that the architecture is useful by showing that it can be integrated with existing decision support systems and comparing its coverage to that of other architectures. We apply this framework to several well-known decision support architectures, including Arden Syntax, GLIF, SEBASTIAN and SAGE PMID:18462999

Wright, Adam; Sittig, Dean F.

2008-01-01

71

Computerized Physician Order Entry  

PubMed Central

Computerized physician order entry (CPOE) has been promoted as an important component of patient safety, quality improvement, and modernization of medical practice. In practice, however, CPOE affects health care delivery in complex ways, with benefits as well as risks. Every implementation of CPOE is associated with both generally recognized and unique local factors that can facilitate or confound its rollout, and neurohospitalists will often be at the forefront of such rollouts. In this article, we review the literature on CPOE, beginning with definitions and proceeding to comparisons to the standard of care. We then proceed to discuss clinical decision support systems, negative aspects of CPOE, and cultural context of CPOE implementation. Before concluding, we follow the experiences of a Chief Medical Information Officer and neurohospitalist who rolled out a CPOE system at his own health care organization and managed the resulting workflow changes and setbacks. PMID:24381708

Khanna, Raman; Yen, Tony

2014-01-01

72

Medical Decision Making in Clinical Care: Avoiding Common Errors  

E-print Network

4/8/13 1 Medical Decision Making in Clinical Care: Avoiding Common Errors Misbah Keen, MD, MBI, MPH S2 - S23 #12;4/8/13 3 Heuristics · Heuristics are mental processes which we use every day in medical to mind. Availability Error ì Examples of Availability Error in Clinical SeCngs ì

Maxwell, Bruce D.

73

Mining Diabetes Complication and Treatment Patterns for Clinical Decision Support  

E-print Network

Mining Diabetes Complication and Treatment Patterns for Clinical Decision Support Lu Liu , Jie Tang to utilize the heterogeneous medical records to aid the clinical treatments of diabetes mellitus. Diabetes mellitus, simply diabetes, is a group of metabolic diseases, which is often accompa- nied with many

74

Improving clinical decisions and outcomes with information: a review  

Microsoft Academic Search

The clinical information available to clinicians is expanding rapidly. It can enhance clinical decision-making, but it can also confuse the process. To be most useful, information should be available at the time and place it is needed and be specific to the task at hand. In the new paradigm of medicine, one based on continuous quality improvement, useful information must

William M. Tierney

2001-01-01

75

Clinical Factors and the Decision to Transfuse Chronic Dialysis Patients  

PubMed Central

Summary Background and objectives Red blood cell transfusion was previously the principle therapy for anemia in CKD but became less prevalent after the introduction of erythropoiesis-stimulating agents. This study used adaptive choice-based conjoint analysis to identify preferences and predictors of transfusion decision-making in CKD. Design, setting, participants, & measurements A computerized adaptive choice-based conjoint survey was administered between June and August of 2012 to nephrologists, internists, and hospitalists listed in the American Medical Association Masterfile. The survey quantified the relative importance of 10 patient attributes, including hemoglobin levels, age, occult blood in stool, severity of illness, eligibility for transplant, iron indices, erythropoiesis-stimulating agents, cardiovascular disease, and functional status. Triggers of transfusions in common dialysis scenarios were studied, and based on adaptive choice-based conjoint-derived preferences, relative importance by performing multivariable regression to identify predictors of transfusion preferences was assessed. Results A total of 350 providers completed the survey (n=305 nephrologists; mean age=46 years; 21% women). Of 10 attributes assessed, absolute hemoglobin level was the most important driver of transfusions, accounting for 29% of decision-making, followed by functional status (16%) and cardiovascular comorbidities (12%); 92% of providers transfused when hemoglobin was 7.5 g/dl, independent of other factors. In multivariable regression, Veterans Administration providers were more likely to transfuse at 8.0 g/dl (odds ratio, 5.9; 95% confidence interval, 1.9 to 18.4). Although transplant eligibility explained only 5% of decision-making, nephrologists were five times more likely to value it as important compared with non-nephrologists (odds ratio, 5.2; 95% confidence interval, 2.4 to11.1). Conclusions Adaptive choice-based conjoint analysis was useful in predicting influences on transfusion decisions. Hemoglobin level, functional status, and cardiovascular comorbidities most strongly influenced transfusion decision-making, but preference variations were observed among subgroups. PMID:23929931

Whitman, Cynthia B.; Shreay, Sanatan; Gitlin, Matthew; van Oijen, Martijn G. H.

2013-01-01

76

Virtual medical record implementation for enhancing clinical decision support.  

PubMed

Development of clinical decision support systems (CDS) is a process which highly depends on the local databases, this resulting in low interoperability. To increase the interoperability of CDS a standard representation of clinical information is needed. The paper suggests a CDS architecture which integrates several HL7 standards and the new vMR (virtual Medical Record). The clinical information for the CDS systems (the vMR) is represented with Topic Maps technology. Beside the implementation of the vMR, the architecture integrates: a Data Manager, an interface, a decision making system (based on Egadss), a retrieving data module. Conclusions are issued. PMID:22874164

Gomoi, Valentin-Sergiu; Dragu, Daniel; Stoicu-Tivadar, Vasile

2012-01-01

77

ORIGINAL CONTRIBUTION Clinical Decision Support and  

E-print Network

new antimicro- bial agent development.1 Overuse of an- timicrobial agents fosters the spread infections and therefore are not clinically indicated.9-12 Behavioral fa- cilitators of antimicrobial overuse in the antibiotics "never-indicated" category during the post- intervention period was 32% in CDSS communities and 5

Campbell, A. Malcolm

78

Cognitive elements in clinical decision-making  

Microsoft Academic Search

Physician cognition, metacognition and affect may have an impact upon the quality of clinical reasoning. The purpose of this\\u000a study was to examine the relationship between measures of physician metacognition and affect and patient outcomes in obstetric\\u000a practice. Reflective coping (RC), proactive coping, need for cognition (NFC), tolerance for ambiguity, state-trait anxiety\\u000a and metacognitive awareness were assessed for obstetricians (n = 12)

Bruce C. Dunphy; Robert Cantwell; Sid Bourke; Mark Fleming; Bruce Smith; K. S. Joseph; Stacey L. Dunphy

2010-01-01

79

A Computerized Information System Model for Decision Making for the Oklahoma State Department of Vocational and Technical Education.  

ERIC Educational Resources Information Center

The objectives of the study presented in the dissertation were to identify present and anticipated information requirements of the various departments within the Oklahoma State Department of Vocational and Technical Education, to design a computerized information system model utilizing an integrated systems concept to meet information…

Smith, Hubert Gene

80

Clinical Decision Making in Renal Pain Management  

PubMed Central

Objectives: To determine the optimal medication for the treatment of renal colic using evidence based medicine (EBM) parameters (RR, ARR, NNT, NNH, ARI, RRI). Sample and Methodology: During 2010, an ITT study was conducted on 400 outpatients of the Sarajevo University Clinical Center Urology Clinic in order to investigate renal colic pain relief drugs. Each group consisting of 100 patients was administered either Metamizol amp. i.v., or Diclofenac amp. i.m., or Butylscopolamine amp. i.v., while 100 patients belonged to the placebo group that was given distilled water (aqua redestilata). All patients completed visual analogue pain scale (VAPS) from 0 to 10 prior to and after the treatment. Results: Using EBM parameters Diclofenac Na and Metamizol were shown to be the most efficient in the treatment of renal colic. In these two groups, relative risk (RR) was 21 and 8,5% respectively; Absolute Risk Reduction (ARR) was 74 and 86% respectively, and Number Needed to Treat (NNT) was 1 for both groups, while chi-squared (X2) test has shown that there is no statistically significant difference between these two drugs when it comes to their effect. In the Butylscopolamine group, RR was 81; ARR 18%, while NNT was 5. With respect to side effects, only in his group it was shown that Relative Risk Increase (RRI) was 84, ARI 83%, while Number Needed to Harm (NNH) was 2. Conclusion: The most optimal medication for the treatment of renal colic according to EBM parameters is Diclofenac Na, followed by Metamizol. Butylscopolamine is not recommended for the treatment of renal colic. PMID:23322949

Aganovic, Damir; Prcic, Alen; Kulovac, Benjamin; Hadziosmanovic, Osman

2012-01-01

81

Operationalizing Prostate Cancer Clinical Pathways: An Ontological Model to Computerize, Merge and  

E-print Network

to be operationalized as a decision-support and care planning tool at the point-of-care. We applied a knowledge man be executed through a logic-based engine to realize a point-of-care decision-support system for managing prostate cancer care. 1 INTRODUCTION Prostate cancer is the most common type of cancer among Cana- dian men

Abidi, Syed Sibte Raza

82

The role of emotions in clinical reasoning and decision making.  

PubMed

What role, if any, should emotions play in clinical reasoning and decision making? Traditionally, emotions have been excluded from clinical reasoning and decision making, but with recent advances in cognitive neuropsychology they are now considered an important component of them. Today, cognition is thought to be a set of complex processes relying on multiple types of intelligences. The role of mathematical logic (hypothetico-deductive thinking) or verbal linguistic intelligence in cognition, for example, is well documented and accepted; however, the role of emotional intelligence has received less attention-especially because its nature and function are not well understood. In this paper, I argue for the inclusion of emotions in clinical reasoning and decision making. To that end, developments in contemporary cognitive neuropsychology are initially examined and analyzed, followed by a review of the medical literature discussing the role of emotions in clinical practice. Next, a published clinical case is reconstructed and used to illustrate the recognition and regulation of emotions played during a series of clinical consultations, which resulted in a positive medical outcome. The paper's main thesis is that emotions, particularly in terms of emotional intelligence as a practical form of intelligence, afford clinical practitioners a robust cognitive resource for providing quality medical care. PMID:23975905

Marcum, James A

2013-10-01

83

Statistical decisions and the interim analyses of clinical trials.  

PubMed

This paper analyzes statistical decisions during the interim analyses of clinical trials. After some general remarks about the ethical and scientific demands of clinical trials, I introduce the notion of a hard-case clinical trial, explain the basic idea behind it, and provide a real example involving the interim analyses of zidovudine in asymptomatic HIV-infected patients. The example leads me to propose a decision analytic framework for handling ethical conflicts that might arise during the monitoring of hard-case clinical trials. I use computer simulations to show how the framework can assist in reconciling certain ethical conflicts. The framework is partial, lacking the precision of a complete systematization of statistical monitoring procedures in practice. PMID:21222041

Stanev, Roger

2011-02-01

84

Evaluating the decision accuracy and speed of clinical data visualizations  

PubMed Central

Clinicians face an increasing volume of biomedical data. Assessing the efficacy of systems that enable accurate and timely clinical decision making merits corresponding attention. This paper discusses the multiple-reader multiple-case (MRMC) experimental design and linear mixed models as means of assessing and comparing decision accuracy and latency (time) for decision tasks in which clinician readers must interpret visual displays of data. These tools can assess and compare decision accuracy and latency (time). These experimental and statistical techniques, used extensively in radiology imaging studies, offer a number of practical and analytic advantages over more traditional quantitative methods such as percent-correct measurements and ANOVAs, and are recommended for their statistical efficiency and generalizability. An example analysis using readily available, free, and commercial statistical software is provided as an appendix. While these techniques are not appropriate for all evaluation questions, they can provide a valuable addition to the evaluative toolkit of medical informatics research. PMID:20190060

Finkelstein, Stanley M

2010-01-01

85

Using Clinical Decision Support Software in Health Insurance Company  

NASA Astrophysics Data System (ADS)

This paper proposes the idea to use Clinical Decision Support software in Health Insurance Company as a tool to reduce the expenses related to Medication Errors. As a prove that this class of software will help insurance companies reducing the expenses, the research was conducted in eight hospitals in United Arab Emirates to analyze the amount of preventable common Medication Errors in drug prescription.

Konovalov, R.; Kumlander, Deniss

86

Can patient decision aids help people make good decisions about participating in clinical trials? A study protocol  

Microsoft Academic Search

BACKGROUND: Evidence shows that the standard process for obtaining informed consent in clinical trials can be inadequate, with study participants frequently not understanding even basic information fundamental to giving informed consent. Patient decision aids are effective decision support tools originally designed to help patients make difficult treatment or screening decisions. We propose that incorporating decision aids into the informed consent

Jamie C Brehaut; Alison Lott; Dean A Fergusson; Kaveh G Shojania; Jonathan Kimmelman; Raphael Saginur

2008-01-01

87

Standards in clinical decision support: activities in health level seven.  

PubMed

Health Level Seven (HL7) has evolved into an international standards development organization (SDO) with a suite of standards. Prominent among these are formalisms related to clinical decision support, including the Arden Syntax, GELLO and Decision Support Service (DSS) standards. Continuing improvement in these standards and ongoing development of future decision support standards require wide participation in order to maximize their success. Accordingly, the purpose of the workshop is twofold. First, instructors will convey the latest developments regarding existing decision support standards and related efforts to develop new standards. Second, the instructors will solicit feedback so that attendees who do not participate in HL7 can have input into the standards activities of that organization. The instructors of this workshop, who are the co-chairs and/or members of the Clinical Decision Support Technical Committee of HL7, will review progress in these areas. They will present the details of the ongoing development of the extant Arden Syntax, GELLO and DSS standards. They will discuss work on current draft and proposed future standards, including the Infobutton communication and Order Set standards that are undergoing development in anticipation of certification as standards. Finally, they will solicit discussion regarding the future direction of standards development in these areas. PMID:18998884

Jenders, Robert A; Jenders, Robert Allen; Del Fiol, Guilherme; Kawamoto, Kensaku; Sailors, R Matthew

2008-01-01

88

Clinical Decision Support Alert Appropriateness: A Review and Proposal for Improvement  

PubMed Central

Background Many healthcare providers are adopting clinical decision support (CDS) systems to improve patient safety and meet meaningful use requirements. Computerized alerts that prompt clinicians about drug-allergy, drug-drug, and drug-disease warnings or provide dosing guidance are most commonly implemented. Alert overrides, which occur when clinicians do not follow the guidance presented by the alert, can hinder improved patient outcomes. Methods We present a review of CDS alerts and describe a proposal to develop novel methods for evaluating and improving CDS alerts that builds upon traditional informatics approaches. Our proposal incorporates previously described models for predicting alert overrides that utilize retrospective chart review to determine which alerts are clinically relevant and which overrides are justifiable. Results Despite increasing implementations of CDS alerts, detailed evaluations rarely occur because of the extensive labor involved in manual chart reviews to determine alert and response appropriateness. Further, most studies have solely evaluated alert overrides that are appropriate or justifiable. Our proposal expands the use of web-based monitoring tools with an interactive dashboard for evaluating CDS alert and response appropriateness that incorporates the predictive models. The dashboard provides 2 views, an alert detail view and a patient detail view, to provide a full history of alerts and help put the patient's events in context. Conclusion The proposed research introduces several innovations to address the challenges and gaps in alert evaluations. This research can transform alert evaluation processes across healthcare settings, leading to improved CDS, reduced alert fatigue, and increased patient safety. PMID:24940129

McCoy, Allison B.; Thomas, Eric J.; Krousel-Wood, Marie; Sittig, Dean F.

2014-01-01

89

Mechanistic biomarkers for clinical decision making in rheumatic diseases  

PubMed Central

The use of biomarkers is becoming increasingly intrinsic to the practice of medicine and holds great promise for transforming the practice of rheumatology. Biomarkers have the potential to aid clinical diagnosis when symptoms are present or to provide a means of detecting early signs of disease when they are not. Some biomarkers can serve as early surrogates of eventual clinical outcomes or guide therapeutic decision making by enabling identification of individuals likely to respond to a specific therapy. Using biomarkers might reduce the costs of drug development by enabling individuals most likely to respond to be enrolled in clinical trials, thereby minimizing the number of participants required. In this Review, we discuss the current use and the potential of biomarkers in rheumatology and in select fields at the forefront of biomarker research. We emphasize the value of different types of biomarkers, addressing the concept of ‘actionable’ biomarkers, which can be used to guide clinical decision making, and ‘mechanistic’ biomarkers, a subtype of actionable biomarker that is embedded in disease pathogenesis and, therefore, represents a superior biomarker. We provide examples of actionable and mechanistic biomarkers currently available, and discuss how development of such biomarkers could revolutionize clinical practice and drug development. PMID:23419428

Robinson, William H.; Lindstrom, Tamsin M.; Cheung, Regina K.; Sokolove, Jeremy

2013-01-01

90

CEDRIC: A Computerized Chronic Disease Management System for Urban, Safety Net Clinics  

PubMed Central

To meet the challenge of improving health care quality in urban, medically underserved areas of the US that have a predominance of chronic diseases such as diabetes, we have developed a new information system called CEDRIC for managing chronic diseases. CEDRIC was developed in collaboration with clinicians at an urban safety net clinic, using a community-participatory partnered research approach, with a view to addressing the particular needs of urban clinics with a high physician turnover and large uninsured/underinsured patient population. The pilot implementation focuses on diabetes management. In this paper, we describe the system’s architecture and features. PMID:20841679

Ogunyemi, Omolola; Mukherjee, Sukrit; Ani, Chizobam; Hindman, David; George, Sheba; Ilapakurthi, Ramarao; Verma, Mary; Dayrit, Melvin

2011-01-01

91

Viewpoint Paper: Evaluation and Certification of Computerized Provider Order Entry Systems  

Microsoft Academic Search

Computerized physician order entry (CPOE) is an application that is used to electronically write physician orders either in the hospital or in the outpatient setting. It is used in about 15% of U.S. Hospitals and a smaller percentage of ambulatory clinics. It is linked with clinical decision support, which provides much of the value of implementing it. A number of

David C. Classen; Anthony J. Avery; David W. Bates

2007-01-01

92

Intracranial pressure monitoring in intensive care: clinical advantages of a computerized system over manual recording  

Microsoft Academic Search

INTRODUCTION: The presence of intracranial hypertension (HICP) after traumatic brain injury (TBI) affects patient outcome. Intracranial pressure (ICP) data from electronic monitoring equipment are usually calculated and recorded hourly in the clinical chart by trained nurses. Little is known, however, about how precisely this method reflects the real patterns of ICP after severe TBI. In this study, we compared hourly

Elisa Roncati Zanier; Fabrizio Ortolano; Laura Ghisoni; Angelo Colombo; Sabina Losappio; Nino Stocchetti

2007-01-01

93

Counseling About Medication-Induced Birth Defects with Clinical Decision Support in Primary Care  

PubMed Central

Abstract Background We evaluated how computerized clinical decision support (CDS) affects the counseling women receive when primary care physicians (PCPs) prescribe potential teratogens and how this counseling affects women's behavior. Methods Between October 2008 and April 2010, all women aged 18–50 years visiting one of three community-based family practice clinics or an academic general internal medicine clinic were invited to complete a survey 5–30 days after their clinic visit. Women who received prescriptions were asked if they were counseled about teratogenic risks or contraception and if they used contraception at last intercourse. Results Eight hundred one women completed surveys; 27% received a prescription for a potential teratogen. With or without CDS, women prescribed potential teratogens were more likely than women prescribed safer medications to report counseling about teratogenic risks. However, even with CDS 43% of women prescribed potential teratogens reported no counseling. In multivariable models, women were more likely to report counseling if they saw a female PCP (odds ratio: 1.97; 95% confidence interval: 1.26–3.09). Women were least likely to report counseling if they received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Women who were pregnant or trying to conceive were not more likely to report counseling. Nonetheless, women who received counseling about contraception or teratogenic risks were more likely to use contraception after being prescribed potential teratogens than women who received no counseling. Conclusions Physician counseling can reduce risk of medication-induced birth defects. However, efforts are needed to ensure that PCPs consistently inform women of teratogenic risks and provide access to highly effective contraception. PMID:23930947

Parisi, Sara M.; Handler, Steven M.; Koren, Gideon; Shevchik, Grant; Fischer, Gary S.

2013-01-01

94

Computer-Based Medical Decision Support System based on guidelines, clinical pathways and decision nodes.  

PubMed

A continuous and dynamic development of medical sciences which is currently taking place all over the world is associated with a considerable increase in the number of scientific reports and papers of importance in enhancing the effectiveness of treatment and quality of medical care. However, it is difficult, or, indeed, impossible, for physicians to regularly follow all recent innovations in medical knowledge and to apply the latest research findings to their daily clinical practice. More and more studies conducted both in Poland and worldwide as well as experience from clinical practice in various countries provide convincing evidence that various systems supporting medical decision-making by physicians or other medical professionals visibly improve the quality of medical care. The use of such systems is already possible and recently has been developing especially dynamically, as the level of knowledge and information and communication technology now permits their effective implementation. Currently, electronic knowledge bases, together with inference procedures, form intelligent medical information systems, which offer many possibilities for the support of medical decision-making, mainly in regard to interactive diagnostic work-up, but also the selection of the most suitable treatment plan (clinical pathway). Regardless of their scale and area of application, these systems are referred to as Computer-Based Medical Decision Support Systems (CBMDSS). PMID:22741924

Tomaszewski, Wies?aw

2012-01-01

95

Clinical Decision Making--A Functional Medicine Perspective  

PubMed Central

As 21st century health care moves from a disease-based approach to a more patient-centric system that can address biochemical individuality to improve health and function, clinical decision making becomes more complex. Accentuating the problem is the lack of a clear standard for this more complex functional medicine approach. While there is relatively broad agreement in Western medicine for what constitutes competent assessment of disease and identification of related treatment approaches, the complex functional medicine model posits multiple and individualized diagnostic and therapeutic approaches, most or many of which have reasonable underlying science and principles, but which have not been rigorously tested in a research or clinical setting. This has led to non-rigorous thinking and sometimes to uncritical acceptance of both poorly documented diagnostic procedures and ineffective therapies, resulting in less than optimal clinical care. PMID:24278827

2012-01-01

96

Agreement of Decision Analyses and Subsequent Clinical Studies in Infectious Diseases  

PubMed Central

Purpose: Decision analysis techniques can compare management strategies when there are insufficient data from clinical studies to guide decision-making. We compared the outcomes of decision analyses and subsequent clinical studies in the infectious disease literature to assess the validity of the conclusions of the decision analyses. Methods: A search strategy to identify decision analyses in infectious diseases topics published from 1990-2005 was developed and performed using PubMed. Abstracts of all identified articles were reviewed and infectious diseases-related decision analyses were retained. Subsequent clinical trials and observational studies that corresponded to these decision analyses were identified using pre-specified search strategies. Clinical studies were considered a match for the decision analysis if they assessed the same patient population, intervention, and outcome. Agreement or disagreement between the conclusions of the decision analysis and clinical study were determined by author review. Results: The initial PubMed search yielded 318 references. Forty decision analyses pertaining to 29 infectious diseases topics were identified. Of the 40, 16 (40%) from 13 infectious diseases topics had matching clinical studies. In 12/16 (75%), conclusions of at least one clinical study agreed with those of the decision analysis. Three of the four decision analyses in which conclusions disagreed were from the same topic (management of febrile children). Conclusions: There was substantial agreement between the conclusions of decision analyses and clinical studies in infectious diseases, supporting the validity of decision analysis and its utility in guiding management decisions. PMID:17466659

Bress, Joshua N.; Hulgan, Todd; Lyon, Jennifer A.; Johnston, Cecilia P.; Lehmann, Harold; Sterling, Timothy R.

2007-01-01

97

Using a mock trial to make a difficult clinical decision.  

PubMed

Many clinical decisions have to be taken with inadequate scientific information. Reaching a consensus among experts has been tried as one response to this problem. Another, described here, is to use legal process to dissect a difficult question. In this case a mock trial--using barristers, expert witnesses, and a jury--was conducted on whether bone marrow transplantation should be offered to all children with symptomatic sickle cell disease. Transplantation seems to offer about a 90% cure rate for a condition that may kill 15% of children before they reach 20. But transplantation carries a 10% risk of death or severe disability, and doctors cannot predict which children will suffer severely from their sickle cell disease and which will suffer little or nothing. The jury eventually reached a majority decision that transplantation should not be offered now to all symptomatic children. PMID:1477577

Smith, R

1992-11-21

98

Clinical genomics information management software linking cancer genome sequence and clinical decisions.  

PubMed

Using sequencing information to guide clinical decision-making requires coordination of a diverse set of people and activities. In clinical genomics, the process typically includes sample acquisition, template preparation, genome data generation, analysis to identify and confirm variant alleles, interpretation of clinical significance, and reporting to clinicians. We describe a software application developed within a clinical genomics study, to support this entire process. The software application tracks patients, samples, genomic results, decisions and reports across the cohort, monitors progress and sends reminders, and works alongside an electronic data capture system for the trial's clinical and genomic data. It incorporates systems to read, store, analyze and consolidate sequencing results from multiple technologies, and provides a curated knowledge base of tumor mutation frequency (from the COSMIC database) annotated with clinical significance and drug sensitivity to generate reports for clinicians. By supporting the entire process, the application provides deep support for clinical decision making, enabling the generation of relevant guidance in reports for verification by an expert panel prior to forwarding to the treating physician. PMID:23603536

Watt, Stuart; Jiao, Wei; Brown, Andrew M K; Petrocelli, Teresa; Tran, Ben; Zhang, Tong; McPherson, John D; Kamel-Reid, Suzanne; Bedard, Philippe L; Onetto, Nicole; Hudson, Thomas J; Dancey, Janet; Siu, Lillian L; Stein, Lincoln; Ferretti, Vincent

2013-09-01

99

Utilizing Computerized Entertainment Education in the Development of Decision Aids for Lower Literate and Naïve Computer Users  

Microsoft Academic Search

Decision aids have been developed by using various delivery methods, including interactive computer programs. Such programs, however, still rely heavily on written information, health and digital literacy, and reading ease. We describe an approach to overcome these potential barriers for low-literate, underserved populations by making design considerations for poor readers and naïve computer users and by using concepts from entertainment

Maria L. Jibaja-Weiss; Robert J. Volk

2007-01-01

100

Utilizing computerized entertainment education in the development of decision aids for lower literate and naïve computer users.  

PubMed

Decision aids have been developed by using various delivery methods, including interactive computer programs. Such programs, however, still rely heavily on written information, health and digital literacy, and reading ease. We describe an approach to overcome these potential barriers for low-literate, underserved populations by making design considerations for poor readers and naïve computer users and by using concepts from entertainment education to engage the user and to contextualize the content for the user. The system design goals are to make the program both didactic and entertaining and the navigation and graphical user interface as simple as possible. One entertainment education strategy, the soap opera, is linked seamlessly to interactive learning modules to enhance the content of the soap opera episodes. The edutainment decision aid model (EDAM) guides developers through the design process. Although designing patient decision aids that are educational, entertaining, and targeted toward poor readers and those with limited computer skills is a complex task, it is a promising strategy for aiding this population. Entertainment education may be a highly effective approach to promoting informed decision making for patients with low health literacy. PMID:17934944

Jibaja-Weiss, Maria L; Volk, Robert J

2007-01-01

101

Studying the Vendor Perspective on Clinical Decision Support  

PubMed Central

In prior work, using a Rapid Assessment Process (RAP), we have investigated clinical decision support (CDS) in ambulatory clinics and hospitals. We realized that individuals in these settings provide only one perspective related to the CDS landscape, which also includes content vendors and electronic health record (EHR) vendors. To discover content vendors’ perspectives and their perceived challenges, we modified RAP for industrial settings. We describe how we employed RAP, and show its utility by describing two illustrative themes. We found that while the content vendors believe they provide unique much-needed services, the amount of labor involved in content development is underestimated by others. We also found that the content vendors believe their products are resources to be used by practitioners, so they are somewhat protected from liability issues. To promote adequate understanding about these issues, we recommend a “three way conversation” among content vendors, EHR vendors, and user organizations. PMID:22195058

Ash, Joan S.; Sittig, Dean F.; McMullen, Carmit K.; McCormack, James L.; Wright, Adam; Bunce, Arwen; Wasserman, Joseph; Mohan, Vishnu; Cohen, Deborah J.; Shapiro, Michael; Middleton, Blackford

2011-01-01

102

Computerized Drug Information Services  

ERIC Educational Resources Information Center

To compare computerized services in chemistry, pharmacology, toxicology, and clinical medicine of pharmaceutical interest, equivalent profiles were run on magnetic tape files of CA-Condensates," CBAC," Excerpta Medica," MEDLARS" and Ringdoc." The results are tabulated for overlap of services, relative speed of citing references, and unique…

And Others; Smith, Daniel R.

1972-01-01

103

Accuracy and Factors Affecting the Outcome of Multi-Detector Computerized Tomography Urography for Bladder Tumors in the Clinical Setting  

PubMed Central

Purpose The objective of this study was to investigate the diagnostic accuracy of multi-detector computerized tomography urography (MDCTU) for the detection of bladder tumors. Materials and Methods We retrospectively reviewed the medical records of 143 patients who were scanned by use of 64-channel MDCTU and who underwent cystoscopy due to painless hematuria or a clinical suspicion of bladder tumor. We examined the accuracy of MDCTU for the detection of bladder tumors by comparing the results obtained by MDCTU with those obtained by cystoscopy. The associations between tumor characteristics, frequency of transurethral resection (TUR), and bladder volume and detectability of bladder tumors on MDCTU were also analyzed. Results Of 143 patients, 50 patients had a history of urothelial carcinomas. In these patients, the sensitivity and specificity of MDCTU were 60.0% and 80.0%, respectively. In 93 patients without previous urothelial carcinomas, the sensitivity and specificity of MDCTU were 86.7% and 96.8%, respectively. Falsely diagnosed cases had a smaller distended bladder volume (p=0.014) and a smaller tumor size (p=0.022) than did true diagnosed cases. The false-negative rate increased when the bladder tumor was located at the bladder neck. In the univariate analysis, the tumor location, size, frequency of TUR, bladder volume, and initial hematuria were associated with detectability by MDCTU (p<0.05). Conclusions To improve the accuracy of MDCTU for diagnosing bladder tumors, bladder filling is recommended. Thus, cystoscopy should be considered as a standard diagnostic tool for bladder tumors even in patients with normal MDCTU results, especially in the evaluation of recurrent, bladder neck-located, small, or sessile bladder tumors. PMID:21344025

Hwang, Eu Chang; Kim, Jun Seok; Kim, Sun-Ouck; Kang, Taek Won; Kwon, Dong Deuk; Park, Kwangsung; Ryu, Soo Bang; Kim, Jin Woong; Wan, Lu Ji

2011-01-01

104

Free and Open Source Enabling Technologies for Patient-Centric, Guideline-Based Clinical Decision Support: A Survey  

PubMed Central

Summary Objectives: Guideline-based clinical decision support is an emerging paradigm to help reduce error, lower cost, and improve quality in evidence-based medicine. The free and open source (FOS) approach is a promising alternative for delivering cost-effective information technology (IT) solutions in health care. In this paper, we survey the current FOS enabling technologies for patient-centric, guideline-based care, and discuss the current trends and future directions of their role in clinical decision support. Methods: We searched PubMed, major biomedical informatics websites, and the web in general for papers and links related to FOS health care IT systems. We also relied on our background and knowledge for specific subtopics. We focused on the functionalities of guideline modeling tools, and briefly examined the supporting technologies for terminology, data exchange and electronic health record (EHR) standards. Results: To effectively support patient-centric, guideline-based care, the computerized guidelines and protocols need to be integrated with existing clinical information systems or EHRs. Technologies that enable such integration should be accessible, interoperable, and scalable. A plethora of FOS tools and techniques for supporting different knowledge management and quality assurance tasks involved are available. Many challenges, however, remain in their implementation. Conclusions: There are active and growing trends of deploying FOS enabling technologies for integrating clinical guidelines, protocols, and pathways into the main care processes. The continuing development and maturation of such technologies are likely to make increasingly significant contributions to patient-centric, guideline-based clinical decision support. PMID:17700908

Leong, T.-Y.; Kaiser, K.; Miksch, S.

2010-01-01

105

Biostatistics in clinical decision making for cardiothoracic radiologists.  

PubMed

Cardiothoracic radiologists are intuitively aware of sensitivity and specificity as they pertain to diagnostic tests involving clinical information. However, many cardiothoracic radiologists are unfamiliar with odds ratios, likelihood ratios, predictive values, and receiver operating characteristic (ROC) curves, which provide more information about the performance of a test. Our article will first review the fundamental concepts of sensitivity, specificity, predictive values, and likelihood ratios. The ROC curve methodology will be covered with an emphasis on creating a look-up table, a straightforward table that communicates important information to the clinician to aid in diagnosis. The article reviews sensitivity and specificity, as well as predictive values, logistic regression, and ROC curves, using conceptual principles without unnecessary mathematical rigor. We will apply principles of sensitivity and specificity to continuous measurements by constructing ROC curves in order to tie together key ideas in diagnostic decision making. Three clinical examples are presented to illustrate these fundamental statistical concepts: predictors of pulmonary embolism in children, use of dobutamine-cardiac magnetic resonance imaging to identify impaired ventricular function in patients who have suffered a myocardial infarction, and diagnostic accuracy of 64-multidetector row computed tomography to identify occluded vessels in adult patients with suspected coronary artery disease. In addition, a glossary is provided at the end of the article with key terms important in diagnostic imaging. An understanding of the concepts presented will assist cardiothoracic radiologists in critically discerning the usefulness of diagnostic tests and how these statistics can be applied to make judgments and decisions that are essential to clinical practice. PMID:23358369

Zurakowski, David; Johnson, Victor M; Lee, Edward Y

2013-11-01

106

Decision making for cancer clinical trial participation: a systematic review. | accrualnet.cancer.gov  

Cancer.gov

More research on the decision-making process for participation in cancer clinical trials is needed. A better understanding of the decision-making process may help improve patient-provider communication and create interventions to facilitate decision-making, leading to increased clinical trial participation.

107

A Four-Phase Model of the Evolution of Clinical Decision Support Architectures  

PubMed Central

Background A large body of evidence over many years suggests that clinical decision support systems can be helpful in improving both clinical outcomes and adherence to evidence-based guidelines. However, to this day, clinical decision support systems are not widely used outside of a small number of sites. One reason why decision support systems are not widely used is the relative difficulty of integrating such systems into clinical workflows and computer systems. Purpose To review and synthesize the history of clinical decision support systems, and to propose a model of various architectures for integrating clinical decision support systems with clinical systems. Methods The authors conducted an extensive review of the clinical decision support literature since 1959, sequenced the systems and developed a model. Results The model developed consists of four phases: standalone decision support systems, decision support integrated into clinical systems, standards for sharing clinical decision support content and service models for decision support. These four phases have not heretofore been identified, but they track remarkably well with the chronological history of clinical decision support, and show evolving and increasingly sophisticated attempts to ease integrating decision support systems into clinical workflows and other clinical systems. Conclusions Each of the four evolutionary approaches to decision support architecture has unique advantages and disadvantages. A key lesson was that there were common limitations that almost all the approaches faced, and no single approach has been able to entirely surmount: 1) fixed knowledge representation systems inherently circumscribe the type of knowledge that can be represented in them, 2) there are serious terminological issues, 3) patient data may be spread across several sources with no single source having a complete view of the patient, and 4) major difficulties exist in transferring successful interventions from one site to another. PMID:18353713

Wright, Adam; Sittig, Dean F.

2008-01-01

108

[Necessity of clinical decision support system created by medical staff].  

PubMed

To support patient safety, we have established a new system that collates medical facility clinical records, examination results and orders, and implementation information comprehensively in real time, checks for consistency and validity, and sends warnings to the appropriate people at the appropriate time. Because our system actually corrects inaccurate operation information, it is different from most existing facilities for patient safety in that it reconstructs information independently from the HIS (Hospital Information System). We were permitted to send warning messages not only to the doctor who entered the orders, but also to the chief of medical staff and team members. For the warning method, we tried screen flashes and chimes, mobile phone messages, and high quality interactive voice responses. We also investigated the degree of message usefulness. Therein, by not relying on "authenticity" and "readability," but by exhaustively collecting and appropriately revising in alignment with the use of information, we have created an original system that collects accurate information. This original system was established by medical staff members. The appropriate revisions mentioned herein are items which meticulously reflect the medical professional's comments and selected operation and signify why a "Clinical Decision Support System created by medical staff" is necessary. PMID:21706869

Yamamoto, Yasuhito

2011-05-01

109

Impact of a Clinical Decision Support System on Pharmacy Clinical Interventions, Documentation Efforts, and Costs  

PubMed Central

Health care organizations are turning to electronic clinical decision support systems (CDSSs) to increase quality of patient care and promote a safer environment. A CDSS is a promising approach to the aggregation and use of patient data to identify patients who would most benefit from interventions by pharmacy clinicians. However, there are limited published reports describing the impact of CDSS on clinical pharmacy measures. In February 2011, Good Shepherd Medical Center, a 425-bed acute care community hospital in East Texas, implemented a CDSS (TheraDoc clinical surveillance system). Prior to CDSS implementation, clinicians struggled with obtaining and documenting the data needed to support clinical initiatives. The value of having both clinical and staff pharmacists utilizing the CDSS has improved communication and knowledge among staff and improved relationships with medical staff, nursing, and case management. The department of pharmacy increased its clinical interventions from an average of 1,986 per month to 4,065 per month; this represents a 105% increase in the number of interventions. The annual estimated cost savings after CDSS implementation is $2,999,508, representing a 96% increase per year and translating into a $1,469,907 annual return on investment. PMID:24421548

Akilo, Hameed A.; Bierman, Kyle

2013-01-01

110

Clinical decision-making in early breast cancer.  

PubMed Central

OBJECTIVE: This in-depth review of the multidisciplinary approach to early breast cancer treatment (in situ, stage I and II) will update the surgeon about the indications, risks, and benefits of breast surgery, radiation therapy, adjuvant chemotherapy and hormonal therapy, and the importance of breast reconstructive surgery. SUMMARY BACKGROUND DATA: Breast cancer will occur in one of eight women in the United States during their lifetime and is the second leading cause of death in women from cancer. The practice of multidisciplinary breast cancer treatment has become the standard of care for the majority of breast cancer patients. If the surgeon is to retain the primary coordinating role in breast cancer management, then he or she must fully understand all modalities of oncology therapy and know how to deploy them to benefit individual patients. CONCLUSIONS: This article provides a framework for making clinical decisions about the appropriate combination and sequence of treatment for various presentations of early breast cancer. Images Figure 4. PMID:8383953

Balch, C M; Singletary, S E; Bland, K I

1993-01-01

111

A Computer Simulation for the Entry-Level Rn: Enhancing Clinical Decision Making  

Microsoft Academic Search

Staff development educators struggle to prepare today's entry-level RN for effective decision making in a new healthcare climate that demands both skill and expertise with patients with high acuity levels. The clinical decision making simulator is an innovative approach to teaching and learning decision-making skills. The authors discuss the development and use of a computer simulation that provides repeated opportunities

Marie N. Bremner; Jane D. Brannan

2000-01-01

112

Computerized analysis of mammographic parenchymal patterns on a large clinical dataset of full-field digital mammograms: robustness study with two high-risk datasets.  

PubMed

The purpose of this study was to demonstrate the robustness of our prior computerized texture analysis method for breast cancer risk assessment, which was developed initially on a limited dataset of screen-film mammograms. This current study investigated the robustness by (1) evaluating on a large clinical dataset, (2) using full-field digital mammograms (FFDM) as opposed to screen-film mammography, and (3) incorporating analyses over two types of high-risk patient sets, as well as patients at low risk for breast cancer. The evaluation included the analyses on the parenchymal patterns of women at high risk of developing of breast cancer, including both BRCA1/2 gene mutation carriers and unilateral cancer patients, and of women at low risk of developing breast cancer. A total of 456 cases, including 53 women with BRCA1/2 gene mutations, 75 women with unilateral cancer, and 328 low-risk women, were retrospectively collected under an institutional review board approved protocol. Regions-of-interest (ROIs), were manually selected from the central breast region immediately behind the nipple. These ROIs were subsequently used in computerized feature extraction to characterize the mammographic parenchymal patterns in the images. Receiver operating characteristic analysis was used to assess the performance of the computerized texture features in the task of distinguishing between high-risk and low-risk subjects. In a round robin evaluation on the FFDM dataset with Bayesian artificial neural network analysis, AUC values of 0.82 (95% confidence interval [0.75, 0.88]) and 0.73 (95% confidence interval [0.67, 0.78]) were obtained between BRCA1/2 gene mutation carriers and low-risk women, and between unilateral cancer and low-risk women, respectively. These results from computerized texture analysis on digital mammograms demonstrated that high-risk and low-risk women have different mammographic parenchymal patterns. On this large clinical dataset, we validated our methods for quantitative analyses of mammographic patterns on FFDM, statistically demonstrating again that women at high risk tend to have dense breasts with coarse and low-contrast texture patterns. PMID:22246204

Li, Hui; Giger, Maryellen L; Lan, Li; Bancroft Brown, Jeremy; MacMahon, Aoife; Mussman, Mary; Olopade, Olufunmilayo I; Sennett, Charlene

2012-10-01

113

Clinical decision guidelines for NHS cosmetic surgery: analysis of current limitations and recommendations for future development  

Microsoft Academic Search

Because of increasing demand for publicly funded elective cosmetic surgery, clinical decision guidelines have been developed to select those patients who should receive it. The aims of this study were to identify: the main characteristics of such guidelines; whether and how they influence clinical decision making; and ways in which they should be improved. UK health authorities were asked for

S. A Cook; R Rosser; S Meah; M. I James; P Salmon

2003-01-01

114

Decision Making in the PICU: An Examination of Factors Influencing Participation Decisions in Phase III Randomized Clinical Trials  

PubMed Central

Background. In stressful situations, decision making processes related to informed consent may be compromised. Given the profound levels of distress that surrogates of children in pediatric intensive care units (PICU) experience, it is important to understand what factors may be influencing the decision making process beyond the informed consent. The purpose of this study was to evaluate the role of clinician influence and other factors on decision making regarding participation in a randomized clinical trial (RCT). Method. Participants were 76 children under sedation in a PICU and their surrogate decision makers. Measures included the Post Decision Clinician Survey, observer checklist, and post-decision interview. Results. Age of the pediatric patient was related to participation decisions in the RCT such that older children were more likely to be enrolled. Mentioning the sponsoring institution was associated with declining to participate in the RCT. Type of health care provider and overt recommendations to participate were not related to enrollment. Conclusion. Decisions to participate in research by surrogates of children in the PICU appear to relate to child demographics and subtleties in communication; however, no modifiable characteristics were related to increased participation, indicating that the informed consent process may not be compromised in this population. PMID:25161672

Slosky, Laura E.; Burke, Natasha L.; Siminoff, Laura A.

2014-01-01

115

Implementing clinical practice guidelines while taking account of changing evidence: ATHENA DSS, an easily modifiable decision-support system for managing hypertension in primary care.  

PubMed Central

This paper describes the ATHENA Decision Support System (DSS), which operationalizes guidelines for hypertension using the EON architecture. ATHENA DSS encourages blood pressure control and recommends guideline-concordant choice of drug therapy in relation to comorbid diseases. ATHENA DSS has an easily modifiable knowledge base that specifies eligibility criteria, risk stratification, blood pressure targets, relevant comorbid diseases, guideline-recommended drug classes for patients with comorbid disease, preferred drugs within each drug class, and clinical messages. Because evidence for best management of hypertension evolves continually, ATHENA DSS is designed to allow clinical experts to customize the knowledge base to incorporate new evidence or to reflect local interpretations of guideline ambiguities. Together with its database mediator Athenaeum, ATHENA DSS has physical and logical data independence from the legacy Computerized Patient Record System (CPRS) supplying the patient data, so it can be integrated into a variety of electronic medical record systems. PMID:11079893

Goldstein, M. K.; Hoffman, B. B.; Coleman, R. W.; Musen, M. A.; Tu, S. W.; Advani, A.; Shankar, R.; O'Connor, M.

2000-01-01

116

Clinical decision rules and D-Dimer in venous thromboembolism: current controversies and future research priorities.  

PubMed

Venous thromboembolism (VTE) is a potentially lethal clinical condition that is suspected in patients with common clinical complaints, in many and varied, clinical care settings. Once VTE is diagnosed, optimal therapeutic management (thrombolysis, IVC filters, type and duration of anticoagulants) and ideal therapeutic management settings (outpatient, critical care) are also controversial. Clinical prediction tools, including clinical decision rules and D-Dimer, have been developed, and some validated, to assist clinical decision making along the diagnostic and therapeutic management paths for VTE. Despite these developments, practice variation is high and there remain many controversies in the use of the clinical prediction tools. In this narrative review, we highlight challenges and controversies in VTE diagnostic and therapeutic management with a focus on clinical decision rules and D-Dimer. PMID:25129416

Rodger, Marc A; Le Gal, Gregoire; Wells, Philip; Baglin, Trevor; Aujesky, Drahomir; Righini, Marc; Palareti, Gualtiero; Huisman, Menno; Meyer, Guy

2014-10-01

117

Representation of Clinical Practice Guidelines in Conventional and Augmented Decision Tables  

PubMed Central

Abstract Objective: To develop a knowledge representation model for clinical practice guidelines that is linguistically adequate, comprehensible, reusable, and maintainable. Design: Decision tables provide the basic framework for the proposed knowledge representation model. Guideline logic is represented as rules in conventional decision tables. These tables are augmented by layers where collateral information is recorded in slots beneath the logic. Results: Decision tables organize rules into cohesive rule sets wherein complex logic is clarified. Decision table rule sets may be verified to assure completeness and consistency. Optimization and display of rule sets as sequential decision trees may enhance the comprehensibility of the logic. The modularity of the rule formats may facilitate maintenance. The augmentation layers provide links to descriptive language, information sources, decision variable characteristics, costs and expected values of policies, and evidence sources and quality. Conclusion: Augmented decision tables can serve as a unifying knowledge representation for developers and implementers of clinical practice guidelines. PMID:9292844

Shiffman, Richard N.

1997-01-01

118

EBMPracticeNet: A Bilingual National Electronic Point-Of-Care Project for Retrieval of Evidence-Based Clinical Guideline Information and Decision Support  

PubMed Central

Background In Belgium, the construction of a national electronic point-of-care information service, EBMPracticeNet, was initiated in 2011 to optimize quality of care by promoting evidence-based decision-making. The collaboration of the government, health care providers, evidence-based medicine (EBM) partners, and vendors of electronic health records (EHR) is unique to this project. All Belgian health care professionals get free access to an up-to-date database of validated Belgian and nearly 1000 international guidelines, incorporated in a portal that also provides EBM information from other sources than guidelines, including computerized clinical decision support that is integrated in the EHRs. Objective The objective of this paper was to describe the development strategy, the overall content, and the management of EBMPracticeNet which may be of relevance to other health organizations creating national or regional electronic point-of-care information services. Methods Several candidate providers of comprehensive guideline solutions were evaluated and one database was selected. Translation of the guidelines to Dutch and French was done with translation software, post-editing by translators and medical proofreading. A strategy is determined to adapt the guideline content to the Belgian context. Acceptance of the computerized clinical decision support tool has been tested and a randomized controlled trial is planned to evaluate the effect on process and patient outcomes. Results Currently, EBMPracticeNet is in "work in progress" state. Reference is made to the results of a pilot study and to further planned research including a randomized controlled trial. Conclusions The collaboration of government, health care providers, EBM partners, and vendors of EHRs is unique. The potential value of the project is great. The link between all the EHRs from different vendors and a national database held on a single platform that is controlled by all EBM organizations in Belgium are the strengths of EBMPracticeNet. PMID:23842038

2013-01-01

119

Implementation of workflow engine technology to deliver basic clinical decision support functionality  

PubMed Central

Background Workflow engine technology represents a new class of software with the ability to graphically model step-based knowledge. We present application of this novel technology to the domain of clinical decision support. Successful implementation of decision support within an electronic health record (EHR) remains an unsolved research challenge. Previous research efforts were mostly based on healthcare-specific representation standards and execution engines and did not reach wide adoption. We focus on two challenges in decision support systems: the ability to test decision logic on retrospective data prior prospective deployment and the challenge of user-friendly representation of clinical logic. Results We present our implementation of a workflow engine technology that addresses the two above-described challenges in delivering clinical decision support. Our system is based on a cross-industry standard of XML (extensible markup language) process definition language (XPDL). The core components of the system are a workflow editor for modeling clinical scenarios and a workflow engine for execution of those scenarios. We demonstrate, with an open-source and publicly available workflow suite, that clinical decision support logic can be executed on retrospective data. The same flowchart-based representation can also function in a prospective mode where the system can be integrated with an EHR system and respond to real-time clinical events. We limit the scope of our implementation to decision support content generation (which can be EHR system vendor independent). We do not focus on supporting complex decision support content delivery mechanisms due to lack of standardization of EHR systems in this area. We present results of our evaluation of the flowchart-based graphical notation as well as architectural evaluation of our implementation using an established evaluation framework for clinical decision support architecture. Conclusions We describe an implementation of a free workflow technology software suite (available at http://code.google.com/p/healthflow) and its application in the domain of clinical decision support. Our implementation seamlessly supports clinical logic testing on retrospective data and offers a user-friendly knowledge representation paradigm. With the presented software implementation, we demonstrate that workflow engine technology can provide a decision support platform which evaluates well against an established clinical decision support architecture evaluation framework. Due to cross-industry usage of workflow engine technology, we can expect significant future functionality enhancements that will further improve the technology's capacity to serve as a clinical decision support platform. PMID:21477364

2011-01-01

120

Analysis of an integrated clinical decision support system in nursing home clinical information systems.  

PubMed

This descriptive study evaluated a clinical decision support system (CDSS) in three nursing homes. The CDSS included alerts for decline in condition, improvement in condition, constipation, dehydration, loss of skin integrity, weight loss, and weight gain. Frequencies of alerts and their triggers were counted, and Spearman's rank correlations were determined between active alert frequency and number of secondary diagnoses. The most frequent alerts were for dehydration and improvement in condition. One significant positive correlation existed between number of secondary diagnoses and weight gain alert frequencies in residents with cerebral vascular accident. Health care leaders face challenges constructing an implementation strategy that addresses usability, ensures accuracy, and guides users to critical information about residents. PMID:18286788

Alexander, Gregory L

2008-02-01

121

Interim monitoring of clinical trials: decision theory, dynamic programming and optimal stopping  

E-print Network

Interim monitoring of clinical trials: decision theory, dynamic programming and optimal stopping.S.A ABSTRACT It is standard practice to monitor clinical trials with a view to stopping early if results multipliers. Applications of these methods in clinical trial design include the derivation of optimal adaptive

Budd, Chris

122

The Clinical Intuition Exploration Guide: A Decision-Making Tool for Counselors and Supervisors  

ERIC Educational Resources Information Center

Clinical intuition is a common experience among counselors, yet many do not know what to do with intuition when it occurs. This article reviews the role intuition plays in clinical work and presents the research-based Clinical Intuition Exploration Guide to help counselors navigate the decision-making process. The guide consists of self-reflection…

Jeffrey, Aaron

2012-01-01

123

Clinical Decision Making among Fourth-Year Nursing Students: An Interpretive Study.  

ERIC Educational Resources Information Center

Interviews with 17 fourth-year nursing students identified essential components in the process of learning clinical decision making: gaining confidence, building relationships with staff, connecting with patients, being comfortable with nurse identity, and understanding the clinical picture. Results indicate that, without the big picture, clinical

White, Ann H.

2003-01-01

124

Critical care outreach: the need for effective decision-making in clinical practice (part 2).  

PubMed

As the extension of nursing into roles previously within the domain of medicine and the demand for evidence based practice continue to increase, the quality of decision making becomes imperative. Making accurate decisions is essential, both for the practitioner and for the patient, especially in the provision of critical care outreach (CCOR), to improve outcomes of care. With changes in health care delivery and increased accountability for practitioners' decisions, it is important to understand more about how clinical decisions are made and what factors influence them in order to inform practice. The previous paper outlined the theoretical background of clinical decision making and the knowledge that underpins practice in CCOR. In this paper, the authors, a Nurse Consultant in CCOR and a research fellow, examine the process of a practitioner's decision making in the practice of CCOR, through a collaborative reflective account of a case study. From this, recommendations are made about the future development of CCOR practitioners and services. PMID:16949288

Hancock, Helen C; Durham, Lesley

2007-04-01

125

An Examination of Accelerated and Basic Baccalaureate Nursing Students' Perceptions of Clinical Decision Making  

ERIC Educational Resources Information Center

Developing decision-making skills is essential in education in order to be a competent nurse. The purpose of this study was to examine and compare the perceptions of clinical decision-making skills of students enrolled in accelerated and basic baccalaureate nursing programs. A comparative descriptive research design was used for this study.…

Krumwiede, Kelly A.

2010-01-01

126

Critical Thinking and Clinical Decision Making In Critical Care Nursing: A Pilot Study  

Microsoft Academic Search

ObjectiveThis pilot study examined the relationship of education level, years of critical care nursing experience, and critical thinking (CT) ability (skills and dispositions) to consistency in clinical decision making among critical care nurses. Consistency was defined as the degree to which intuitive and analytical decision processes resulted in similar selection of interventions in tasks of low and high complexity.

Frank D. Hicks; Sharon L. Merritt; Arthur S. Elstein

2003-01-01

127

Factors Predicting Oncology Care Providers' Behavioral Intention to Adopt Clinical Decision Support Systems  

ERIC Educational Resources Information Center

The purpose of this quantitative correlation study was to examine the predictors of user behavioral intention on the decision of oncology care providers to adopt or reject the clinical decision support system. The Unified Theory of Acceptance and Use of Technology (UTAUT) formed the foundation of the research model and survey instrument. The…

Wolfenden, Andrew

2012-01-01

128

Mental Workload as a Key Factor in Clinical Decision Making  

ERIC Educational Resources Information Center

The decision making process is central to the practice of a clinician and has traditionally been described in terms of the hypothetico-deductive model. More recently, models adapted from cognitive psychology, such as the dual process and script theories have proved useful in explaining patterns of practice not consistent with purely cognitive…

Byrne, Aidan

2013-01-01

129

Clinical Decision Making in Restorative Dentistry, Endodontics, and Antibiotic Prescription  

Microsoft Academic Search

The purpose of this study was to evaluate the influence of geographic location of graduation (Israel, Eastern Europe, Latin America) on decision making regarding management of dental caries, periapical lesions, and antibiotic prescribing routines. A questionnaire was given to ninety-eight general practitioners regarding demographic and work habits. Photographs of lesions were shown on a screen. Participants reported recommended treatment and

Liran Levin; Gabriela Goldschleger

130

Evaluation of a novel electronic genetic screening and clinical decision support tool in prenatal clinical settings.  

PubMed

"The Pregnancy and Health Profile" (PHP) is a free prenatal genetic screening and clinical decision support (CDS) software tool for prenatal providers. PHP collects family health history (FHH) during intake and provides point-of-care risk assessment for providers and education for patients. This pilot study evaluated patient and provider responses to PHP and effects of using PHP in practice. PHP was implemented in four clinics. Surveys assessed provider confidence and knowledge and patient and provider satisfaction with PHP. Data on the implementation process were obtained through semi-structured interviews with administrators. Quantitative survey data were analyzed using Chi square test, Fisher's exact test, paired t tests, and multivariate logistic regression. Open-ended survey questions and interviews were analyzed using qualitative thematic analysis. Of the 83% (513/618) of patients that provided feedback, 97% felt PHP was easy to use and 98% easy to understand. Thirty percent (21/71) of participating physicians completed both pre- and post-implementation feedback surveys [13 obstetricians (OBs) and 8 family medicine physicians (FPs)]. Confidence in managing genetic risks significantly improved for OBs on 2/6 measures (p values ?0.001) but not for FPs. Physician knowledge did not significantly change. Providers reported value in added patient engagement and reported mixed feedback about the CDS report. We identified key steps, resources, and staff support required to implement PHP in a clinical setting. To our knowledge, this study is the first to report on the integration of patient-completed, electronically captured and CDS-enabled FHH software into primary prenatal practice. PHP is acceptable to patients and providers. Key to successful implementation in the future will be customization options and interoperability with electronic health records. PMID:24101435

Edelman, Emily A; Lin, Bruce K; Doksum, Teresa; Drohan, Brian; Edelson, Vaughn; Dolan, Siobhan M; Hughes, Kevin; O'Leary, James; Vasquez, Lisa; Copeland, Sara; Galvin, Shelley L; DeGroat, Nicole; Pardanani, Setul; Gregory Feero, W; Adams, Claire; Jones, Renee; Scott, Joan

2014-07-01

131

Using the Clinical Document Architecture as Open Data Exchange Format for Interfacing EMRs with Clinical Decision Support Systems  

Microsoft Academic Search

Clinical decision support systems (CDSS) can significantly increase the quality of care while decreasing cost and effort. They are difficult to develop and most existing systems are proprietary, tightly integrated with specific electronic medical record (EMR) systems, and expensive to own. EGADSS is an open-source CDSS that has been developed as a standalone, standards-based, re-usable component to make decision-support available

Iryna Bilykh; Jens H. Jahnke; Glen Mccallum; Morgan Price

2006-01-01

132

Using Decision Analysis to Modify Clinical Decisions Made by Pharmacists and Students.  

ERIC Educational Resources Information Center

A study investigated whether the decision making of pharmacists and pharmacy students could be modified by providing computer-generated information on probabilities for efficacy and adverse reactions for antihypertensive agents, using case scenarios. Pharmacists were more likely than students to be influenced by probability information.…

Brown, Thomas E. R.; And Others

1995-01-01

133

Integrating Healthcare Knowledge Artifacts for Clinical Decision Support: Towards Semantic  

E-print Network

; (b) clinical pathways for procedural protocols to exercise these recommendations; and (c) medical to pursue a context-sensitive selection and integration of medical knowledge from multiple knowledge reconciliation of independent data sources, under a defined

Abidi, Syed Sibte Raza

134

By-Person Factor Analysis in Clinical Ethical Decision Making: Q Methodology in End-of-Life Care Decisions  

Microsoft Academic Search

Objective: To determine the usefulness of Q methodology to locate and describe shared subjective influences on clinical decision making among participant physicians using hypothetical cases containing common ethical issues.Design: Qualitative study using by-person factor analysis of subjective Q sort data matrix.Setting: University medical center.Participants: Convenience sample of internal medicine attending physicians and house staff (n = 35) at one midwestern

William Wong; Arnold R. Eiser; Robert G. Mrtek; Paul S. Heckerling

2004-01-01

135

A decision tree and clinical paths for the assessment and management of children with ADHD.  

PubMed

Attention Deficit/Hyperactivity Disorder (ADHD) is a common neurobehavioral disorder. Children with ADHD are disproportionately represented in pediatric populations characterized by school failure, criminal behavior, and substance abuse. Many children who present with ADHD symptomatology do not receive systematic assessments nor comprehensive treatment that is well coordinated across home and school environments. And yet, evidence suggests that early detection and appropriate treatment can alter the probability of a negative developmental trajectory. The Decision Tree and Clinical Paths for Assessment and Management of ADHD identify the critical components of care through a stepwise decision-making process involving the assessment, diagnosis, treatment, and outcome evaluation of children who present with ADHD symptomatology. Preliminary field testing supports the clinical utility and validity of the ADHD Decision Tree/Paths. In addition, cross-validation comparisons indicate consistency between the ADHD Decision Tree/Paths and recently released ADHD clinical guidelines issued by several national professional organizations. PMID:12217221

Magyary, Diane; Brandt, Patricia

2002-09-01

136

Computerized information-gathering in specialist rheumatology clinics: an initial evaluation of an electronic version of the Short Form 36  

Microsoft Academic Search

Objectives. Longitudinal outcome data are important for research and are becoming part of routine clinical practice. We assessed an initial version of an electronic Short Form 36 (SF-36), a well-established health assessment questionnaire, in comparison with standard paper forms, in two specialist rheumatology clinics. Methods. Out-patients (20 with systemic lupus erythematosus and 31 with vasculitis) were randomly selected to complete

A. S. Wilson; G. D. Kitas; D. M. Carruthers; C. Reay; J. Skan; S. Harris; G. J. Treharne; S. P. Young; P. A. Bacon

2002-01-01

137

C2-fractures: part II. A morphometrical analysis of computerized atlantoaxial motion, anatomical alignment and related clinical outcomes  

Microsoft Academic Search

Knowledge on the outcome of C2-fractures is founded on heterogenous samples with cross-sectional outcome assessment focusing\\u000a on union rates, complications and technical concerns related to surgical treatment. Reproducible clinical and functional outcome\\u000a assessments are scant. Validated generic and disease specific outcome measures were rarely applied. Therefore, the aim of\\u000a the current study is to investigate the radiographic, functional and clinical

Heiko Koller; Frank Acosta; Rosemarie Forstner; Juliane Zenner; Herbert Resch; Mark Tauber; Stefan Lederer; Alexander Auffarth; Wolfgang Hitzl

2009-01-01

138

"Quality of prenatal and maternal care: bridging the know-do gap" (QUALMAT study): an electronic clinical decision support system for rural Sub-Saharan Africa  

PubMed Central

Background Despite strong efforts to improve maternal care, its quality remains deficient in many countries of Sub-Saharan Africa as persistently high maternal mortality rates testify. The QUALMAT study seeks to improve the performance and motivation of rural health workers and ultimately quality of primary maternal health care services in three African countries Burkina Faso, Ghana, and Tanzania. One major intervention is the introduction of a computerized Clinical Decision Support System (CDSS) for rural primary health care centers to be used by health care workers of different educational levels. Methods A stand-alone, java-based software, able to run on any standard hardware, was developed based on assessment of the health care situation in the involved countries. The software scope was defined and the final software was programmed under consideration of test experiences. Knowledge for the decision support derived from the World Health Organization (WHO) guideline “Pregnancy, Childbirth, Postpartum and Newborn Care; A Guide for Essential Practice”. Results The QUALMAT CDSS provides computerized guidance and clinical decision support for antenatal care, and care during delivery and up to 24 hours post delivery. The decision support is based on WHO guidelines and designed using three principles: (1) Guidance through routine actions in maternal and perinatal care, (2) integration of clinical data to detect situations of concern by algorithms, and (3) electronic tracking of peri- and postnatal activities. In addition, the tool facilitates patient management and is a source of training material. The implementation of the software, which is embedded in a set of interventions comprising the QUALMAT study, is subject to various research projects assessing and quantifying the impact of the CDSS on quality of care, the motivation of health care staff (users) and its health economic aspects. The software will also be assessed for its usability and acceptance, as well as for its influence on workflows in the rural setting of primary health care in the three countries involved. Conclusion The development and implementation of a CDSS in rural primary health care centres presents challenges, which may be overcome with careful planning and involvement of future users at an early stage. A tailored software with stable functionality should offer perspectives to improve maternal care in resource-poor settings. Trial registration http://www.clinicaltrials.gov/NCT01409824. PMID:23574764

2013-01-01

139

A Three-Question Framework to Facilitate Clinical Decision Making  

ERIC Educational Resources Information Center

Context: Highly developed critical thinking and the ability to discriminate among many possible therapeutic interventions is a core behavior for the practicing athletic trainer. However, while athletic training students receive a great deal of clinically applicable information, many are not explicitly trained in efficient methods for channeling…

Sibold, Jeremy

2012-01-01

140

Social, Organizational, and Contextual Characteristics of Clinical Decision Support Systems for Intensive Insulin Therapy: A Literature Review and Case Study  

PubMed Central

Introduction: Evaluations of computerized clinical decision support systems (CDSS) typically focus on clinical performance changes and do not include social, organizational, and contextual characteristics explaining use and effectiveness. Studies of CDSS for intensive insulin therapy (IIT) are no exception, and the literature lacks an understanding of effective computer-based IIT implementation and operation. Results: This paper presents (1) a literature review of computer-based IIT evaluations through the lens of institutional theory, a discipline from sociology and organization studies, to demonstrate the inconsistent reporting of workflow and care process execution and (2) a single-site case study to illustrate how computer-based IIT requires substantial organizational change and creates additional complexity with unintended consequences including error. Discussion: Computer-based IIT requires organizational commitment and attention to site-specific technology, workflow, and care processes to achieve intensive insulin therapy goals. The complex interaction between clinicians, blood glucose testing devices, and CDSS may contribute to workflow inefficiency and error. Evaluations rarely focus on the perspective of nurses, the primary users of computer-based IIT whose knowledge can potentially lead to process and care improvements. Conclusion: This paper addresses a gap in the literature concerning the social, organizational, and contextual characteristics of CDSS in general and for intensive insulin therapy specifically. Additionally, this paper identifies areas for future research to define optimal computer-based IIT process execution: the frequency and effect of manual data entry error of blood glucose values, the frequency and effect of nurse overrides of CDSS insulin dosing recommendations, and comprehensive ethnographic study of CDSS for IIT. PMID:19815452

Campion, Thomas R.; Waitman, Lemuel R.; May, Addison K.; Ozdas, Asli; Lorenzi, Nancy M.; Gadd, Cynthia S.

2009-01-01

141

Replacing the mercury manometer with an oscillometric device in a hypertension clinic: implications for clinical decision making  

Microsoft Academic Search

Oscillometric devices are being widely used for ambulatory, home and office blood pressure (BP) measurement, and several of them have been validated using established protocols. This cross-sectional study assessed the impact on antihypertensive treatment decisions of replacing the mercury sphygmomanometer by a validated oscillometric device. Consecutive subjects attending a hypertension clinic had triplicate simultaneous same-arm BP measurements using a mercury

G S Stergiou; P Lourida; D Tzamouranis

2011-01-01

142

Research Paper: Effects of a Pharmacist-to-Dose Computerized Request on Promptness of Antimicrobial Therapy  

Microsoft Academic Search

ObjectivesTo examine the effects of computerized requests for pharmacist-to-dose (PTD), an advanced clinical decision support tool for dosing guidance, on antimicrobial therapy with vancomycin and aminoglycosides, describe PTD request utilization, and identify factors that may prolong this process.DesignA retrospective review was conducted of patients hospitalized from Jan 2004 to Jun 2006 with suspected pneumonia who received vancomycin, tobramycin, or gentamicin

William R. Vincent; Craig A. Martin; P. Shane Winstead; Kelly M. Smith; Jennifer Gatz; Daniel A. Lewis

2009-01-01

143

Multi-criteria clinical decision support: A primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare  

PubMed Central

Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers. Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine “hard data” with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings. The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP) PMID:21394218

Dolan, James G.

2010-01-01

144

Comparative evaluation of different medication safety measures for the emergency department: physicians' usage and acceptance of training, poster, checklist and computerized decision support  

PubMed Central

Background Although usage and acceptance are important factors for a successful implementation of clinical decision support systems for medication, most studies only concentrate on their design and outcome. Our objective was to comparatively investigate a set of traditional medication safety measures such as medication safety training for physicians, paper-based posters and checklists concerning potential medication problems versus the additional benefit of a computer-assisted medication check. We concentrated on usage, acceptance and suitability of such interventions in a busy emergency department (ED) of a 749 bed acute tertiary care hospital. Methods A retrospective, qualitative evaluation study was conducted using a field observation and a questionnaire-based survey. Six physicians were observed while treating 20 patient cases; the questionnaire, based on the Technology Acceptance Model 2 (TAM2), has been answered by nine ED physicians. Results During field observations, we did not observe direct use of any of the implemented interventions for medication safety (paper-based and electronic). Questionnaire results indicated that the electronic medication safety check was the most frequently used intervention, followed by checklist and posters. However, despite their positive attitude, physicians most often stated that they use the interventions in only up to ten percent for subjectively “critical” orders. Main reasons behind the low usage were deficits in ease-of-use and fit to the workflow. The intention to use the interventions was rather high after overcoming these barriers. Conclusions Methodologically, the study contributes to Technology Acceptance Model (TAM) research in an ED setting and confirms TAM2 as a helpful diagnostic tool in identifying barriers for a successful implementation of medication safety interventions. In our case, identified barriers explaining the low utilization of the implemented medication safety interventions - despite their positive reception - include deficits in accessibility, briefing for the physicians about the interventions, ease-of-use and compatibility to the working environment. PMID:23890121

2013-01-01

145

Clinical Decision Support Systems for the Practice of Evidence-based Medicine  

Microsoft Academic Search

BackgroundThe use of clinical decision support systems to facilitate the practice of evidence-based medicine promises to substantially improve health care quality.ObjectiveTo describe, on the basis of the proceedings of the Evidence and Decision Support track at the 2000 AMIA Spring Symposium, the research and policy challenges for capturing research and practice-based evidence in machine-interpretable repositories, and to present recommendations for

Ida Sim; Paul Gorman; Robert A Greenes; R Brian Haynes; Bonnie Kaplan; Harold Lehmann; Paul C Tang

2001-01-01

146

Is there a link between the hospital-acquired injurious fall rates in US acute care hospitals and these institutions' implementation levels of computerized systems?  

PubMed

Medicare no longer reimburses acute care hospitals for the costs of additional care required due to hospital-acquired injuries. Consequently, this study explored the effective computerized systems to inform practice for better interventions to reduce fall risk. It provided a correlation between type of computerized system and hospital-acquired injurious fall rates at acute care hospitals in California, Florida, and New York. It used multiple publicly available data sets, with the hospital as the unit of analysis. Descriptive and Pearson correlation analyses were used. The analysis included 462 hospitals. Significant correlations could be categorized into two groups: (1) meaningful computerized systems that were associated with lower injurious fall rates: the decision support systems for drug allergy alerts, drug-drug interaction alerts, and drug-laboratory interaction alerts; and (2) computerized systems that were associated with higher injurious fall rates: the decision support system for drug-drug interaction alerts and the computerized provider order entry system for radiology tests. Future research may include additional states, multiple years of data, and patient-level data to validate this study's findings. This effort may further inform policy makers and the public about effective clinical computerized systems provided to clinicians to improve their practice decisions and care outcomes. PMID:21825973

Tzeng, Huey-Ming; Hu, Hsou Mei; Yin, Chang-Yi

2011-12-01

147

Implementing an integrative multi-agent clinical decision support system with open source software.  

PubMed

Clinical decision making is a complex multi-stage process. Decision support can play an important role at each stage of this process. At present, the majority of clinical decision support systems have been focused on supporting only certain stages. In this paper we present the design and implementation of MET3-a prototype multi-agent system providing an integrative decision support that spans over the entire decision making process. The system helps physicians with data collection, diagnosis formulation, treatment planning and finding supporting evidence. MET3 integrates with external hospital information systems via HL7 messages and runs on various computing platforms available at the point of care (e.g., tablet computers, mobile phones). Building MET3 required sophisticated and reliable software technologies. In the past decade the open source software movement has produced mature, stable, industrial strength software systems with a large user base. Therefore, one of the decisions that should be considered before developing or acquiring a decision support system is whether or not one could use open source technologies instead of proprietary ones. We believe MET3 shows that the answer to this question is positive. PMID:20703742

Sayyad Shirabad, Jelber; Wilk, Szymon; Michalowski, Wojtek; Farion, Ken

2012-02-01

148

How updating textual clinical practice guidelines impacts clinical decision support systems: a case study with bladder cancer management.  

PubMed

Guideline-based clinical decision support systems (CDSSs) can be effective in increasing physician compliance with recommendations. However, the ever growing pace at which medical knowledge is produced requires that clinical practice guidelines (CPGs) be updated regularly. It is therefore mandatory that CDSSs be revised accordingly. The French Association for Urology publishes CPGs on bladder cancer management every 2 years. We studied the impact of the 2004 revision of these guidelines, with respect to the 2002 version with a CDSS, UroDoc. We proposed a typology of knowledge base modifications resulting from the update of CPGs making the difference between practice, clinical conditions and recommendations refinement as opposed to new practice and new recommendations. The number of formalized recommendations increased from 577 in 2002 to 1,081 in 2004. We evaluated the two versions of UroDoc on a randomized sample of patient records. A single new practice that modifies a decision taken in 49% of all recorded decisions leads to a fall from 67% to 46% of the compliance rate of decisions. PMID:17911832

Bouaud, Jacques; Séroussi, Brigitte; Brizon, Ambre; Culty, Thibault; Mentré, France; Ravery, Vincent

2007-01-01

149

A controlled time-series trial of clinical reminders: using computerized firm systems to make quality improvement research a routine part of mainstream practice.  

PubMed Central

OBJECTIVE: To explore the feasibility of conducting unobtrusive interventional research in community practice settings by integrating firm-system techniques with time-series analysis of relational-repository data. STUDY SETTING: A satellite teaching clinic divided into two similar, but geographically separated, primary care group practices called firms. One firm was selected by chance to receive the study intervention. Forty-two providers and 2,655 patients participated. STUDY DESIGN: A nonrandomized controlled trial of computer-generated preventive reminders. Net effects were determined by quantitatively combining population-level data from parallel experimental and control interrupted time series extending over two-month baseline and intervention periods. DATA COLLECTION: Mean rates at which mammography, colorectal cancer screening, and cholesterol testing were performed on patients due to receive each maneuver at clinic visits were the trial's outcome measures. PRINCIPAL FINDINGS: Mammography performance increased on the experimental firm by 154 percent (0.24 versus 0.61, p = .03). No effect on fecal occult blood testing was observed. Cholesterol ordering decreased on both the experimental (0.18 versus 0.1 1, p = .02) and control firms (0.13 versus 0.07, p = .03) coincident with national guidelines retreating from recommending screening for young adults. A traditional uncontrolled interrupted time-series design would have incorrectly attributed the experimental-firm decrease to the introduction of reminders. The combined analysis properly indicated that no net prompting effect had occurred, as the difference between firms in cholesterol testing remained stochastically stable over time (0.05 versus 0.04, p = .75). A logistic-regression analysis applied to individual-level data produced equivalent findings. The trial incurred no supplementary data collection costs. CONCLUSIONS: The apparent validity and practicability of our reminder implementation study should encourage others to develop computerized firm systems capable of conducting controlled time-series trials. Images Fig. 1 PMID:10737451

Goldberg, H. I.; Neighbor, W. E.; Cheadle, A. D.; Ramsey, S. D.; Diehr, P.; Gore, E.

2000-01-01

150

Medication recommendations vs. peer practice in pediatric levothyroxine dosing : a study of collective intelligence from a clinical data warehouse as a potential model for clinical decision support  

E-print Network

Clinical decision support systems (CDSS) are developed primarily from knowledge gleaned from evidence-based research, guidelines, trusted resources and domain experts. While these resources generally represent information ...

Scheufele, Elisabeth Lee

2009-01-01

151

Computerized tomographic colonography: performance evaluation in a retrospective multicenter setting 1 1 Vital Images Inc. has supported research at UCLA (to D. S. K. L., J. A. B., and E. G. M.). Monex provided support (to M. M.). GE Medical Systems provided software license and research support (to C. D. J., J. A. B., and A. H. D.). Voxar, Inc. produces products that compete with products listed in this paper (to M. A. B.). The study design was approved by the National Cancer Institute Cancer Therapy Evaluation Program. Computerized tomographic colonography examinations for American College of Radiology Imaging Network Protocol A6656 were submitted by E. G. McFarland, Mallinckrodt Institute of Radiology, St. Louis, Missouri; M. Zalis, Massachusetts General Hospital, Boston, Massachusetts; C. D. Johnson, Mayo Clinic, Rochester, Minnesota; M. Macari, New York University, New York, New York; D. Lu, University of California, Los Angeles, California; A. H. Dachman, University of Chicago, C  

Microsoft Academic Search

Background & Aims: No multicenter study has been reported evaluating the performance and interobserver variability of computerized tomographic colonography. The aim of this study was to assess the accuracy of computerized tomographic colonography for detecting clinically important colorectal neoplasia (polyps ?10 mm in diameter) in a multi-institutional study. Methods: A retrospective study was developed from 341 patients who had computerized

C. Daniel Johnson; Alicia Y. Toledano; Benjamin A. Herman; Abraham H. Dachman; Elizabeth G. Mcfarland; Matthew A. Barish; James A. Brink; Randy D. Ernst; Joel G. Fletcher; Robert A. Halvorsen; Amy K. Hara; Kenneth D. Hopper; Robert E. Koehler; David S. K. Lu; Michael Macari; Robert L. Maccarty; Frank H. Miller; Martina Morrin; Erik K. Paulson; Judy Yee; Michael Zalis

2003-01-01

152

Decision theory in medicine: a review and critique.  

PubMed

Decision theory's role in medicine will lie between the extremes of naive optimism ("a Rosetta stone") and unmitigated pessimism ("a computerized Ouija board"). Its application to public health policy, research, and administrative problem-solving is established; experience offers some guidelines for more limited use in clinical practice. PMID:100721

Albert, D A

1978-01-01

153

Constructing a clinical decision-making framework for image-guided radiotherapy using a Bayesian Network  

NASA Astrophysics Data System (ADS)

A decision-making framework for image-guided radiotherapy (IGRT) is being developed using a Bayesian Network (BN) to graphically describe, and probabilistically quantify, the many interacting factors that are involved in this complex clinical process. Outputs of the BN will provide decision-support for radiation therapists to assist them to make correct inferences relating to the likelihood of treatment delivery accuracy for a given image-guided set-up correction. The framework is being developed as a dynamic object-oriented BN, allowing for complex modelling with specific subregions, as well as representation of the sequential decision-making and belief updating associated with IGRT. A prototype graphic structure for the BN was developed by analysing IGRT practices at a local radiotherapy department and incorporating results obtained from a literature review. Clinical stakeholders reviewed the BN to validate its structure. The BN consists of a sub-network for evaluating the accuracy of IGRT practices and technology. The directed acyclic graph (DAG) contains nodes and directional arcs representing the causal relationship between the many interacting factors such as tumour site and its associated critical organs, technology and technique, and inter-user variability. The BN was extended to support on-line and off-line decision-making with respect to treatment plan compliance. Following conceptualisation of the framework, the BN will be quantified. It is anticipated that the finalised decision-making framework will provide a foundation to develop better decision-support strategies and automated correction algorithms for IGRT.

Hargrave, C.; Moores, M.; Deegan, T.; Gibbs, A.; Poulsen, M.; Harden, F.; Mengersen, K.

2014-03-01

154

Mobile clinical decision support systems and applications: a literature and commercial review.  

PubMed

The latest advances in eHealth and mHealth have propitiated the rapidly creation and expansion of mobile applications for health care. One of these types of applications are the clinical decision support systems, which nowadays are being implemented in mobile apps to facilitate the access to health care professionals in their daily clinical decisions. The aim of this paper is twofold. Firstly, to make a review of the current systems available in the literature and in commercial stores. Secondly, to analyze a sample of applications in order to obtain some conclusions and recommendations. Two reviews have been done: a literature review on Scopus, IEEE Xplore, Web of Knowledge and PubMed and a commercial review on Google play and the App Store. Five applications from each review have been selected to develop an in-depth analysis and to obtain more information about the mobile clinical decision support systems. Ninety-two relevant papers and 192 commercial apps were found. Forty-four papers were focused only on mobile clinical decision support systems. One hundred seventy-one apps were available on Google play and 21 on the App Store. The apps are designed for general medicine and 37 different specialties, with some features common in all of them despite of the different medical fields objective. The number of mobile clinical decision support applications and their inclusion in clinical practices has risen in the last years. However, developers must be careful with their interface or the easiness of use, which can impoverish the experience of the users. PMID:24399281

Martínez-Pérez, Borja; de la Torre-Díez, Isabel; López-Coronado, Miguel; Sainz-de-Abajo, Beatriz; Robles, Montserrat; García-Gómez, Juan Miguel

2014-01-01

155

Paying more wisely: effects of payment reforms on evidence-based clinical decision-making.  

PubMed

This article reviews the recent research, policy and conceptual literature on the effects of payment policy reforms on evidence-based clinical decision-making by physicians at the point-of-care. Payment reforms include recalibration of existing fee structures in fee-for-service, pay-for-quality, episode-based bundled payment and global payments. The advantages and disadvantages of these reforms are considered in terms of their effects on the use of evidence in clinical decisions made by physicians and their patients related to the diagnosis, testing, treatment and management of disease. The article concludes with a recommended pathway forward for improving current payment incentives to better support evidence-based decision-making. PMID:24236624

Lake, Timothy K; Rich, Eugene C; Valenzano, Christal Stone; Maxfield, Myles M

2013-05-01

156

An Introspective Component-Based Approach for Meta-Level Reasoning in Clinical Decision Support Systems  

E-print Network

of palliative care. The goal of the reported research is to develop an architecture and an integrated set of clinical decision support for palliative care. In a cooperation with the Palliative Medicine Unit, Cancer related to palliative care for long-term cancer patients. A motivation for that project is also

Aamodt, Agnar

157

Multimorbidity, service organization and clinical decision making in primary care: a qualitative study  

Microsoft Academic Search

BACKGROUND: Primary care professionals often manage patients with multiple long-term health conditions, but managing multimorbidity is challenging given time and resource constraints and interactions between conditions. OBJECTIVE: To explore GP and nurse perceptions of multimorbidity and the influence on service organization and clinical decision making. METHODS: A qualitative interview study with primary care professionals in practices in Greater Manchester, U.K.

P. Bower; W. Macdonald; E. Harkness; L. Gask; T. Kendrick; J. M. Valderas; C. Dickens; T. Blakeman; B. S. Sibbald

2011-01-01

158

Design of a Phone-Based Clinical Decision Support System for Resource-Limited Settings  

E-print Network

, mobile phones, mHealth 1. INTRODUCTION Of the 33 million people globally who have HIV [51], 22 million core findings that are important for implementers of mobile systems for health care providersDesign of a Phone-Based Clinical Decision Support System for Resource-Limited Settings Yaw Anokwa

Parikh, Tapan S.

159

Knowledge of risk factors and the periodontal disease-systemic link in dental students' clinical decisions.  

PubMed

This study evaluated second-, third-, and fourth-year dental students' ability to identify systemic conditions associated with periodontal disease, risk factors most important for referral, and medications with an effect on the periodontium and their ability to apply this knowledge to make clinical decisions regarding treatment and referral of periodontal patients. A twenty-one question survey was administered at one U.S. dental school in the spring semester of 2012 to elicit the students' knowledge and confidence regarding clinical reasoning. The response rate was 86 percent. Periodontal risk factors were accurately selected by at least 50 percent of students in all three classes; these were poorly controlled diabetes, ?6 mm pockets posteriorly, and lack of response to previous non-surgical therapy. Confidence in knowledge, knowledge of risk factors, and knowledge of medications with an effect on the periodontium improved with training and were predictive of better referral decision making. The greatest impact of training was seen on the students' ability to make correct decisions about referral and treatment for seven clinical scenarios. Although the study found a large increase in the students' abilities from the second through fourth years, the mean of 4.6 (out of 7) for the fourth-year students shows that, on average, those students missed correct treatment or referral on more than two of seven clinical cases. These results suggest that dental curricula should emphasize more critical decision making with respect to referral and treatment criteria in managing the periodontal patient. PMID:25179920

Friesen, Lynn Roosa; Walker, Mary P; Kisling, Rebecca E; Liu, Ying; Williams, Karen B

2014-09-01

160

Clinical Decision Making About Psychopathy and Violence Risk Assessment in Public Sector Mental Health Settings  

Microsoft Academic Search

Although there has been extensive research on psychopathy, it is unknown how, or whether, clinicians in public sector mental health settings consider the Psychopathy Checklist (PCL) for assessing violence risk. Mental health clinicians (N = 135) from 4 facilities were interviewed by using multiple methods for collecting data on decision making. Participants considered clinical information most often when assessing violence

Eric B. Elbogen; Matthew T. Huss; Alan J. Tomkins; Mario J. Scalora

2005-01-01

161

The Contribution of Polysyllabic Words in Clinical Decision Making about Children's Speech  

ERIC Educational Resources Information Center

Poor polysyllabic word (PSW) production seems to mark paediatric speech impairment as well as impairment in language, literacy and phonological processing. As impairment in these domains may only manifest in PSWs, PSW production may provide unique information that is often excluded from clinical decision making because insufficient PSWs are…

James, Deborah G. H.; van Doorn, Jan; McLeod, Sharynne

2008-01-01

162

Application of the Stockholm Hierarchy to Defining the Quality of Reference Intervals and Clinical Decision Limits  

PubMed Central

The Stockholm Hierarchy is a professional consensus created to define the preferred approaches to defining analytical quality. The quality of a laboratory measurement can also be classified by the quality of the limits that the value is compared with, namely reference interval limits and clinical decision limits. At the highest level in the hierarchy would be placed clinical decision limits based on clinical outcome studies. The second level would include both formal reference interval studies (studies of intra and inter-individual variations) and clinical decision limits based on clinician survey. While these approaches are commonly used, they require a lot of resources to define accurately. Placing laboratory experts on the third level would suggest that although they can also define reference intervals by consensus, theirs aren’t as well regarded as clinician defined limits which drive clinical behaviour. Ideally both analytical and clinical considerations should be made, with clinicians and laboratorians both having important information to consider. The fourth level of reference intervals would be for those defined by survey or by regulatory authorities because of the focus on what is commonly achieved rather than what is necessarily correct. Finally, laboratorians know that adopting reference limits from kit inserts or textbook publications is problematic because both methodological issues and reference populations are often not the same as their own. This approach would rank fifth and last. When considering which so called ‘common’ or ‘harmonised reference intervals’ to adopt, both these characteristics and the quality of individual studies need to be assessed. Finally, we should also be aware that reference intervals describe health and physiology while clinical decision limits focus on disease and pathology, and unless we understand and consider the two corresponding issues of test specificity and test sensitivity, we cannot assure the quality of the limits that we report. PMID:23267246

Sikaris, Ken

2012-01-01

163

Uninformed Clinical Decisions Resulting From Lack of Adherence Assessment in Children with New Onset Epilepsy  

PubMed Central

This study examined the relationship between non-adherence to antiepileptic drug (AED) therapy and clinical decision-making in a cohort of 112 children with newly-diagnosed epilepsy. AED adherence was monitored using electronic monitoring over the first six months of therapy. The primary outcome measure was rate of uninformed clinical decisions as defined by number of participants with AED dosage or drug changes to address continued seizures who demonstrated non-adherence prior to the seizure. Among the 52 (47%) participants who had an AED change for continued seizures, 30 (27% of the overall cohort) had imperfect medication adherence prior to their seizures. A quarter of children with new onset epilepsy had uninformed medication changes because adherence was not rigorously assessed in clinical practice. Results highlight the importance of routinely assessing medication adherence in this population. PMID:23159375

Modi, Avani C.; Wu, Yelena P.; Guilfoyle, Shanna M.; Glauser, Tracy A.

2012-01-01

164

Workshop on using natural language processing applications for enhancing clinical decision making: an executive summary.  

PubMed

In April 2012, the National Institutes of Health organized a two-day workshop entitled 'Natural Language Processing: State of the Art, Future Directions and Applications for Enhancing Clinical Decision-Making' (NLP-CDS). This report is a summary of the discussions during the second day of the workshop. Collectively, the workshop presenters and participants emphasized the need for unstructured clinical notes to be included in the decision making workflow and the need for individualized longitudinal data tracking. The workshop also discussed the need to: (1) combine evidence-based literature and patient records with machine-learning and prediction models; (2) provide trusted and reproducible clinical advice; (3) prioritize evidence and test results; and (4) engage healthcare professionals, caregivers, and patients. The overall consensus of the NLP-CDS workshop was that there are promising opportunities for NLP and CDS to deliver cognitive support for healthcare professionals, caregivers, and patients. PMID:23921193

Pai, Vinay M; Rodgers, Mary; Conroy, Richard; Luo, James; Zhou, Ruixia; Seto, Belinda

2014-02-01

165

Clinical decision guidelines for NHS cosmetic surgery: analysis of current limitations and recommendations for future development.  

PubMed

Because of increasing demand for publicly funded elective cosmetic surgery, clinical decision guidelines have been developed to select those patients who should receive it. The aims of this study were to identify: the main characteristics of such guidelines; whether and how they influence clinical decision making; and ways in which they should be improved. UK health authorities were asked for their current guidelines for elective cosmetic surgery and, in a single plastic surgery unit, we examined the impact of its guidelines by observing consultations and interviewing surgeons and managers. Of 115 authorities approached, 32 reported using guidelines and provided sufficient information for analysis. Guidelines mostly concerned arbitrary sets of cosmetic procedures and lacked reference to an evidence base. They allowed surgery for specified anatomical, functional or symptomatic reasons, but these indications varied between guidelines. Most guidelines also permitted surgery 'exceptionally' for psychological reasons. The guidelines that were studied in detail did not appreciably influence surgeons' decisions, which reflected criteria that were not cited in the guidelines, including cost of the procedure and whether patients sought restoration or improvement of their appearance. Decision guidelines in this area have several limitations. Future guidelines should: include all cosmetic procedures; be informed by a broad range of evidence; and, arguably, include several nonclinical criteria that currently inform surgeons' decision-making. PMID:12890455

Cook, S A; Rosser, R; Meah, S; James, M I; Salmon, P

2003-07-01

166

45 CFR 307.5 - Mandatory computerized support enforcement systems.  

Code of Federal Regulations, 2011 CFR

...action taken to modify the system if the system contributed to the deficiency...disapproval is a final administrative decision and is not subject to administrative...FFP for costs of computerized support enforcement systems. (2) FFP for...

2011-10-01

167

45 CFR 307.5 - Mandatory computerized support enforcement systems.  

Code of Federal Regulations, 2010 CFR

...action taken to modify the system if the system contributed to the deficiency...disapproval is a final administrative decision and is not subject to administrative...FFP for costs of computerized support enforcement systems. (2) FFP for...

2010-10-01

168

The influence of providing a clinical practice guideline on dental students' decision making.  

PubMed

The aim of this study was to assess the effect of the provision of a clinical practice guideline (CPG) on dental students' decisions to remove asymptomatic, impacted lower third molars. All dental students, who in 2001 were in the 3rd, 4th or 5th (final) year of their study at the Nijmegen College of Dental Sciences, were invited to participate. A pre-test-post-test control group design was used. Given 36 patient cases, all dental students were asked to assess the need for removal of asymptomatic, impacted lower third molars. All pre-test respondents were randomly allocated to the control or intervention group. After the provision of a CPG to the intervention group, both groups were asked to assess the same cases again. Frequencies of decisions to remove the third molars were calculated. Chi-square tests and anova were used to test the influence of study year and gender on the drop-out rate and on the effect of the provision of a CPG on students' treatment decisions. The decrease in indications to remove third molars by the intervention group was statistically significant (P < 0.05). In the control group, no significant decrease was observed. It was concluded that the provision of a CPG significantly influences dental students' decision making about treatment in a third-molar decision task. Students who used the CPG showed more guideline-conformed decision making. PMID:14717683

van der Sanden, Wil J M; Mettes, Dirk G; Plasschaert, Alphons J M; Mulder, Jan; Verdonschot, Emiel H

2004-02-01

169

The Use of Intuition in Homeopathic Clinical Decision Making: An Interpretative Phenomenological Study  

PubMed Central

While intuition plays a role in clinical decision making within conventional medicine, little is understood about its use in complementary and alternative medicine (CAM). The aim of this qualitative study was to investigate intuition from the perspective of homeopathic practitioners; its' manifestation, how it was recognized, its origins and when it was used within daily clinical practice. Semi-structured interviews were carried out with clinically experienced non-National Health Service (NHS) UK homeopathic practitioners. Interpretative phenomenological analysis was used to analyze the data. Homeopaths reported many similarities with conventional medical practitioner regarding the nature, perceived origin and manifestation of their intuitions in clinical practice. Intuition was used in two key aspects of the consultation: (i) to enhance the practitioner-patient relationship, these were generally trusted; and (ii) intuitions relating to the prescribing decision. Homeopaths were cautious about these latter intuitions, testing any intuitive thoughts through deductive reasoning before accepting them. Their reluctance is not surprising given the consequences for patient care, but we propose this also reflects homeopaths' sensitivity to the academic and medical mistrust of both homeopathy and intuition. This study is the first to explore the use of intuition in decision making in any form of complementary medicine. The similarities with conventional practitioners may provide confidence in validating intuition as a legitimate part of the decision making process for these specific practitioners. Further work is needed to elucidate if these findings reflect intuitive use in clinical practice of other CAM practitioners in both private and NHS (i.e., time limited) settings. PMID:19773389

Brien, Sarah; Dibb, Bridget; Burch, Alex

2011-01-01

170

Molecular and protein markers for clinical decision making in breast cancer: today and tomorrow.  

PubMed

In early breast cancer (eBC), established clinicopathological factors are not sufficient for clinical decision making particularly regarding adjuvant chemotherapy since substantial over- or undertreatment may occur. Thus, novel protein- and molecular markers have been put forward as decision aids. Since these potential prognosis and/or predictive tests differ substantially regarding their methodology, analytical and clinical validation, this review attempts to summarize the essential facts for clinicians. This review focuses on those markers which are the most advanced so far in their development towards routine clinical application, i.e. two protein markers (i.e. uPA/PAI-1 and IHC4) and six molecular multigene tests (i.e. Mammaprint®, Oncotype DX®, PAM50, Endopredict®, the 97-gene genomic grade, and 76 gene Rotterdam signatures). Next to methodological aspects, we summarized the clinical evidences, in particular the main prospective clinical trials which have already been fully recruited (i.e. MINDACT, TAILORx, WSG PLAN B) or are still ongoing (i.e. RxPONDER/SWOG S1007, WSG-ADAPT). Last but not least, this review points out the key elements for clinicians to select one test among the wide panel of proposed assays, for a specific population of patients in term of level of evidence, analytical and clinical validity as well as cost effectiveness. PMID:24138841

Harbeck, Nadia; Sotlar, Karl; Wuerstlein, Rachel; Doisneau-Sixou, Sophie

2014-04-01

171

Evidence-based decision making in action: Part 2--evaluating and applying the clinical evidence.  

PubMed

This is the second of a two-part series addressing the use of evidence-based decision making (EBDM) in the use of home bleaching. In Part 1, a case scenario demonstrated the skills involved in (1) structuring a clinical question and (2) conducting an online search using PubMed.1 Part 2 demonstrates the third and fourth steps in the EBDM process, i.e., (3) critical appraisal to assess the validity of a study and (4) applying that information to clinical decision making. This 4-step approach to EBDM recognizes that clinicians can never be completely current with all conditions, medications, materials, and products. Thus, EBDM provides a mechanism for addressing these gaps in knowledge in order to provide the best care possible. PMID:12595932

Forrest, Jane L; Miller, Syrene A

2003-02-15

172

Workflow-based Data Reconciliation for Clinical Decision Support: Case of Colorectal Cancer Screening and Surveillance  

PubMed Central

A major barrier for computer-based clinical decision support (CDS), is the difficulty in obtaining the patient information required for decision making. The information gap is often due to deficiencies in the clinical documentation. One approach to address this gap is to gather and reconcile data from related documents or data sources. In this paper we consider the case of a CDS system for colorectal cancer screening and surveillance. We describe the use of workflow analysis to design data reconciliation processes. Further, we perform a quantitative analysis of the impact of these processes on system performance using a dataset of 106 patients. Results show that data reconciliation considerably improves the performance of the system. Our study demonstrates that, workflow-based data reconciliation can play a vital role in designing new-generation CDS systems that are based on complex guideline models and use natural language processing (NLP) to obtain patient data. PMID:24303280

Wagholikar, Kavishwar; Sohn, Sunghwan; Wu, Stephen; Kaggal, Vinod; Buehler, Sheila; Greenes, Robert A.; Wu, Tsung-Teh; Larson, David; Liu, Hongfang; Chaudhry, Rajeev; Boardman, Lisa

173

Impact of Court-Mandated Substance Abuse Treatment on Clinical Decision Making  

PubMed Central

California’s Proposition 36 offers nonviolent drug offenders community-based treatment as an alternative to incarceration or probation without treatment. The study objective was to examine how substance abuse treatment providers perceive the impact of Proposition 36 on their clinical decision making. Program surveys were completed by 115 treatment programs in five California counties to assess the impact of the law on clinical decision making, and five focus groups were conducted with 37 treatment providers to better understand their perspectives. Compared to residential programs, outpatient programs reported that the policy impacted them to a greater extent in terms of drug testing, reporting to criminal justice personnel, and determining client discharge. Providers in the focus groups particularly highlighted their changing roles in assessing clients’ treatment needs and determining the best routes of care for them. The findings indicate that alternate strategies for determining treatment placement and continuing care should be developed. PMID:18618265

Hamilton, Alison; Hser, Yih-Ing

2010-01-01

174

Lung Cancer Assistant: a hybrid clinical decision support application for lung cancer care  

PubMed Central

Multidisciplinary team (MDT) meetings are becoming the model of care for cancer patients worldwide. While MDTs have improved the quality of cancer care, the meetings impose substantial time pressure on the members, who generally attend several such MDTs. We describe Lung Cancer Assistant (LCA), a clinical decision support (CDS) prototype designed to assist the experts in the treatment selection decisions in the lung cancer MDTs. A novel feature of LCA is its ability to provide rule-based and probabilistic decision support within a single platform. The guideline-based CDS is based on clinical guideline rules, while the probabilistic CDS is based on a Bayesian network trained on the English Lung Cancer Audit Database (LUCADA). We assess rule-based and probabilistic recommendations based on their concordances with the treatments recorded in LUCADA. Our results reveal that the guideline rule-based recommendations perform well in simulating the recorded treatments with exact and partial concordance rates of 0.57 and 0.79, respectively. On the other hand, the exact and partial concordance rates achieved with probabilistic results are relatively poorer with 0.27 and 0.76. However, probabilistic decision support fulfils a complementary role in providing accurate survival estimations. Compared to recorded treatments, both CDS approaches promote higher resection rates and multimodality treatments. PMID:24990290

Sesen, M. Berkan; Peake, Michael D.; Banares-Alcantara, Rene; Tse, Donald; Kadir, Timor; Stanley, Roz; Gleeson, Fergus; Brady, Michael

2014-01-01

175

Gastric Polyps: A Review of Clinical, Endoscopic, and Histopathologic Features and Management Decisions  

PubMed Central

The increasing use of endoscopy has led to more discernable abnormalities in the stomach, including polyps. Gastric polyps encompass a spectrum of pathologic conditions that can vary in histology, neoplastic potential, and management. Despite their high prevalence, there is a paucity of literature to support management and treatment decisions for endoscopists. The goal of this review is to summarize clinical, endoscopic, and histopathologic features of various polyps, review syndromes associated with such polyps, and provide management recommendations. PMID:24764778

Islam, Rafiul Sameer; Patel, Neal C.; Lam-Himlin, Dora

2013-01-01

176

Utilizing Case-Based Reasoning and Multimedia to Enhance Clinical Decision Making of Novice Practitioners  

Microsoft Academic Search

Abstract This paper describes the outcomes,of a self-paced multimedia learning environment,designed to enhance critical thinking skills in clinical decision making,of graduate nurses entering the workforce. The multimedia-learning environment represents a contrived situation that simulates the complexities of life in a typical hospital ward, which places the users in the role of problem-solvers. Problem solving in the simulation is based on

Mary Oliver; Som Naidu; Andy Koronios

177

Governance for clinical decision support: case studies and recommended practices from leading institutions  

PubMed Central

Objective Clinical decision support (CDS) is a powerful tool for improving healthcare quality and ensuring patient safety; however, effective implementation of CDS requires effective clinical and technical governance structures. The authors sought to determine the range and variety of these governance structures and identify a set of recommended practices through observational study. Design Three site visits were conducted at institutions across the USA to learn about CDS capabilities and processes from clinical, technical, and organizational perspectives. Based on the results of these visits, written questionnaires were sent to the three institutions visited and two additional sites. Together, these five organizations encompass a variety of academic and community hospitals as well as small and large ambulatory practices. These organizations use both commercially available and internally developed clinical information systems. Measurements Characteristics of clinical information systems and CDS systems used at each site as well as governance structures and content management approaches were identified through extensive field interviews and follow-up surveys. Results Six recommended practices were identified in the area of governance, and four were identified in the area of content management. Key similarities and differences between the organizations studied were also highlighted. Conclusion Each of the five sites studied contributed to the recommended practices presented in this paper for CDS governance. Since these strategies appear to be useful at a diverse range of institutions, they should be considered by any future implementers of decision support. PMID:21252052

Sittig, Dean F; Ash, Joan S; Bates, David W; Feblowitz, Joshua; Fraser, Greg; Maviglia, Saverio M; McMullen, Carmit; Nichol, W Paul; Pang, Justine E; Starmer, Jack; Middleton, Blackford

2011-01-01

178

Privacy-preserving clinical decision support system using Gaussian kernel-based classification.  

PubMed

A clinical decision support system forms a critical capability to link health observations with health knowledge to influence choices by clinicians for improved healthcare. Recent trends toward remote outsourcing can be exploited to provide efficient and accurate clinical decision support in healthcare. In this scenario, clinicians can use the health knowledge located in remote servers via the Internet to diagnose their patients. However, the fact that these servers are third party and therefore potentially not fully trusted raises possible privacy concerns. In this paper, we propose a novel privacy-preserving protocol for a clinical decision support system where the patients' data always remain in an encrypted form during the diagnosis process. Hence, the server involved in the diagnosis process is not able to learn any extra knowledge about the patient's data and results. Our experimental results on popular medical datasets from UCI-database demonstrate that the accuracy of the proposed protocol is up to 97.21% and the privacy of patient data is not compromised. PMID:24403404

Rahulamathavan, Yogachandran; Veluru, Suresh; Phan, Raphael C-W; Chambers, Jonathon A; Rajarajan, Muttukrishnan

2014-01-01

179

Informational resources utilized in clinical decision making: common practices in dentistry.  

PubMed

This study investigated current trends of Iowa dental practitioners with regard to acquisition and utilization of scientific information resources to support decision making in the clinical practice of dentistry. A survey questionnaire regarding the utilization of various sources of information to support clinical decisions was mailed in September 2009 to all dentists licensed and practicing in the state of Iowa. Dentists appointed full-time within the University of Iowa College of Dentistry were excluded from this study. Continuing education courses were the most frequently utilized and preferred information source by respondents, followed by print journals and consultation with other health care professionals. Practice patterns according to decade of dental school graduation as well as scope of practice were noted. The results of this study demonstrate that dental practitioners utilize a variety of evidence-based and non-evidence-based information resources to support decisions in clinical practice. The habits of newer graduates vary somewhat from those of earlier graduates; the habits of specialists vary from those of general practitioners. PMID:21460265

Straub-Morarend, Cheryl L; Marshall, Teresa A; Holmes, David C; Finkelstein, Michael W

2011-04-01

180

Critical care outreach: the need for effective decision-making in clinical practice (Part 1).  

PubMed

Since the publication of 'Comprehensive Critical Care' (2000) critical care outreach (CCOR) services have been developed to meet the needs of patients through critical care provision 'without walls'. Now embedded nationally, CCOR is a central part of health care delivery in the National Health Service (NHS). To date, approximately 75% of hospitals in England have introduced and developed the service according, at least to some extent, to local needs and resources. While this has resulted in a somewhat inconsistent approach to the development and configuration of these services, a number of common elements remain. Arguably, effective clinical decision-making by CCOR practitioners is fundamental to efficient patient care management and the success of these services. In its examination of CCOR service provision this, the first of two papers, addresses the theoretical background of clinical decision making and the knowledge that underpins practice in CCOR. In the second paper, through collaborative reflection and analysis of a case study, the authors bring these together in a process that illuminates the realities of clinical decision making for CCOR practitioners. From this, recommendations are made about the future development of CCOR practitioners and services. PMID:16949289

Hancock, Helen C; Durham, Lesley

2007-02-01

181

Combining decision support methodologies to diagnose pneumonia.  

PubMed Central

OBJECTIVE: To evaluate the performance of a computerized decision support system that combines two different decision support methodologies (a Bayesian network and a natural language understanding system) for the diagnosis of patients with pneumonia. DESIGN: Evaluation study using data from a prospective, clinical study. PATIENTS: All patients 18 years and older who presented to the emergency department of a tertiary care setting and whose chest x-ray report was available during the encounter. METHODS: The computerized decision support system calculated a probability of pneumonia using information provided by the two systems. Outcome measures were the area under the receiver operating characteristic curve, sensitivity, specificity, predictive values, likelihood ratios, and test effectiveness. RESULTS: During the 3-month study period there were 742 patients (45 with pneumonia). The area under the receiver operating characteristic curve was 0.881 (95% CI: 0.822, 0.925) for the Bayesian network alone and 0.916 (95% CI: 0.869, 0.949) for the Bayesian network combined with the natural language understanding system (p=0.01). CONCLUSION: Combining decision support methodologies that process information stored in different data formats can increase the performance of a computerized decision support system. PMID:11825148

Aronsky, D.; Fiszman, M.; Chapman, W. W.; Haug, P. J.

2001-01-01

182

Impact of clinical and health services research projects on decision-making: a qualitative study  

PubMed Central

Background This article reports on the impact assessment experience of a funding program of non-commercial clinical and health services research. The aim was to assess the level of implementation of results from a subgroup of research projects (on respiratory diseases), and to detect barriers (or facilitators) in the translation of new knowledge to informed decision-making. Methods A qualitative study was performed. The sample consisted of six projects on respiratory diseases funded by the Agency for Health Quality and Assessment of Catalonia between 1996 and 2004. Semi-structured interviews to key informants including researchers and healthcare decision-makers were carried out. Interviews were recorded, transcribed verbatim and analysed on an individual (key informant) and group (project) basis. In addition, the differences between achieved and expected impacts were described. Results Twenty-three semi-structured interviews were conducted. Most participants indicated changes in health services or clinical practice had resulted from research. The channels used to transfer new knowledge were mainly conventional ones, but also in less explicit ways, such as with the involvement of local scientific societies, or via debates and discussions with colleagues and local leaders. The barriers and facilitators identified were mostly organizational (in research management, and clinical and healthcare practice), although there were also some related to the nature of the research as well as personal factors. Both the expected and achieved impacts enabled the identification of the gaps between what is expected and what is truly achieved. Conclusions In this study and according to key informants, the impact of these research projects on decision-making can be direct (the application of a finding or innovation) or indirect, contributing to a more complex change in clinical practice and healthcare organization, both having other contextual factors. The channels used to transfer this new knowledge to clinical practice are complex. Local scientific societies and the relationships between researchers and decision-makers can play a very important role. Specifically, the relationships between managers and research teams and the mutual knowledge of their activity have shown to be effective in applying research funding to practice and decision-making. Finally the facilitating factors and barriers identified by the respondents are closely related to the idiosyncrasy of the human relations between the different stakeholders involved. PMID:23663364

2013-01-01

183

The Need for Clinical Decision Support Integrated with the Electronic Health Record for the Clinical Application of Whole Genome Sequencing Information  

PubMed Central

Whole genome sequencing (WGS) is rapidly approaching widespread clinical application. Technology advancements over the past decade, since the first human genome was decoded, have made it feasible to use WGS for clinical care. Future advancements will likely drive down the price to the point wherein WGS is routinely available for care. However, were this to happen today, most of the genetic information available to guide clinical care would go unused due to the complexity of genetics, limited physician proficiency in genetics, and lack of genetics professionals in the clinical workforce. Furthermore, these limitations are unlikely to change in the future. As such, the use of clinical decision support (CDS) to guide genome-guided clinical decision-making is imperative. In this manuscript, we describe the barriers to widespread clinical application of WGS information, describe how CDS can be an important tool for overcoming these barriers, and provide clinical examples of how genome-enabled CDS can be used in the clinical setting.

Welch, Brandon M.; Kawamoto, Kensaku

2014-01-01

184

Students' stereotypes of patients as barriers to clinical decision-making.  

PubMed

The ability to formulate quick, accurate clinical judgments is stressed in medical training. Speed is usually an asset when a physician sorts through his biomedical knowledge, but it is often a liability when the physician assesses the sociocultural context of a clinical encounter. At the Michigan State University College of Osteopathic Medicine, a study was designed which graphically illustrated to beginning students that unconscious sociocultural stereotypes may influence clinical decision-making. Three entering classes of students were shown a videotape depicting five simulated patients (attractive black woman, attractive white woman, professional man, middle-aged housewife, and elderly man), each presenting with the same physical complaint. Elements of positive and negative stereotypes were incorporated into each of the portrayals, and the students rated these patients on positive and negative characteristics. The results suggested that the students attributed both positive and negative characteristics to patients on the basis of irrelevant characteristics, such as attractiveness, and with little further justification for their attributions. Such stereotypic generalizations held by students may become barriers to the students' objective clinical decision-making. PMID:3755759

Johnson, S M; Kurtz, M E; Tomlinson, T; Howe, K R

1986-09-01

185

Genetic Stratification in Myeloid Diseases: From Risk Assessment to Clinical Decision Support Tool  

PubMed Central

Genetic aberrations have become a dominant factor in the stratification of myeloid malignancies. Cytogenetic and a few mutation studies are the backbone of risk assessment models of myeloid malignancies which are a major consideration in clinical decisions, especially patient assignment for allogeneic stem cell transplantation. Progress in our understanding of the genetic basis of the pathogenesis of myeloid malignancies and the growing capabilities of mass sequencing may add new roles for the clinical usage of genetic data. A few recently identified mutations recognized to be associated with specific diseases or clinical scenarios may soon become part of the diagnostic criteria of such conditions. Mutational studies may also advance our capabilities for a more efficient patient selection process, assigning the most effective therapy at the best timing for each patient. The clinical utility of genetic data is anticipated to advance further with the adoption of deep sequencing and next-generation sequencing techniques. We herein suggest some future potential applications of sequential genetic data to identify pending deteriorations at time points which are the best for aggressive interventions such as allogeneic stem cell transplantation. Genetics is moving from being mostly a prognostic factor to becoming a multitasking decision support tool for hematologists. Physicians must pay attention to advances in molecular hematology as it will soon be accessible and influential for most of our patients. PMID:25386341

Ofran, Yishai

2014-01-01

186

Technical desiderata for the integration of genomic data with clinical decision support.  

PubMed

The ease with which whole genome sequence (WGS) information can be obtained is rapidly approaching the point where it can become useful for routine clinical care. However, significant barriers will inhibit widespread adoption unless clinicians are able to effectively integrate this information into patient care and decision-making. Electronic health records (EHR) and clinical decision support (CDS) systems may play a critical role in this integration. A previously published technical desiderata focused primarily on the integration of genomic data into the EHR. This manuscript extends the previous desiderata by specifically addressing needs related to the integration of genomic information with CDS. The objective of this study is to develop and validate a guiding set of technical desiderata for supporting the clinical use of WGS through CDS. A panel of domain experts in genomics and CDS developed a proposed set of seven additional requirements. These desiderata were reviewed by 63 experts in genomics and CDS through an online survey and refined based on the experts' comments. These additional desiderata provide important guiding principles for the technical development of CDS capabilities for the clinical use of WGS information. PMID:24931434

Welch, Brandon M; Eilbeck, Karen; Del Fiol, Guilherme; Meyer, Laurence J; Kawamoto, Kensaku

2014-10-01

187

Eye tracking users of a visual diagnostic clinical decision support system to discover decision-making strategies and to inform user interface design.  

PubMed

Clinical decision support systems (CDSS) assist physicians and other medical professionals in tasks such as differential diagnosis. End users may use different decision-making strategies depending on medical training. Study of eye movements reveals information processing strategies that are executed at a level below consciousness. Eye tracking of student physician assistants and medical residents, while using a visual diagnostic CDSS in diagnostic tasks, showed adoption of distinct strategies and informed recommendations for effective user interface design. PMID:18999126

Haake, Anne R; Pelz, Jeff B; Smagner, Jessica; Colombo, Daniel; Lindsay, Laura; Papier, Art

2008-01-01

188

Decision Tree for Data and Safety Monitoring for Clinical Trials Human Subjects involved? (even if exempted under 45 CFR 46)?  

E-print Network

Decision Tree for Data and Safety Monitoring for Clinical Trials YES NO YES NO YES NO Human not applyIs a Clinical Trial proposed (any Phase) ? Is the Data and Safety Monitoring Plan Acceptable? 1-site clinical trials of interventions with potential risk to participants. Plan not required UNACCEPTABLE

Rau, Don C.

189

Use of electronic health records and clinical decision support systems for antimicrobial stewardship.  

PubMed

Electronic health records (EHRs) and clinical decision support systems (CDSSs) have the potential to enhance antimicrobial stewardship. Numerous EHRs and CDSSs are available and have the potential to enable all clinicians and antimicrobial stewardship programs (ASPs) to more efficiently review pharmacy, microbiology, and clinical data. Literature evaluating the impact of EHRs and CDSSs on patient outcomes is lacking, although EHRs with integrated CDSSs have demonstrated improvements in clinical and economic outcomes. Both technologies can be used to enhance existing ASPs and their implementation of core ASP strategies. Resolution of administrative, legal, and technical issues will enhance the acceptance and impact of these systems. EHR systems will increase in value when manufacturers include integrated ASP tools and CDSSs that do not require extensive commitment of information technology resources. Further research is needed to determine the true impact of current systems on ASP and the ultimate goal of improved patient outcomes through optimized antimicrobial use. PMID:25261539

Forrest, Graeme N; Van Schooneveld, Trevor C; Kullar, Ravina; Schulz, Lucas T; Duong, Phu; Postelnick, Michael

2014-10-15

190

ASSESSMENT OF UPPER EXTREMITY IMPAIRMENT, FUNCTION, AND ACTIVITY FOLLOWING STROKE: FOUNDATIONS FOR CLINICAL DECISION MAKING  

PubMed Central

The purpose of this review is to provide a comprehensive approach for assessing the upper extremity (UE) after stroke. First, common upper extremity impairments and how to assess them are briefly discussed. While multiple UE impairments are typically present after stroke, the severity of one impairment, paresis, is the primary determinant of UE functional loss. Second, UE function is operationally defined and a number of clinical measures are discussed. It is important to consider how impairment and loss of function affect UE activity outside of the clinical environment. Thus, this review also identifies accelerometry as an objective method for assessing UE activity in daily life. Finally, the role that each of these levels of assessment should play in clinical decision making is discussed in order to optimize the provision of stroke rehabilitation services. PMID:22975740

Lang, Catherine E.; Bland, Marghuretta D.; Bailey, Ryan R.; Schaefer, Sydney Y.; Birkenmeier, Rebecca L.

2012-01-01

191

Structured representation for core elements of common clinical decision support interventions to facilitate knowledge sharing.  

PubMed

At present, there are no widely accepted, standard approaches for representing computer-based clinical decision support (CDS) intervention types and their structural components. This study aimed to identify key requirements for the representation of five widely utilized CDS intervention types: alerts and reminders, order sets, infobuttons, documentation templates/forms, and relevant data presentation. An XML schema was proposed for representing these interventions and their core structural elements (e.g., general metadata, applicable clinical scenarios, CDS inputs, CDS outputs, and CDS logic) in a shareable manner. The schema was validated by building CDS artifacts for 22 different interventions, targeted toward guidelines and clinical conditions called for in the 2011 Meaningful Use criteria. Custom style sheets were developed to render the XML files in human-readable form. The CDS knowledge artifacts were shared via a public web portal. Our experience also identifies gaps in existing standards and informs future development of standards for CDS knowledge representation and sharing. PMID:23920543

Zhou, Li; Hongsermeier, Tonya; Boxwala, Aziz; Lewis, Janet; Kawamoto, Kensaku; Maviglia, Saverio; Gentile, Douglas; Teich, Jonathan M; Rocha, Roberto; Bell, Douglas; Middleton, Blackford

2013-01-01

192

Formative evaluation of the accuracy of a clinical decision support system for cervical cancer screening  

PubMed Central

Objectives We previously developed and reported on a prototype clinical decision support system (CDSS) for cervical cancer screening. However, the system is complex as it is based on multiple guidelines and free-text processing. Therefore, the system is susceptible to failures. This report describes a formative evaluation of the system, which is a necessary step to ensure deployment readiness of the system. Materials and methods Care providers who are potential end-users of the CDSS were invited to provide their recommendations for a random set of patients that represented diverse decision scenarios. The recommendations of the care providers and those generated by the CDSS were compared. Mismatched recommendations were reviewed by two independent experts. Results A total of 25 users participated in this study and provided recommendations for 175 cases. The CDSS had an accuracy of 87% and 12 types of CDSS errors were identified, which were mainly due to deficiencies in the system's guideline rules. When the deficiencies were rectified, the CDSS generated optimal recommendations for all failure cases, except one with incomplete documentation. Discussion and conclusions The crowd-sourcing approach for construction of the reference set, coupled with the expert review of mismatched recommendations, facilitated an effective evaluation and enhancement of the system, by identifying decision scenarios that were missed by the system's developers. The described methodology will be useful for other researchers who seek rapidly to evaluate and enhance the deployment readiness of complex decision support systems. PMID:23564631

Wagholikar, Kavishwar Balwant; MacLaughlin, Kathy L; Kastner, Thomas M; Casey, Petra M; Henry, Michael; Greenes, Robert A; Liu, Hongfang; Chaudhry, Rajeev

2013-01-01

193

The influence of patient's age on clinical decision-making about coronary heart disease in the USA and the UK  

Microsoft Academic Search

This paper examines UK and US primary care doctors' decision-making about older (aged 75 years) and midlife (aged 55 years) patients presenting with coronary heart disease (CHD). Using an analytic approach based on conceptualising clinical decision-making as a classification process, it explores the ways in which doctors' cognitive processes contribute to ageism in health-care at three key decision points during

ANN ADAMS; CHRISTOPHER D. BUCKINGHAM; SARA ARBER; JOHN B. MCKINLAY; LISA MARCEAU; CAROL LINK

2006-01-01

194

Computerized Energy Information Sources  

E-print Network

Many computerized files of energy- and energy conservation-related information are currently available through commercial and governmental sources such as Lockheed Information Systems, System Development Corporation, and DOE/RECON. Private...

Gordon, D.

1979-01-01

195

Computerized Adaptive Testing.  

ERIC Educational Resources Information Center

Describes a system in which questions tailored to the examinee's capabilities are administered by computer. Enumerates possible benefits of the system, reviews the "state of the art," and predicts potential applications of computerized adaptive testing. (MCG)

McBride, James R.

1985-01-01

196

Utility analysis for clinical decision-making in small treatment settings.  

PubMed

Data-driven clinical decision-making can be difficult in settings that service relatively few patients because of the small samples available, the patients' potential dissimilarity from participants in published research, and highly limited resources. This study was designed to demonstrate how utility analyses might assist clinical decision-making in small treatment settings and provide data for promoting programmatic improvements. Data came from a study to identify rural juvenile delinquents suspected to not benefit from residential behavioral treatment. A prospective correlational design was used with data from a midwestern juvenile criminal justice residential unit in which about 30 males were treated annually. Outcomes included treatment performance measures and number of delinquent offenses during the year after treatment. Utility analyses suggested that delinquents who were less likely to benefit from residential treatment could be identified a priori using a modified Psychopathy Checklist, Revised. Cost utility analysis estimated $180,000 less would be spent on residential treatment as a result of selecting residents based on the pretreatment assessment. This money might be reallocated toward alternative intervention for delinquents who are not likely to benefit from the residential treatment. More importantly, results suggested specific alternative interventions for the delinquents who were less likely to benefit from the treatment by providing direct links to existing literature. Advantages of utility analysis research include strong external validity, minimal interference with treatment during data collection, results that estimate clinical and practical significance, and results that are easily communicated to laymen. PMID:12803143

Ridenour, Ty A; Treloar, James H; Dean, Raymond S

2003-03-01

197

Instruments to assess the perception of physicians in the decision-making process of specific clinical encounters: a systematic review  

Microsoft Academic Search

BACKGROUND: The measurement of processes and outcomes that reflect the complexity of the decision-making process within specific clinical encounters is an important area of research to pursue. A systematic review was conducted to identify instruments that assess the perception physicians have of the decision-making process within specific clinical encounters. METHODS: For every year available up until April 2007, PubMed, PsycINFO,

David Moher; Glyn Elwyn; Annie LeBlanc; Karine Gravel

2007-01-01

198

Systematic review of clinical decision support interventions with potential for inpatient cost reduction  

PubMed Central

Background Healthcare costs are increasing rapidly and at an unsustainable rate in many countries, and inpatient hospitalizations are a significant driver of these costs. Clinical decision support (CDS) represents a promising approach to not only improve care but to reduce costs in the inpatient setting. The purpose of this study was to systematically review trials of CDS interventions with the potential to reduce inpatient costs, so as to identify promising interventions for more widespread implementation and to inform future research in this area. Methods To identify relevant studies, MEDLINE was searched up to July 2013. CDS intervention studies with the potential to reduce inpatient healthcare costs were identified through titles and abstracts, and full text articles were reviewed to make a final determination on inclusion. Relevant characteristics of the studies were extracted and summarized. Results Following a screening of 7,663 articles, 78 manuscripts were included. 78.2% of studies were controlled before-after studies, and 15.4% were randomized controlled trials. 53.8% of the studies were focused on pharmacotherapy. The majority of manuscripts were published during or after 2008. 70.5% of the studies resulted in statistically and clinically significant improvements in an explicit financial measure or a proxy financial measure. Only 12.8% of the studies directly measured the financial impact of an intervention, whereas the financial impact was inferred in the remainder of studies. Data on cost effectiveness was available for only one study. Conclusions Significantly more research is required on the impact of clinical decision support on inpatient costs. In particular, there is a remarkable gap in the availability of cost effectiveness studies required by policy makers and decision makers in healthcare systems. PMID:24344752

2013-01-01

199

Lambdoid synostosis and occipital plagiocephaly: clinical decision rules for surgical intervention.  

PubMed

Lambdoid craniosynostosis has been regarded as one of the least common categories of premature fusion of the cranial sutures, yet reports have suggested the incidence may be increasing. To guide treatment decisions, the authors describe a set of rules based on radiographic indicators and clinical assessment in the child. Experience suggests that children can have abnormal-appearing cranial sutures with normal neurological status and normal-appearing sutures with neurological deficits or marked cerebral compression. Early evaluation and follow-up treatment is essential for children with suspected craniosynostosis. PMID:15096021

Carson, B S; James, C S; VanderKolk, C A; Guarnieri, M

1997-02-15

200

Computerized Grading of Anatomy Laboratory Practical Examinations  

ERIC Educational Resources Information Center

At the Medical College of Wisconsin, a procedure was developed to allow computerized grading and grade reporting of laboratory practical examinations in the Clinical Human Anatomy course. At the start of the course, first year medical students were given four Lists of Structures. On these lists, numbered items were arranged alphabetically; the…

Krippendorf, Beth B.; Bolender, David L.; Kolesari, Gary L.

2008-01-01

201

The Nijmegen Decision Tool for Chronic Low Back Pain. Development of a Clinical Decision Tool for Secondary or Tertiary Spine Care Specialists  

PubMed Central

Background In Western Europe, low back pain has the greatest burden of all diseases. When back pain persists, different medical specialists are involved and a lack of consensus exists among these specialists for medical decision-making in Chronic Low Back Pain (CLBP). Objective To develop a decision tool for secondary or tertiary spine care specialists to decide which patients with CLBP should be seen by a spine surgeon or by other non-surgical medical specialists. Methods A Delphi study was performed to identify indicators predicting the outcome of interventions. In the preparatory stage evidence from international guidelines and literature were summarized. Eligible studies were reviews and longitudinal studies. Inclusion criteria: surgical or non-surgical interventions and persistence of complaints, CLBP-patients aged 18–65 years, reported baseline measures of predictive indicators, and one or more reported outcomes had to assess functional status, quality of life, pain intensity, employment status or a composite score. Subsequently, a three-round Delphi procedure, to reach consensus on candidate indicators, was performed among a multidisciplinary panel of 29 CLBP-professionals (>five years CLBP-experience). The pre-set threshold for general agreement was ?70%. The final indicator set was used to develop a clinical decision tool. Results A draft list with 53 candidate indicators (38 with conclusive evidence and 15 with inconclusive evidence) was included for the Delphi study. Consensus was reached to include 47 indicators. A first version of the decision tool was developed, consisting of a web-based screening questionnaire and a provisional decision algorithm. Conclusions This is the first clinical decision tool based on current scientific evidence and formal multidisciplinary consensus that helps referring the patient for consultation to a spine surgeon or a non-surgical spine care specialist. We expect that this tool considerably helps in clinical decision-making spine care, thereby improving efficient use of scarce sources and the outcomes of spinal interventions. PMID:25133645

van Hooff, Miranda L.; van Loon, Jan; van Limbeek, Jacques; de Kleuver, Marinus

2014-01-01

202

Which factors play a role in clinical decision-making in subfertility?  

PubMed

Sixteen vignettes of subfertile couples were constructed by varying fertility history, post-coital test, sperm motility, FSH concentration and Chlamydia antibody titre (CAT). Thirty-five gynaecologists estimated probabilities of treatment-independent pregnancy, intrauterine insemination (IUI) and IVF. Thereafter, they chose IUI, IVF or no treatment. The relative contribution of each factor to probability estimates and to subsequent treatment decisions was calculated. Duration of subfertility and maternal age were the most important contributors for gynaecologists' estimates of treatment-independent pregnancy [relative contribution (RC) 41, 26%]. Maternal age and FSH concentration were the most important contributors in the estimates for IUI (RC: 51, 25%) and for IVF (RC: 64, 31%). The decision to start IVF was mainly determined by maternal age, duration of subfertility, FSH concentration and CAT. The relative contribution of maternal age and duration of subfertility was in concordance with existing prediction models, whereas previous pregnancy and FSH concentration were under- and overestimated respectively. In conclusion, maternal age, duration of subfertility and FSH concentration are the main factors in clinical decision-making in subfertility. Gynaecologists overestimate the importance of FSH concentration, but underestimate that of a previous pregnancy, as compared with their importance reported in prediction models and guidelines. PMID:16740221

van der Steeg, Jan W; Steures, Pieternel; Eijkemans, Marinus J C; Habbema, J Dik F; Bossuyt, Patrick M M; Hompes, Peter G A; van der Veen, Fulco; Mol, Ben W J

2006-04-01

203

The effect of the first office blood pressure reading on hypertension-related clinical decisions.  

PubMed

The effect of the first office blood pressure reading (FBPR) on hypertension-related decisions was evaluated using blood pressure (BP) readings taken with the BpTRU BPM-100 device. BP readings were grouped into three pairs: (1) single readings (first and second readings), (2) computed average of three readings (one including and one excluding the first reading), and (3) computed average of five readings (one including and one excluding the first reading). Categorisation of BP readings under JNC-7 classes and distribution into < 140/90 and ? 140/90 mmHg groups were selected as parameters guiding hypertension-related decisions. Readings including FBPR had strong positive correlations to those excluding FBPR (Pearson's correlation coefficient ranged from 0.86-1.00). Also, FBPR-included and FBPR-excluded readings did not differ statistically in JNC-7 categorisation or distribution into < 140/90 or ? 140/90 mmHg groups. Our findings suggest that exclusion of FBPR may have no significant impact on hypertension-related clinical decisions. PMID:23044502

Oladipo, Idris; Ayoade, Adedokun

2012-09-01

204

Principles of educational outreach ('academic detailing') to improve clinical decision making.  

PubMed

With the efficacy and costs of medications rising rapidly, it is increasingly important to ensure that drugs be prescribed as rationally as possible. Yet, physicians' choices of drugs frequently fall short of the ideal of precise and cost-effective decision making. Evidence indicates that such decisions can be improved in a variety of ways. A number of theories and principles of communication and behavior changes can be found that underlie the success of pharmaceutical manufacturers in influencing prescribing practices. Based on this behavioral science and several field trials, it is possible to define the theory and practice of methods to improve physicians' clinical decision making to enhance the quality and cost-effectiveness of care. Some of the most important techniques of such "academic detailing" include (1) conducting interviews to investigate baseline knowledge and motivations for current prescribing patterns, (2) focusing programs on specific categories of physicians as well as on their opinion leaders, (3) defining clear educational and behavioral objectives, (4) establishing credibility through a respected organizational identity, referencing authoritative and unbiased sources of information, and presenting both sides of controversial issues, (5) stimulating active physician participation in educational interactions, (6) using concise graphic educational materials, (7) highlighting and repeating the essential messages, and (8) providing positive reinforcement of improved practices in follow-up visits. Used by the nonprofit sector, the above techniques have been shown to reduce inappropriate prescribing as well as unnecessary health care expenditures. PMID:2104640

Soumerai, S B; Avorn, J

1990-01-26

205

Application of a diagnosis-based clinical decision guide in patients with low back pain  

PubMed Central

Background Low back pain (LBP) is common and costly. Development of accurate and efficacious methods of diagnosis and treatment has been identified as a research priority. A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based means to apply the biopsychosocial model of care. The approach is based on three questions of diagnosis. The purpose of this study is to present the prevalence of findings using the DBCDG in consecutive patients with LBP. Methods Demographic, diagnostic and baseline outcome measure data were gathered on a cohort of LBP patients examined by one of three examiners trained in the application of the DBCDG. Results Data were gathered on 264 patients. Signs of visceral disease or potentially serious illness were found in 2.7%. Centralization signs were found in 41%, lumbar and sacroiliac segmental signs in 23% and 27%, respectively and radicular signs were found in 24%. Clinically relevant myofascial signs were diagnosed in 10%. Dynamic instability was diagnosed in 63%, fear beliefs in 40%, central pain hypersensitivity in 5%, passive coping in 3% and depression in 3%. Conclusion The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as inter-examiner reliability and efficacy of treatment based on the DBCDG. PMID:22018026

2011-01-01

206

Application of a diagnosis-based clinical decision guide in patients with neck pain  

PubMed Central

Background Neck pain (NP) is a common cause of disability. Accurate and efficacious methods of diagnosis and treatment have been elusive. A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based guide in applying the biopsychosocial model of care. The approach is based on three questions of diagnosis. The purpose of this study is to present the prevalence of findings using the DBCDG in consecutive patients with NP. Methods Demographic, diagnostic and baseline outcome measure data were gathered on a cohort of NP patients examined by one of three examiners trained in the application of the DBCDG. Results Data were gathered on 95 patients. Signs of visceral disease or potentially serious illness were found in 1%. Centralization signs were found in 27%, segmental pain provocation signs were found in 69% and radicular signs were found in 19%. Clinically relevant myofascial signs were found in 22%. Dynamic instability was found in 40%, oculomotor dysfunction in 11.6%, fear beliefs in 31.6%, central pain hypersensitivity in 4%, passive coping in 5% and depression in 2%. Conclusion The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, oculomotor dysfunction, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as inter-examiner reliability, validity and efficacy of treatment based on the DBCDG. PMID:21871119

2011-01-01

207

Decision support systems for clinical radiological practice -- towards the next generation.  

PubMed

The huge amount of information that needs to be assimilated in order to keep pace with the continued advances in modern medical practice can form an insurmountable obstacle to the individual clinician. Within radiology, the recent development of quantitative imaging techniques, such as perfusion imaging, and the development of imaging-based biomarkers in modern therapeutic assessment has highlighted the need for computer systems to provide the radiological community with support for academic as well as clinical/translational applications. This article provides an overview of the underlying design and functionality of radiological decision support systems with examples tracing the development and evolution of such systems over the past 40 years. More importantly, we discuss the specific design, performance and usage characteristics that previous systems have highlighted as being necessary for clinical uptake and routine use. Additionally, we have identified particular failings in our current methodologies for data dissemination within the medical domain that must be overcome if the next generation of decision support systems is to be implemented successfully. PMID:20965900

Stivaros, S M; Gledson, A; Nenadic, G; Zeng, X-J; Keane, J; Jackson, A

2010-11-01

208

Clinical decision making in a patient with secondary hip-spine syndrome.  

PubMed

The prevalence of lumbar and hip pathology is on the rise; however, treatment outcomes have not improved, highlighting the difficulty in identifying and treating the correct impairments. The purpose of this case report is to describe the clinical decision making in the examination and treatment of an individual with secondary hip-spine syndrome. Our case study was a 62-year-old male with low back pain with concomitant right hip pain. His Oswestry Disability Index (ODI) was 18%, back numeric pain rating scale (NPRS) was 4/10, fear avoidance beliefs questionnaire (FABQ) work subscale was 0, FABQ physical activity subscale was 18, and patient specific functional scale (PSFS) was 7.33. Physical examination revealed findings consistent with secondary hip-spine syndrome. He was treated for four visits with joint mobilization/manipulation and strengthening exercises directed at the hip. At discharge, all standardized outcome measures achieved full resolution. Clinical decision making in the presence of lumbopelvic-hip pain is often difficult. Previous literature has shown that some patients with lumbopelvic-hip pain respond favorably to manual therapy and exercise targeting regions adjacent to the lumbar spine. The findings of this case report suggest that individuals with a primary complaint of LBP with hip impairments may benefit from interventions to reduce hip impairments. PMID:20795876

Burns, Scott A; Mintken, Paul E; Austin, Gary P

2011-07-01

209

A Mathematical Model for Interpretable Clinical Decision Support with Applications in Gynecology  

PubMed Central

Background Over time, methods for the development of clinical decision support (CDS) systems have evolved from interpretable and easy-to-use scoring systems to very complex and non-interpretable mathematical models. In order to accomplish effective decision support, CDS systems should provide information on how the model arrives at a certain decision. To address the issue of incompatibility between performance, interpretability and applicability of CDS systems, this paper proposes an innovative model structure, automatically leading to interpretable and easily applicable models. The resulting models can be used to guide clinicians when deciding upon the appropriate treatment, estimating patient-specific risks and to improve communication with patients. Methods and Findings We propose the interval coded scoring (ICS) system, which imposes that the effect of each variable on the estimated risk is constant within consecutive intervals. The number and position of the intervals are automatically obtained by solving an optimization problem, which additionally performs variable selection. The resulting model can be visualised by means of appealing scoring tables and color bars. ICS models can be used within software packages, in smartphone applications, or on paper, which is particularly useful for bedside medicine and home-monitoring. The ICS approach is illustrated on two gynecological problems: diagnosis of malignancy of ovarian tumors using a dataset containing 3,511 patients, and prediction of first trimester viability of pregnancies using a dataset of 1,435 women. Comparison of the performance of the ICS approach with a range of prediction models proposed in the literature illustrates the ability of ICS to combine optimal performance with the interpretability of simple scoring systems. Conclusions The ICS approach can improve patient-clinician communication and will provide additional insights in the importance and influence of available variables. Future challenges include extensions of the proposed methodology towards automated detection of interaction effects, multi-class decision support systems, prognosis and high-dimensional data. PMID:22479598

Van Belle, Vanya M. C. A.; Van Calster, Ben; Timmerman, Dirk; Bourne, Tom; Bottomley, Cecilia; Valentin, Lil; Neven, Patrick; Van Huffel, Sabine; Suykens, Johan A. K.; Boyd, Stephen

2012-01-01

210

A Proposed Clinical Decision Support Architecture Capable of Supporting Whole Genome Sequence Information  

PubMed Central

Whole genome sequence (WGS) information may soon be widely available to help clinicians personalize the care and treatment of patients. However, considerable barriers exist, which may hinder the effective utilization of WGS information in a routine clinical care setting. Clinical decision support (CDS) offers a potential solution to overcome such barriers and to facilitate the effective use of WGS information in the clinic. However, genomic information is complex and will require significant considerations when developing CDS capabilities. As such, this manuscript lays out a conceptual framework for a CDS architecture designed to deliver WGS-guided CDS within the clinical workflow. To handle the complexity and breadth of WGS information, the proposed CDS framework leverages service-oriented capabilities and orchestrates the interaction of several independently-managed components. These independently-managed components include the genome variant knowledge base, the genome database, the CDS knowledge base, a CDS controller and the electronic health record (EHR). A key design feature is that genome data can be stored separately from the EHR. This paper describes in detail: (1) each component of the architecture; (2) the interaction of the components; and (3) how the architecture attempts to overcome the challenges associated with WGS information. We believe that service-oriented CDS capabilities will be essential to using WGS information for personalized medicine.

Welch, Brandon M.; Loya, Salvador Rodriguez; Eilbeck, Karen; Kawamoto, Kensaku

2014-01-01

211

The clinical management of suspected herpes virus encephalitis. A decision-analytic view.  

PubMed

This study addresses the issues of brain biopsy and adenine arabinoside (Ara-A) therapy in the clinical management of patients suspected of having herpes simplex virus encephalitis (HVE). The analysis does not speak to experimental studies in which brain biopsy and new therapies are justified by investigational goals outside the scope of this analysis. Decision analytic techniques are used, employing published quantitative data and subjective estimates of probabilities provided by experts in the management of this condition. In patients with features indicative of a high likelihood of HVE--evidence of acute encephalopathy, focal cerebral signs, objective evidence of localization and cerebrospinal-fluid findings compatible with viral infection--a strategy of treating with Ara-A without brain biopsy is consistent with optimal survival under current central estimates for mortality at biopsy, therapeutic effectiveness, drug toxicity, and sensitivity and specificity of brain biopsy. This results depends primarily upon the apparent low toxicity of Ara-A, the relatively high likelihood of HVE in typical clinical presentations and the presence, although at a low rate, of falsely negative biopsy reports expected in the disease. Sensitivity analyses are presented to explore the effects of changes in estimates of values for important variables on the choice of a strategy for clinical management. The analysis provides a structure for assessing the clinical significance of new information on such relevant variables as drug toxicity, biopsy sensitivity and mortality, and the yield of treatable new conditions other than HVE diagnosed by brain biopsy. PMID:7446555

Braun, P

1980-12-01

212

Computerized Mastery Testing With Nonequivalent Testlets  

Microsoft Academic Search

A procedure for determining the effect of testlet nonequivalence on the operating characteristics of a testlet-based computerized mastery test (CMT) is introduced. The procedure involves estimating the CMT decision rule twice—once with testlets treated as equivalent and once with testlets treated as nonequivalent. In the equivalent testlet mode, the likelihood functions (LFS) estimated for specific number-correct (NC) scores are assumed

Kathleen Sheehan; Charles Lewis

1992-01-01

213

Are Chinese Dentists Ready for the Computerization of Dentistry? A Population Investigation of China's Metropolises  

PubMed Central

The authors studied current levels of computerization in dental clinics and the attitudes of dentists towards dental computerization in metropolises in China. A survey consisting of 22 questions was e-mailed or mailed to a random sample of 354 dentists. Of all respondents, 80.5% reported using a computer in their practice. The authors found that administrative tasks were the first to be computerized. A majority of respondents supported the statement that computerization is a benefit to patient care. The authors found that the computerization of dental clinics in Chinese metropolises is a few years behind that of western nations. PMID:19261944

Hu, Jian; Yu, Hao; Luo, En; Song, Enmin; Xu, Xiangyang; Tan, Hongbao; Wang, Yining

2009-01-01

214

Computerized Patient Care Data: An Educational Program for Nurses.  

ERIC Educational Resources Information Center

Describes the five-year educational program at the Clinical Center of the National Institutes of Health that teaches utilization of a computerized Medical Information System for documenting the nursing process. (CT)

Butters, Shirley; And Others

1982-01-01

215

Successful Outcomes of a Clinical Decision Support System in an HIV Practice: A Randomized Controlled Trial  

PubMed Central

Background Data to support improved patient outcomes from clinical decision support systems (CDSS) are lacking in HIV care. Objective To conduct a randomized controlled trial testing the efficacy of a CDSS to improve HIV outcomes in an outpatient clinic. Design We conducted a randomized controlled trial where half of each provider’s patients were randomized to interactive or static computer alerts (ClinicalTrials.gov #NCT00678600). Setting The study was conducted at the Massachusetts General Hospital HIV Clinic. Subjects Participants were HIV providers and their HIV-infected patients. Intervention Computer alerts were generated for virologic failure (HIV RNA >400 c/mL after HIV RNA ?400 c/mL), evidence of suboptimal follow-up, and 11 abnormal laboratory tests. Providers received interactive computer alerts, facilitating appointment rescheduling and repeat laboratory testing, for half of their patients and static alerts for the other half. Measurements The primary endpoint was change in CD4 count. Other endpoints included time-to-clinical event, 6-month suboptimal follow-up, and severe laboratory toxicity. Results Thirty-three HIV providers followed 1,011 HIV-infected patients. For the intervention arm, the mean CD4 count increase was greater (5.3 versus 3.2 cells/mm3/month; difference = 2.0 cells/mm3/month 95% CI [0.1, 4.0], p=0.040) and the rate of 6-month suboptimal follow-up was lower (20.6 versus 30.1 events per 100 patient-years, p=0.022). Median time-to-next scheduled appointment was shorter in the intervention arm after a suboptimal follow-up alert (1.71 versus 3.48 months; p<0.001) and after a toxicity alert (2.79 versus >6 months for control); p=0.072). Ninety-six percent of providers supported adopting the CDSS as part of standard care. Limitations This was a one-year informatics study conducted at a single hospital sub-specialty clinic. Conclusion A CDSS using interactive provider alerts improved CD4 counts and clinic follow-up for HIV-infected patients. Wider implementation of such systems can provide important clinical benefits. PMID:23208165

Robbins, Gregory K.; Lester, William; Johnson, Kristin L.; Chang, Yuchiao; Estey, Gregory; Surrao, Dominic; Zachary, Kimon; Lammert, Sara M.; Chueh, Henry; Meigs, James B.; Freedberg, Kenneth A.

2013-01-01

216

The Arden Syntax standard for clinical decision support: experiences and directions.  

PubMed

Arden Syntax is a widely recognized standard for representing clinical and scientific knowledge in an executable format. It has a history that reaches back until 1989 and is currently maintained by the Health Level 7 (HL7) organization. We created a production-ready development environment, compiler, rule engine and application server for Arden Syntax. Over the course of several years, we have applied this Arden - Syntax - based CDS system in a wide variety of clinical problem domains, such as hepatitis serology interpretation, monitoring of nosocomial infections or the prediction of metastatic events in melanoma patients. We found the Arden Syntax standard to be very suitable for the practical implementation of CDS systems. Among the advantages of Arden Syntax are its status as an actively developed HL7 standard, the readability of the syntax, and various syntactic features such as flexible list handling. A major challenge we encountered was the technical integration of our CDS systems in existing, heterogeneous health information systems. To address this issue, we are currently working on incorporating the HL7 standard GELLO, which provides a standardized interface and query language for accessing data in health information systems. We hope that these planned extensions of the Arden Syntax might eventually help in realizing the vision of a global, interoperable and shared library of clinical decision support knowledge. PMID:22342733

Samwald, Matthias; Fehre, Karsten; de Bruin, Jeroen; Adlassnig, Klaus-Peter

2012-08-01

217

Nottingham Prognostic Index Plus (NPI+): a modern clinical decision making tool in breast cancer  

PubMed Central

Background: Current management of breast cancer (BC) relies on risk stratification based on well-defined clinicopathologic factors. Global gene expression profiling studies have demonstrated that BC comprises distinct molecular classes with clinical relevance. In this study, we hypothesised that molecular features of BC are a key driver of tumour behaviour and when coupled with a novel and bespoke application of established clinicopathologic prognostic variables can predict both clinical outcome and relevant therapeutic options more accurately than existing methods. Methods: In the current study, a comprehensive panel of biomarkers with relevance to BC was applied to a large and well-characterised series of BC, using immunohistochemistry and different multivariate clustering techniques, to identify the key molecular classes. Subsequently, each class was further stratified using a set of well-defined prognostic clinicopathologic variables. These variables were combined in formulae to prognostically stratify different molecular classes, collectively known as the Nottingham Prognostic Index Plus (NPI+). The NPI+ was then used to predict outcome in the different molecular classes. Results: Seven core molecular classes were identified using a selective panel of 10 biomarkers. Incorporation of clinicopathologic variables in a second-stage analysis resulted in identification of distinct prognostic groups within each molecular class (NPI+). Outcome analysis showed that using the bespoke NPI formulae for each biological BC class provides improved patient outcome stratification superior to the traditional NPI. Conclusion: This study provides proof-of-principle evidence for the use of NPI+ in supporting improved individualised clinical decision making. PMID:24619074

Rakha, E A; Soria, D; Green, A R; Lemetre, C; Powe, D G; Nolan, C C; Garibaldi, J M; Ball, G; Ellis, I O

2014-01-01

218

Service oriented architecture for clinical decision support: a systematic review and future directions.  

PubMed

The use of a service-oriented architecture (SOA) has been identified as a promising approach for improving health care by facilitating reliable clinical decision support (CDS). A review of the literature through October 2013 identified 44 articles on this topic. The review suggests that SOA related technologies such as Business Process Model and Notation (BPMN) and Service Component Architecture (SCA) have not been generally adopted to impact health IT systems' performance for better care solutions. Additionally, technologies such as Enterprise Service Bus (ESB) and architectural approaches like Service Choreography have not been generally exploited among researchers and developers. Based on the experience of other industries and our observation of the evolution of SOA, we found that the greater use of these approaches have the potential to significantly impact SOA implementations for CDS. PMID:25325996

Loya, Salvador Rodriguez; Kawamoto, Kensaku; Chatwin, Chris; Huser, Vojtech

2014-12-01

219

Clinical Decision Support in Electronic Prescribing: Recommendations and an Action Plan  

PubMed Central

Clinical decision support (CDS) in electronic prescribing (eRx) systems can improve the safety, quality, efficiency, and cost-effectiveness of care. However, at present, these potential benefits have not been fully realized. In this consensus white paper, we set forth recommendations and action plans in three critical domains: (1) advances in system capabilities, including basic and advanced sets of CDS interventions and knowledge, supporting database elements, operational features to improve usability and measure performance, and management and governance structures; (2) uniform standards, vocabularies, and centralized knowledge structures and services that could reduce rework by vendors and care providers, improve dissemination of well-constructed CDS interventions, promote generally applicable research in CDS methods, and accelerate the movement of new medical knowledge from research to practice; and (3) appropriate financial and legal incentives to promote adoption. PMID:15802474

Teich, Jonathan M.; Osheroff, Jerome A.; Pifer, Eric A.; Sittig, Dean F.; Jenders, Robert A.

2005-01-01

220

Considering clustering: a methodological review of clinical decision support system studies.  

PubMed Central

Computer-based clinical decision support systems (CDSSs) are often implemented at a cluster level, but standard statistical methods for sample estimation and analysis may not be appropriate for such studies. This review aims to determine whether the design and analysis methods of cluster-based studies were adequately addressed in reports of CDSS studies. We retrieved 61 reports of the CDSS controlled trials and identified 24 studies meeting our inclusion criteria. Of these, none included sample size calculations that allowed for clustering, while 14 (58%) took account of clustering in the analysis. Although there is increasing recognition of the methodological issues associated with cluster design in health care, many medical informaticians are still not aware of these issues. Investigators should publish estimates of the intracluster correlation coefficients and variance components in their reports to guide the planning of the future studies. PMID:11079862

Chuang, J. H.; Hripcsak, G.; Jenders, R. A.

2000-01-01

221

Migrating toward a next-generation clinical decision support application: the BJC HealthCare experience.  

PubMed

The next-generation model outlined in the AMIA Roadmap for National Action on Clinical Decision Support (CDS) is aimed to optimize the effectiveness of CDS interventions, and to achieve widespread adoption. BJC HealthCare re-engineered its existing CDS system in alignment with the AMIA roadmap and plans to use it for guidance on further enhancements. We present our experience and discuss an incremental approach to migrate towards the next generation of CDS applications from the viewpoint of a healthcare institution. Specifically, a CDS rule engine service with a standards-based rule representation format was built to simplify maintenance and deployment. Rules were separated from execution code and made customizable for multi-facility deployment. Those changes resulted in system improvement in the short term while aligning with long-term strategic objectives. PMID:18693855

Huang, Yan; Noirot, Laura A; Heard, Kevin M; Reichley, Richard M; Dunagan, Wm Claiborne; Bailey, Thomas C

2007-01-01

222

[From library to clinical decision support systems: access of general practitioner to quality information].  

PubMed

Since 2003, the following tools have been implemented in Belgium for improving the access of general practioners to the EBM literature: the Digital Library for Health and the evidence-linker of the CEBAM, the portal EBMPracticeNet.be and the multidimensional electronic clinical decision support EBMeDS. The aim of this article is to show the progress achieved in the information dissemination toward the belgian general practioners, particularly the access from the electronic health record. From the literature published these last years, the opportunities cited by the users are for using EBM and the strong willingness for using these literature access in the future; the limits are the medical data coding, the irrelevance of the search results, the alerts fatigue induced by EBMeDS. The achievements done and planned for the new EBMPracticeNet guidelines portal and the EBMeDS system are explained in the aim of informing belgian healthcare professionals. These projects are claiming for lauching a participatory process in the production and dissemination of EBM information. The discussion is focused on the belgian healthcare system advantages, the solutions for a reasonable implementation of these projects and for increasing the place of an evidence-based information in the healthcare decision process. Finally the input of these projects to the continuing medical education and to the healthcare quality are discussed, in a context of multifactorial interaction healthcare design (complexity design). PMID:23091948

Fauquert, B

2012-09-01

223

Clinical decision support system for early detection of prostate cancer from benign hyperplasia of prostate.  

PubMed

There has been a growing research interest in the use of intelligent methods in medical informatics studies. Intelligent computer programs were implemented to aid physicians and other medical professionals in making difficult medical decisions. Prostate Neoplasia problems including benign hyperplasia and cancer of prostate are very common and cause significant delay in recovery and often require costly investigations before coming to its diagnosis. The conventional approach to build medical diagnostic system requires the formulation of rules by which the input data can be analyzed. But the formulation of such rules is very difficult with large sets of input data. Realizing the difficulty, a number of quantitative mathematical and statistical models including pattern classification technique such as Artificial neural networks (ANN), rolled based system, discriminate analysis and regression analysis has been applied as an alternative to conventional clinical and medical diagnostic. Among the mathematical and statistical modeling techniques used in medical decision support, Artificial neural networks attract many attentions in recent studies and in the last decade, the use of neural networks has become widely accepted in medical applications. This is manifested by an increasing number of medical devices currently available on the market with embedded AI algorithms, together with an accelerating pace of publication in medical journals, with over 500 academic publications year featuring Artificial Neural Networks (ANNs). PMID:23920702

Ghaderzadeh, Mustafa

2013-01-01

224

Computerized Transportation Management.  

ERIC Educational Resources Information Center

For the past six years, Los Angeles County Office of Education (California) has used a state-of-the-art computerized transportation management system that produces $2 million annual net savings and provides prompt, accurate bus service for students, parents, and teachers. This article details routing and scheduling programs used. Includes seven…

Caswell, Peter J.; Hall, Calvin W.

1987-01-01

225

Psychosocial Communication and Computerization.  

ERIC Educational Resources Information Center

Discusses the effect of computerization of the work environment on psychosocial communication. The RAM program, developed at Stockholm University to explore the effect of computers on the structure of organizations and the psychosocial work environment, is described; theoretical models are explained; and the future use of knowledge-based systems…

Bradley, Gunilla; And Others

1993-01-01

226

Computerized geophysical tomography  

Microsoft Academic Search

Computerized tomography is used as an aid in geophysical exploration. With this method, detailed pictures of electromagnetic properties in the regions between pairs of boreholes can be reconstructed. The spatial distribution of attenuation or propagation velocity is calculated from line integrals along rays in the plane between boreholes, and displayed as a digital picture. In principle, the transmission of seismic

K. A. Dines; R. J. Lytle

1979-01-01

227

Exploring use of images in clinical articles for decision support in evidence-based medicine  

NASA Astrophysics Data System (ADS)

Essential information is often conveyed pictorially (images, illustrations, graphs, charts, etc.) in biomedical publications. A clinician's decision to access the full text when searching for evidence in support of clinical decision is frequently based solely on a short bibliographic reference. We seek to automatically augment these references with images from the article that may assist in finding evidence. In a previous study, the feasibility of automatically classifying images by usefulness (utility) in finding evidence was explored using supervised machine learning and achieved 84.3% accuracy using image captions for modality and 76.6% accuracy combining captions and image data for utility on 743 images from articles over 2 years from a clinical journal. Our results indicated that automatic augmentation of bibliographic references with relevant images was feasible. Other research in this area has determined improved user experience by showing images in addition to the short bibliographic reference. Multi-panel images used in our study had to be manually pre-processed for image analysis, however. Additionally, all image-text on figures was ignored. In this article, we report on developed methods for automatic multi-panel image segmentation using not only image features, but also clues from text analysis applied to figure captions. In initial experiments on 516 figure images we obtained 95.54% accuracy in correctly identifying and segmenting the sub-images. The errors were flagged as disagreements with automatic parsing of figure caption text allowing for supervised segmentation. For localizing text and symbols, on a randomly selected test set of 100 single panel images our methods reported, on the average, precision and recall of 78.42% and 89.38%, respectively, with an accuracy of 72.02%.

Antani, Sameer; Demner-Fushman, Dina; Li, Jiang; Srinivasan, Balaji V.; Thoma, George R.

2008-01-01

228

The 2013 symposium on pathology data integration and clinical decision support and the current state of field  

PubMed Central

Background: Pathologists and informaticians are becoming increasingly interested in electronic clinical decision support for pathology, laboratory medicine and clinical diagnosis. Improved decision support may optimize laboratory test selection, improve test result interpretation and permit the extraction of enhanced diagnostic information from existing laboratory data. Nonetheless, the field of pathology decision support is still developing. To facilitate the exchange of ideas and preliminary studies, we convened a symposium entitled: Pathology data integration and clinical decision support. Methods: The symposium was held at the Massachusetts General Hospital, on May 10, 2013. Participants were selected to represent diverse backgrounds and interests and were from nine different institutions in eight different states. Results: The day included 16 plenary talks and three panel discussions, together covering four broad areas. Summaries of each presentation are included in this manuscript. Conclusions: A number of recurrent themes emerged from the symposium. Among the most pervasive was the dichotomy between diagnostic data and diagnostic information, including the opportunities that laboratories may have to use electronic systems and algorithms to convert the data they generate into more useful information. Differences between human talents and computer abilities were described; well-designed symbioses between humans and computers may ultimately optimize diagnosis. Another key theme related to the unique needs and challenges in providing decision support for genomics and other emerging diagnostic modalities. Finally, many talks relayed how the barriers to bringing decision support toward reality are primarily personnel, political, infrastructural and administrative challenges rather than technological limitations. PMID:24672737

Baron, Jason M.; Dighe, Anand S.; Arnaout, Ramy; Balis, Ulysses J.; Black-Schaffer, W. Stephen; Carter, Alexis B.; Henricks, Walter H.; Higgins, John M.; Jackson, Brian R.; Kim, JiYeon; Klepeis, Veronica E.; Le, Long P.; Louis, David N.; Mandelker, Diana; Mermel, Craig H.; Michaelson, James S.; Nagarajan, Rakesh; Platt, Mihae E.; Quinn, Andrew M.; Rao, Luigi; Shirts, Brian H.; Gilbertson, John R.

2014-01-01

229

Development of a real-time clinical decision support system upon the web mvc-based architecture for prostate cancer treatment  

Microsoft Academic Search

Background  A real-time clinical decision support system (RTCDSS) with interactive diagrams enables clinicians to instantly and efficiently\\u000a track patients' clinical records (PCRs) and improve their quality of clinical care. We propose a RTCDSS to process online\\u000a clinical informatics from multiple databases for clinical decision making in the treatment of prostate cancer based on Web\\u000a Model-View-Controller (MVC) architecture, by which the system

Hsueh-Chun Lin; Hsi-Chin Wu; Chih-Hung Chang; Tsai-Chung Li; Wen-Miin Liang; Jong-Yi Wang Wang

2011-01-01

230

A study to derive a clinical decision rule for triage of emergency department patients with chest pain: design and methodology  

PubMed Central

Background Chest pain is the second most common chief complaint in North American emergency departments. Data from the U.S. suggest that 2.1% of patients with acute myocardial infarction and 2.3% of patients with unstable angina are misdiagnosed, with slightly higher rates reported in a recent Canadian study (4.6% and 6.4%, respectively). Information obtained from the history, 12-lead ECG, and a single set of cardiac enzymes is unable to identify patients who are safe for early discharge with sufficient sensitivity. The 2007 ACC/AHA guidelines for UA/NSTEMI do not identify patients at low risk for adverse cardiac events who can be safely discharged without provocative testing. As a result large numbers of low risk patients are triaged to chest pain observation units and undergo provocative testing, at significant cost to the healthcare system. Clinical decision rules use clinical findings (history, physical exam, test results) to suggest a diagnostic or therapeutic course of action. Currently no methodologically robust clinical decision rule identifies patients safe for early discharge. Methods/design The goal of this study is to derive a clinical decision rule which will allow emergency physicians to accurately identify patients with chest pain who are safe for early discharge. The study will utilize a prospective cohort design. Standardized clinical variables will be collected on all patients at least 25 years of age complaining of chest pain prior to provocative testing. Variables strongly associated with the composite outcome acute myocardial infarction, revascularization, or death will be further analyzed with multivariable analysis to derive the clinical rule. Specific aims are to: i) apply standardized clinical assessments to patients with chest pain, incorporating results of early cardiac testing; ii) determine the inter-observer reliability of the clinical information; iii) determine the statistical association between the clinical findings and the composite outcome; and iv) use multivariable analysis to derive a highly sensitive clinical decision rule to guide triage decisions. Discussion The study will derive a highly sensitive clinical decision rule to identify low risk patients safe for early discharge. This will improve patient care, lower healthcare costs, and enhance flow in our busy and overcrowded emergency departments. PMID:18254973

Hess, Erik P; Wells, George A; Jaffe, Allan; Stiell, Ian G

2008-01-01

231

A clinical decision aid for the selection of antithrombotic therapy for the prevention of stroke due to atrial fibrillation  

PubMed Central

Aims The availability of new antithrombotic agents, each with a unique efficacy and bleeding profile, has introduced a considerable amount of clinical uncertainty with physicians. We have developed a clinical decision aid in order to assist clinicians in determining an optimal antithrombotic regime for the prevention of stroke in patients who are newly diagnosed with non-valvular atrial fibrillation. Methods and results The CHA2DS2-VASc and HAS-BLED scoring systems were used to assess patients’ baseline risks of stroke and major bleeding, respectively. The relative risks of stroke and major bleeding for each antithrombotic agent were then used to identify the agent associated with the lowest net risk. Individual patient factors such as the treatment threshold, bleeding ratio, and cost threshold modified the recommendations in order to generate a final recommendation. By considering both patient factors and clinical research concurrently, this clinical decision aid is able to provide specific advice to clinicians regarding an optimal stroke prevention strategy. The resulting treatment recommendation tables are consistent with the recommendations of the European Society of Cardiology and Canadian Cardiovascular Society Guidelines, which can be incorporated into either a paper-based or electronic format to allow clinicians to have decision support at the point of care. Conclusion The use of a clinical decision aid that considers both patient factors and evidence-based medicine will serve to bridge the knowledge gap and provide practical guidance to clinicians in the prevention of stroke due to atrial fibrillation. PMID:22752615

LaHaye, Stephen Andrew; Gibbens, Sabra Lynn; Ball, David Gerald Andrew; Day, Andrew George; Olesen, Jonas Bjerring; Skanes, Allan Cameron

2012-01-01

232

Using evidence-based algorithms to improve clinical decision making: the case of a first-time anterior shoulder dislocation.  

PubMed

Decision making in health care has evolved substantially over the last century. Up until the late 1970s, medical decision making was predominantly intuitive and anecdotal. It was based on trial and error and involved high levels of problem solving. The 1980s gave way to empirical medicine, which was evidence based probabilistic, and involved pattern recognition and less problem solving. Although this represented a major advance in the quality of medical decision making, limitations existed. The advantages of the gold standard of the randomized controlled clinical trial (RCT) are well-known and this technique is irreplaceable in its ability to answer critical clinical questions. However, the RCT does have drawbacks. RCTs are expensive and can only capture a snapshot in time. As treatments change and new technologies emerge, new expensive clinical trials must be undertaken to reevaluate them. Furthermore, in order to best evaluate a single intervention, other factors must be controlled. In addition, the study population may not match that of another organization or provider. Although evidence-based medicine has provided powerful data for clinicians, effectively and efficiently tailoring it to the individual has not yet evolved. We are now in a period of transition from this evidence-based era to one dominated by the personalization and customization of care. It will be fueled by policy decisions to shift financial responsibility to the patient, creating a powerful and sophisticated consumer, unlike any patient we have known before. The challenge will be to apply medical evidence and personal preferences to medical decisions and deliver it efficiently in the increasingly busy clinical setting. In this article, we provide a robust review of the concepts of customized care and some of techniques to deliver it. We will illustrate this through a personalized decision model for the treatment decision after a first-time anterior shoulder dislocation. PMID:23924748

Federer, Andrew E; Taylor, Dean C; Mather, Richard C

2013-09-01

233

Development and use of active clinical decision support for preemptive pharmacogenomics  

PubMed Central

Background Active clinical decision support (CDS) delivered through an electronic health record (EHR) facilitates gene-based drug prescribing and other applications of genomics to patient care. Objective We describe the development, implementation, and evaluation of active CDS for multiple pharmacogenetic test results reported preemptively. Materials and methods Clinical pharmacogenetic test results accompanied by clinical interpretations are placed into the patient's EHR, typically before a relevant drug is prescribed. Problem list entries created for high-risk phenotypes provide an unambiguous trigger for delivery of post-test alerts to clinicians when high-risk drugs are prescribed. In addition, pre-test alerts are issued if a very-high risk medication is prescribed (eg, a thiopurine), prior to the appropriate pharmacogenetic test result being entered into the EHR. Our CDS can be readily modified to incorporate new genes or high-risk drugs as they emerge. Results Through November 2012, 35 customized pharmacogenetic rules have been implemented, including rules for TPMT with azathioprine, thioguanine, and mercaptopurine, and for CYP2D6 with codeine, tramadol, amitriptyline, fluoxetine, and paroxetine. Between May 2011 and November 2012, the pre-test alerts were electronically issued 1106 times (76 for thiopurines and 1030 for drugs metabolized by CYP2D6), and the post-test alerts were issued 1552 times (1521 for TPMT and 31 for CYP2D6). Analysis of alert outcomes revealed that the interruptive CDS appropriately guided prescribing in 95% of patients for whom they were issued. Conclusions Our experience illustrates the feasibility of developing computational systems that provide clinicians with actionable alerts for gene-based drug prescribing at the point of care. PMID:23978487

Bell, Gillian C; Crews, Kristine R; Wilkinson, Mark R; Haidar, Cyrine E; Hicks, J Kevin; Baker, Donald K; Kornegay, Nancy M; Yang, Wenjian; Cross, Shane J; Howard, Scott C; Freimuth, Robert R; Evans, William E; Broeckel, Ulrich; Relling, Mary V; Hoffman, James M

2014-01-01

234

Cost Effectiveness of an Electronic Medical Record Based Clinical Decision Support System  

PubMed Central

Objective Medical groups have invested billions of dollars in Electronic Medical Records (EMRs), but few studies have examined the cost-effectiveness of EMR-based clinical decision support (CDS). This study examined the cost-effectiveness of EMR-based CDS for adults with diabetes from the perspective of the health care system. Data Sources/Setting Clinical outcome and cost data from a randomized clinical trial of EMR-based CDS were used as inputs into a diabetes simulation model. The simulation cohort included 1,092 patients with diabetes with A1c above goal at baseline. Study Design The UKPDS Outcomes Model, a validated simulation model of diabetes, was used to evaluate remaining life years, quality adjusted life years (QALYs), and health care costs over patient lifetimes (40-year time horizon) from the health system perspective. Principal Findings Patients in the intervention group had significantly lowered A1c (.26%, p=.014) relative to patients in the control arm. Intervention costs were $120 (SE=45) per patient in the first year and $76 (SE=45) per patient in the following years. In the base case analysis, EMR-based CDS increased lifetime QALYs by 0.04 (SE=.01) and increased lifetime costs by $112 (SE=660), resulting in an incremental cost effectiveness ratio of $3,017 per QALY. The cost-effectiveness of EMR-based CDS persisted in one-way, two way, and probabilistic sensitivity analyses. Conclusions Widespread adoption of sophisticated EMR-based CDS has the potential to modestly improve the quality of care for patients with chronic conditions without substantially increasing costs to the health care system. PMID:22578085

O'Connor, Patrick J.; Sperl-Hillen, JoAnn M.; Rush, William A.; Johnson, Paul E.; Amundson, Gerald H.; Asche, Stephen E.; Ekstrom, Heidi L.

2012-01-01

235

Supporting clinical decision making during deep brain stimulation surgery by means of a stochastic dynamical model  

NASA Astrophysics Data System (ADS)

Objective. During deep brain stimulation (DBS) surgery for the treatment of advanced Parkinson's disease (PD), microelectrode recording (MER) in conjunction with functional stimulation techniques are commonly applied for accurate electrode implantation. However, the development of automatic methods for clinical decision making has to date been characterized by the absence of a robust single-biomarker approach. Moreover, it has only been restricted to the framework of MER without encompassing intraoperative macrostimulation. Here, we propose an integrated series of novel single-biomarker approaches applicable to the entire electrophysiological procedure by means of a stochastic dynamical model. Approach. The methods are applied to MER data pertinent to ten DBS procedures. Considering the presence of measurement noise, we initially employ a multivariate phase synchronization index for automatic delineation of the functional boundaries of the subthalamic nucleus (STN) and determination of the acceptable MER trajectories. By introducing the index into a nonlinear stochastic model, appropriately fitted to pre-selected MERs, we simulate the neuronal response to periodic stimuli (130 Hz), and examine the Lyapunov exponent as an indirect indicator of the clinical effectiveness yielded by stimulation at the corresponding sites. Main results. Compared with the gold-standard dataset of annotations made intraoperatively by clinical experts, the STN detection methodology demonstrates a false negative rate of 4.8% and a false positive rate of 0%, across all trajectories. Site eligibility for implantation of the DBS electrode, as implicitly determined through the Lyapunov exponent of the proposed stochastic model, displays a sensitivity of 71.43%. Significance. The suggested comprehensive method exhibits remarkable performance in automatically determining both the acceptable MER trajectories and the optimal stimulation sites, thereby having the potential to accelerate precise target finalization during DBS surgery for PD.

Karamintziou, Sofia D.; Tsirogiannis, George L.; Stathis, Pantelis G.; Tagaris, George A.; Boviatsis, Efstathios J.; Sakas, Damianos E.; Nikita, Konstantina S.

2014-10-01

236

Chronic hepatitis C: Treat or wait? Medical decision making in clinical practice  

PubMed Central

AIM: To analyzes the decision whether patients with chronic hepatitis C virus (HCV) infection are treated or not. METHODS: This prospective cohort study included 7658 untreated patients and 6341 patients receiving pegylated interferon ? 2a/ribavirin, involving 434 physicians/institutions throughout Germany (377 in private practice and 57 in hospital settings). A structured questionnaire had to be answered prior to the treatment decision, which included demographic data, information about the personal life situation of the patients, anamnesis and symptomatology of hepatitis C, virological data, laboratory data and data on concomitant diseases. A second part of the study analyzes patients treated with pegylated interferon ?2a. All questionnaires included reasons against treatment mentioned by the physician. RESULTS: Overall treatment uptake was 45%. By multivariate analysis, genotype 1/4/5/6, HCV-RNA ? 520?000 IU/mL, normal alanine aminotransferase (ALT), platelets ? 142 500/?L, age > 56 years, female gender, infection length > 12.5 years, concomitant diseases, human immunodeficiency virus co-infection, liver biopsy not performed, care in private practice, asymptomatic disease, and unemployment were factors associated with reduced treatment rate. Treatment and sustained viral response rates in migrants (1/3 of cohort) were higher than in German natives although 1/3 of migrants had language problems. Treatment rate and liver biopsy were higher in clinical settings when compared to private practice and were low when ALT and HCV-RNA were low. CONCLUSION: Some reasons against treatment were medically based whereas others were related to fears, socio-economical problems, and information deficits both on the side of physicians and patients. PMID:22493547

Niederau, Claus; Huppe, Dietrich; Zehnter, Elmar; Moller, Bernd; Heyne, Renate; Christensen, Stefan; Pfaff, Rainer; Theilmeier, Arno; Alshuth, Ulrich; Mauss, Stefan

2012-01-01

237

Peering into the black box: a meta-analysis of how clinicians use decision aids during clinical encounters  

PubMed Central

Objective To quantify the extent to which clinicians use clinically-efficacious decision aids as intended during implementation in practice and how fidelity to usage instructions correlates with shared decision making (SDM) outcomes. Methods Participant-level meta-analysis including six practice-based randomized controlled trials of SDM in various clinical settings encompassing a range of decisions. Results Of 339 encounters in the SDM intervention arm of the trials, 229 were video recorded and available for analysis. The mean proportion of fidelity items observed in each encounter was 58.4% (SD?=?23.2). The proportion of fidelity items observed was significantly associated with patient knowledge (p?=?0.01) and clinician involvement of the patient in decision making (p <0.0001), while no association was found with patient decisional conflict or satisfaction with the encounter. Conclusion Clinicians’ fidelity to usage instructions of point-of-care decision aids in randomized trials was suboptimal during their initial implementation in practice, which may have underestimated the potential efficacy of decision aids when used as intended. PMID:24559190

2014-01-01

238

Enhancing decision making about participation in cancer clinical trials: development of a question prompt list. | accrualnet.cancer.gov  

Cancer.gov

This paper examines the usefulness of question prompt lists (QPLs) in aiding doctor-patient communication during discussions of clinical trials. The QPL presents patients with a menu of potential issues to discuss with a physician. Focus groups were conducted to assess the perceived utility of QPLs with trial-experienced and trial-naïve patients. All patients viewed the QPL as a valuable tool to support their decision-making regarding clinical trials.

239

Computerized Adaptive Testing  

SciTech Connect

Using exceedingly easy or difficult test items on a conventional fixed-length mastery test can result in a less-than-optimal measurement of achievement. Studies suggest that the use of variable-length adaptive tests may decrease the average test length, while improving the accuracy of the estimate of achievement. This paper presents an overview of criterion-referenced computerized adaptive testing and described an exploratory study at Westinghouse Hanford Company. 5 refs., 4 figs.

Bickerstaff, D.D.; Gardner, P.R. (Eastern Washington Univ., Cheney (USA). Dept. of Chemistry; Westinghouse Hanford Co., Richland, WA (USA))

1989-10-01

240

A kernel-based integration of genome-wide data for clinical decision support  

PubMed Central

Background Although microarray technology allows the investigation of the transcriptomic make-up of a tumor in one experiment, the transcriptome does not completely reflect the underlying biology due to alternative splicing, post-translational modifications, as well as the influence of pathological conditions (for example, cancer) on transcription and translation. This increases the importance of fusing more than one source of genome-wide data, such as the genome, transcriptome, proteome, and epigenome. The current increase in the amount of available omics data emphasizes the need for a methodological integration framework. Methods We propose a kernel-based approach for clinical decision support in which many genome-wide data sources are combined. Integration occurs within the patient domain at the level of kernel matrices before building the classifier. As supervised classification algorithm, a weighted least squares support vector machine is used. We apply this framework to two cancer cases, namely, a rectal cancer data set containing microarray and proteomics data and a prostate cancer data set containing microarray and genomics data. For both cases, multiple outcomes are predicted. Results For the rectal cancer outcomes, the highest leave-one-out (LOO) areas under the receiver operating characteristic curves (AUC) were obtained when combining microarray and proteomics data gathered during therapy and ranged from 0.927 to 0.987. For prostate cancer, all four outcomes had a better LOO AUC when combining microarray and genomics data, ranging from 0.786 for recurrence to 0.987 for metastasis. Conclusions For both cancer sites the prediction of all outcomes improved when more than one genome-wide data set was considered. This suggests that integrating multiple genome-wide data sources increases the predictive performance of clinical decision support models. This emphasizes the need for comprehensive multi-modal data. We acknowledge that, in a first phase, this will substantially increase costs; however, this is a necessary investment to ultimately obtain cost-efficient models usable in patient tailored therapy. PMID:19356222

2009-01-01

241

Medical decision-making in membranous nephropathy: how to use limited clinical research evidence in patient management.  

PubMed

Evidence-based medicine (EBM) originally referred to the use of a combination of clinical expertise and research evidence to make medical decisions, while carefully considering the patient's preference. In Japan, however, EBM has been misunderstood as the more abstract pursuit of acquiring research evidence and building medical guidelines. This review aims to summarize the available data regarding therapy for membranous nephropathy (MN), a field in which no consensus has been reached, and to discuss medical decision-making by using a decision tree in several model cases. In clinical practice, we have to consider both the risks and benefits of treatment. These are evaluated by their therapeutic effect (the rate of improvement, no change, or worsening) and by the patients' quality of life (QOL). This process is compatible with the essential concept of EBM. PMID:16189628

Imai, Hirokazu

2005-09-01

242

Amatoxin poisoning treatment decision-making: Pharmaco-therapeutic clinical strategy assessment using multidimensional multivariate statistic analysis  

Microsoft Academic Search

Ninety percent of fatal higher fungus poisoning is due to amatoxin-containing mushroom species. In addition to absence of antidote, no chemotherapeutic consensus was reported. The aim of the present study is to perform a retrospective multidimensional multivariate statistic analysis of 2110 amatoxin poisoning clinical cases, in order to optimize therapeutic decision-making. Our results allowed to classify drugs as a function

Patrick Poucheret; Françoise Fons; Jean Christophe Doré; Didier Michelot; Sylvie Rapior

2010-01-01

243

Impact of Patient Characteristics and Clinical Factors on the Decision to Initiate Growth Hormone Treatment in Turner Syndrome  

Microsoft Academic Search

Background\\/Aims: To evaluate factors contributing to the decision to initiate treatment with growth hormone (GH) in patients with Turner syndrome (TS). Methods: Data collected included ethnicity, parents’ education and work status, mid-parental height, age at diagnosis, karyotype, pubertal development, clinical severity score, bone age, height SDS and ages when GH was proposed and initiated. Results: GH was proposed to 59

Karine Khatchadourian; Céline Huot; Nathalie Alos; Guy Van Vliet; Cheri Deal

2008-01-01

244

Clinical Information System Services and Capabilities Desired for Scalable, Standards-Based, Service-oriented Decision Support: Consensus Assessment of the Health Level 7 Clinical Decision Support Work Group  

PubMed Central

A standards-based, service-oriented architecture for clinical decision support (CDS) has the potential to significantly enhance CDS scalability and robustness. To enable such a CDS architecture, the Health Level 7 CDS Work Group reviewed the literature, hosted multi-stakeholder discussions, and consulted domain experts to identify and prioritize the services and capabilities required from clinical information systems (CISs) to enable service-oriented CDS. In addition, relevant available standards were identified. Through this process, ten CIS services and eight CIS capabilities were identified as being important for enabling scalable, service-oriented CDS. In particular, through a survey of 46 domain experts, five services and capabilities were identified as being especially critical: 1) the use of standard information models and terminologies; 2) the ability to leverage a Decision Support Service (DSS); 3) support for a clinical data query service; 4) support for an event subscription and notification service; and 5) support for a user communication service. PMID:23304315

Kawamoto, Kensaku; Jacobs, Jason; Welch, Brandon M.; Huser, Vojtech; Paterno, Marilyn D.; Del Fiol, Guilherme; Shields, David; Strasberg, Howard R.; Haug, Peter J.; Liu, Zhijing; Jenders, Robert A.; Rowed, David W.; Chertcoff, Daryl; Fehre, Karsten; Adlassnig, Klaus-Peter; Curtis, A. Clayton

2012-01-01

245

Dose coefficients and derived guidance and clinical decision levels for contaminated wounds  

SciTech Connect

The NCRP Wound Model describing the retention of selected radionuclides at the site of a contaminated wound and their uptake into the transfer compartment has been combined with the ICRP element-specific systemic models for those radionuclides to derive dose coefficients for intakes via contaminated wounds. Those coefficients have been used to generate derived guidance levels (i.e., the activity in a wound that would result in an effective dose of 20 or 50 mSv, or in some cases, a committed organ equivalent dose of 500 mSv), and clinical decision levels (i.e., activity levels that would indicate the need for consideration of medical intervention to remove activity from the wound site or administration of decorporation therapy or both), typically set at 5 times the derived guidance levels. Data are provided for the radionuclides commonly encountered at nuclear power plants and nuclear weapons, fuel fabrication or recycling, waste disposal, medical and research facilities. These include: {sup 60}Co, {sup 90}Sr, {sup 99m}Tc, {sup 131}I, {sup 137}Cs, {sup 192}Ir, {sup 210}Po, {sup 226,228}Ra, {sup 228,232}Th, {sup 235,238}U, {sup 237}Np, {sup 238,239}Pu, {sup 241}Am, {sup 242,244}Cm, and {sup 252}Cf.

Bertelli, Luiz [Los Alamos National Laboratory; Toohey, Richard E [ORISE/ORAU; Sugarman, Steven A [ORISE/ORAU; Christensen, Doran R [ORISE/ORAU

2009-01-01

246

Examining clinical decision support integrity: is clinician self-reported data entry accurate?  

PubMed

The aim of this study was to assess the accuracy of clinician-entered data in imaging clinical decision support (CDS). We used CDS-guided CT angiography (CTA) for pulmonary embolus (PE) in the emergency department as a case example because it required clinician entry of d-dimer results which could be unambiguously compared with actual laboratory values. Of 1296 patients with CTA orders for suspected PE during 2011, 1175 (90.7%) had accurate d-dimer values entered. In 55 orders (4.2%), incorrectly entered data shielded clinicians from intrusive computer alerts, resulting in potential CTA overuse. Remaining data entry errors did not affect user workflow. We found no missed PEs in our cohort. The majority of data entered by clinicians into imaging CDS are accurate. A small proportion may be intentionally erroneous to avoid intrusive computer alerts. Quality improvement methods, including academic detailing and improved integration between electronic medical record and CDS to minimize redundant data entry, may be necessary to optimize adoption of evidence presented through CDS. PMID:23886922

Gupta, Anurag; Raja, Ali S; Khorasani, Ramin

2014-01-01

247

Molecular profiling of liver tumors: classification and clinical translation for decision making.  

PubMed

Hepatocellular carcinoma (HCC) is a complex disease with a dismal prognosis. Consequently, a translational approach is required to personalized clinical decision making to improve survival of HCC patients. Molecular signatures from cirrhotic livers and single nucleotide polymorphism have been linked with HCC occurrence. Identification of high-risk populations will be useful to design chemopreventive trials. In addition, molecular signatures derived from tumor and nontumor samples are associated with early tumor recurrence due to metastasis and late tumor recurrence due to de novo carcinogenesis after curative treatment, respectively. Identification of patients with a high risk of relapse will guide adjuvant randomized trials. The genetic landscape drawn by next-generation sequencing has highlighted the genomic diversity of HCC. Genetic drivers recurrently mutated belong to different signaling pathways including telomere maintenance, cell-cycle regulators, chromatin remodeling, Wnt/b-catenin, RAS/RAF/MAPK kinase, and AKT/mTOR pathway. These cancer genes will be ideally targeted by biotherapies as a paradigm of stratified medicine adapted to tumor biology. PMID:25369299

Pinyol, Roser; Nault, Jean Charles; Quetglas, Iris M; Zucman-Rossi, Jessica; Llovet, Josep M

2014-11-01

248

A Clinical Decision Support System for Femoral Peripheral Arterial Disease Treatment  

PubMed Central

One of the major challenges of providing reliable healthcare services is to diagnose and treat diseases in an accurate and timely manner. Recently, many researchers have successfully used artificial neural networks as a diagnostic assessment tool. In this study, the validation of such an assessment tool has been developed for treatment of the femoral peripheral arterial disease using a radial basis function neural network (RBFNN). A data set for training the RBFNN has been prepared by analyzing records of patients who had been treated by the thoracic and cardiovascular surgery clinic of a university hospital. The data set includes 186 patient records having 16 characteristic features associated with a binary treatment decision, namely, being a medical or a surgical one. K-means clustering algorithm has been used to determine the parameters of radial basis functions and the number of hidden nodes of the RBFNN is determined experimentally. For performance evaluation, the proposed RBFNN was compared to three different multilayer perceptron models having Pareto optimal hidden layer combinations using various performance indicators. Results of comparison indicate that the RBFNN can be used as an effective assessment tool for femoral peripheral arterial disease treatment. PMID:24382983

Yurtkuran, Alk?n; Tok, Mustafa

2013-01-01

249

Amatoxin poisoning treatment decision-making: pharmaco-therapeutic clinical strategy assessment using multidimensional multivariate statistic analysis.  

PubMed

Ninety percent of fatal higher fungus poisoning is due to amatoxin-containing mushroom species. In addition to absence of antidote, no chemotherapeutic consensus was reported. The aim of the present study is to perform a retrospective multidimensional multivariate statistic analysis of 2110 amatoxin poisoning clinical cases, in order to optimize therapeutic decision-making. Our results allowed to classify drugs as a function of their influence on one major parameter: patient survival. Active principles were classified as first intention, second intention, adjuvant or controversial pharmaco-therapeutic clinical intervention. We conclude that (1) retrospective multidimensional multivariate statistic analysis of complex clinical dataset might help future therapeutic decision-making and (2) drugs such as silybin, N-acetylcystein and putatively ceftazidime are clearly associated, in amatoxin poisoning context, with higher level of patient survival. PMID:20152849

Poucheret, Patrick; Fons, Françoise; Doré, Jean Christophe; Michelot, Didier; Rapior, Sylvie

2010-06-15

250

Study protocol: a dissemination trial of computerized psychological treatment for depression and alcohol/other drug use comorbidity in an Australian clinical service  

PubMed Central

Background The rise of the internet and related technologies has significant implications for the treatment of complex health problems, including the combination of depression and alcohol/other drug (AOD) misuse. To date, no research exists to test the real world uptake of internet and computer-delivered treatment programs in clinical practice. This study is important, as it is the first to examine the adoption of the SHADE treatment program, a DVD-based psychological treatment for depression and AOD use comorbidity, by clinicians working in a publicly-funded AOD clinical service. The study protocol that follows describes the methodology of this dissemination trial. Methods/design 19 clinicians within an AOD service on the Central Coast of New South Wales, Australia, will be recruited to the trial. Consenting clinicians will participate in a baseline focus group discussion designed to explore their experiences and perceived barriers to adopting innovation in their clinical practice. Computer comfort and openness to innovation will also be assessed. Throughout the trial, current, new and wait-list clients will be referred to the research program via the clinical service, which will involve clients completing a baseline and 15-week follow-up clinical assessment with independent research assistants, comprising a range of mental health and AOD measures. Clinicians will also complete session checklists following each clinical session with a client, outlining the extent to which the SHADE computer program was used. Therapeutic alliance will be measured at intake and discharge from both the clinician and client perspectives. Discussion This study will provide comprehensive data on the factors associated with the adoption of an innovative, computer-delivered evidence-based treatment program, SHADE, by clinicians working in an AOD service. The results will contribute to the development of a model of dissemination of SHADE, which could be applied to a range of technological innovations. Clinical trials registry Australian Clinical Trial Registration Number: ACTRN12611000382976. PMID:22770390

2012-01-01

251

A Report on Project CVIS (Computerized Vocational Information System).  

ERIC Educational Resources Information Center

The Computerized Vocational Information System (CVIS) team, has designed a system utilizing a computer as a tool to help students explore occupations in the light of their own student records. This system aims at teaching a decision-making process in a way that interests students and allows counselors more time for counseling functions. The…

Willowbrook High School, Villa Park, IL. Computerized Vocational Information System Project.

252

Guidelines for the Development of Computerized Student Information Systems.  

ERIC Educational Resources Information Center

Designed to provide guidelines for the development of computerized student information systems, this report raises policy issues and questions to be resolved at the campus level and describes a variety of computer-generated reports and records that can assist in educational decision making and planning. Introductory material discusses the…

Armes, Nancy, Ed.; And Others

253

Computerized procedures system  

DOEpatents

An online data driven computerized procedures system that guides an operator through a complex process facility's operating procedures. The system monitors plant data, processes the data and then, based upon this processing, presents the status of the current procedure step and/or substep to the operator. The system supports multiple users and a single procedure definition supports several interface formats that can be tailored to the individual user. Layered security controls access privileges and revisions are version controlled. The procedures run on a server that is platform independent of the user workstations that the server interfaces with and the user interface supports diverse procedural views.

Lipner, Melvin H. (Monroeville, PA); Mundy, Roger A. (North Huntingdon, PA); Franusich, Michael D. (Upper St. Clair, PA)

2010-10-12

254

Computerized ionospheric tomography  

SciTech Connect

In this paper the background of computerized tomography (CT) and its application to the ionosphere is reviewed. CT techniques, using only total electron content (TEC) data, can be used to reconstruct a two-dimensional image of the electron density in the ionosphere. The limitations of this technique are discussed and examples showing the limitations and capabilities are presented. Simulation results for two applications are presented: imaging the high latitude trough, and the correction of tracking radar range rate errors. Some possible extensions of the technique are presented.

Austen, J.R.; Raymund, T.D.; Klobuchar, J.A.; Stalker, J.; Liu, C.H.

1990-05-03

255

Interface design principles for usable decision support: a targeted review of best practices for clinical prescribing interventions.  

PubMed

Developing effective clinical decision support (CDS) systems for the highly complex and dynamic domain of clinical medicine is a serious challenge for designers. Poor usability is one of the core barriers to adoption and a deterrent to its routine use. We reviewed reports describing system implementation efforts and collected best available design conventions, procedures, practices and lessons learned in order to provide developers a short compendium of design goals and recommended principles. This targeted review is focused on CDS related to medication prescribing. Published reports suggest that important principles include consistency of design concepts across networked systems, use of appropriate visual representation of clinical data, use of controlled terminology, presenting advice at the time and place of decision making and matching the most appropriate CDS interventions to clinical goals. Specificity and contextual relevance can be increased by periodic review of trigger rules, analysis of performance logs and maintenance of accurate allergy, problem and medication lists in health records in order to help avoid excessive alerting. Developers need to adopt design practices that include user-centered, iterative design and common standards based on human-computer interaction (HCI) research methods rooted in ethnography and cognitive science. Suggestions outlined in this report may help clarify the goals of optimal CDS design but larger national initiatives are needed for systematic application of human factors in health information technology (HIT) development. Appropriate design strategies are essential for developing meaningful decision support systems that meet the grand challenges of high-quality healthcare. PMID:22995208

Horsky, Jan; Schiff, Gordon D; Johnston, Douglas; Mercincavage, Lauren; Bell, Douglas; Middleton, Blackford

2012-12-01

256

Clinical decision support systems could be modified to reduce 'alert fatigue' while still minimizing the risk of litigation.  

PubMed

Clinical decision support systems--interactive computer systems that help doctors make clinical choices--can reduce errors in drug prescribing by offering real-time alerts about possible adverse reactions. But physicians and other users often suffer "alert fatigue" caused by excessive numbers of warnings about items such as potentially dangerous drug interactions. As a result, they may pay less attention to or even ignore some vital alerts, thus limiting these systems' effectiveness. Designers and vendors sharply limit the ability to modify alert systems because they fear being exposed to liability if they permit removal of a warning that could have prevented a harmful prescribing error. Our analysis of product liability principles and existing research into the use of clinical decision support systems, however, finds that more finely tailored or parsimonious warnings could ease alert fatigue without imparting a high risk of litigation for vendors, purchasers, and users. Even so, to limit liability in this area, we recommend stronger government regulation of clinical decision support systems and development of international practice guidelines highlighting the most important warnings. PMID:22147858

Kesselheim, Aaron S; Cresswell, Kathrin; Phansalkar, Shobha; Bates, David W; Sheikh, Aziz

2011-12-01

257

Electronic risk assessment for venous thromboembolism: investigating physicians' rationale for bypassing clinical decision support recommendations  

PubMed Central

Objective The underutilisation of venous thromboembolism (VTE) prophylaxis is still a problem in the UK despite the emergence of national guidelines and incentives to increase the number of patients undergoing VTE risk assessments. Our objective was to examine the reasons doctors gave for not prescribing enoxaparin when recommended by an electronic VTE risk assessment alert. Design We used a qualitative research design to conduct a thematic analysis of free text entered into an electronic prescribing system. Setting The study took place in a large University teaching hospital, which has a locally developed electronic prescribing system known as PICS (Prescribing, Information and Communication System). Participants We extracted prescription data from all inpatient admissions over a 7-month period in 2012 using the audit database of PICS. Intervention The completion of the VTE risk assessment form introduced into the hospital-wide electronic prescribing and health records system is mandatory. Where doctors do not prescribe VTE prophylaxis when recommended, they are asked to provide a reason for this decision. The free-text field was introduced in May 2012. Primary and secondary outcome measures Free-text reasons for not prescribing enoxaparin when recommended were thematically coded. Results A total of 1136 free-text responses from 259 doctors were collected in the time period and 1206 separate reasons were analysed and coded. 389 reasons (32.3%) for not prescribing enoxaparin were coded as being due to ‘clinical judgment’; in 288 (23.9%) of the responses, doctors were going to reassess the patient or prescribe enoxaparin; and in 245 responses (20.3%), the system was seen to have produced an inappropriate alert. Conclusions In order to increase specificity of warnings and avoid users developing alert fatigue, it is essential that an evaluation of user responses and/or end user feedback as to the appropriateness and timing of alerts is obtained. PMID:25260369

Nwulu, Ugochi; Brooks, Hannah; Richardson, Suzanna; McFarland, Lorraine; Coleman, Jamie J

2014-01-01

258

Computerized Dental Injection Fear Treatment  

PubMed Central

One in four adults reports a clinically significant fear of dental injections, leading many to avoid dental care. While systematic desensitization is the most common therapeutic method for treating specific phobias such as fear of dental injections, lack of access to trained therapists, as well as dentists’ lack of training and time in providing such a therapy, means that most fearful individuals are not able to receive the therapy needed to be able to receive necessary dental treatment. Computer Assisted Relaxation Learning (CARL) is a self-paced computerized treatment based on systematic desensitization for dental injection fear. This multicenter, block-randomized, dentist-blind, parallel-group study conducted in 8 sites in the United States compared CARL with an informational pamphlet in reducing fear of dental injections. Participants completing CARL reported significantly greater reduction in self-reported general and injection-specific dental anxiety measures compared with control individuals (p < .001). Twice as many CARL participants (35.3%) as controls (17.6%) opted to receive a dental injection after the intervention, although this was not statistically significant. CARL, therefore, led to significant changes in self-reported fear in study participants, but no significant differences in the proportion of participants having a dental injection (ClinicalTrials.gov, NCT00609648). PMID:23690352

Heaton, L.J.; Leroux, B.G.; Ruff, P.A.; Coldwell, S.E.

2013-01-01

259

Religion, Spirituality and Health Care Treatment Decisions: The Role of Chaplains in the Australian Clinical Context  

Microsoft Academic Search

This paper summarizes the views of Australian health care chaplains concerning their role and involvement in patient\\/family health care treatment decisions. In general terms the findings indicated that the majority of chaplains surveyed believed that it was part of their pastoral role to help patients and their families make decisions about their health care treatment. Differences in involvement of volunteer

Lindsay B. Carey; Jeffrey Cohen

2009-01-01

260

Translating shared decision-making into health care clinical practices: Proof of concepts  

Microsoft Academic Search

BACKGROUND: There is considerable interest today in shared decision-making (SDM), defined as a decision-making process jointly shared by patients and their health care provider. However, the data show that SDM has not been broadly adopted yet. Consequently, the main goal of this proposal is to bring together the resources and the expertise needed to develop an interdisciplinary and international research

Glyn Elwyn; Martin Fishbein; Pierre Frémont; Dominick Frosch; Marie-Pierre Gagnon; David A Kenny; Michel Labrecque; Dawn Stacey; Sylvie St-Jacques; Trudy van der Weijden

2008-01-01

261

Clinical decisions in patients with diabetes and other cardiovascular risk factors. A statement of the Spanish Society of Internal Medicine.  

PubMed

Although the mortality associated to cardiovascular diseases (CVD) has been reduced in the last decades, CVD remains the main cause of mortality in Spain and they are associated with an important morbidity and a huge economic burden. The increasing prevalence of obesity and diabetes could be slowing down the mortality reduction in Spain. Clinicians have often difficulty making clinical decisions due to the multiple clinical guidelines available. Moreover, in the current context of economic crisis it is critical to promote an efficient use of diagnostic and therapeutic proceedings to ensure the viability of public health care systems. The Spanish Society of Internal Medicine (SEMI) has coordinated a consensus document to answer questions of daily practice with the aim of facilitating physicians' decision-making in the management of diabetes and cardiovascular risk factors from a cost-efficiency point of view. PMID:24602600

Gómez-Huelgas, R; Pérez-Jiménez, F; Serrano-Ríos, M; González-Santos, P; Román, P; Camafort, M; Conthe, P; García-Alegría, J; Guijarro, R; López-Miranda, J; Tirado-Miranda, R; Valdivielso, P

2014-05-01

262

Decision tree analysis of treatment strategies for mild and moderate cases of clinical mastitis occurring in early lactation.  

PubMed

The objective of this study was to develop a decision tree to evaluate the economic impact of different durations of intramammary treatment for the first case of mild or moderate clinical mastitis (CM) occurring in early lactation with various scenarios of pathogen distributions and use of on-farm culture. The tree included 2 decision and 3 probability events. The first decision evaluated use of on-farm culture (OFC; 2 programs using OFC and 1 not using OFC) and the second decision evaluated treatment strategies (no intramammary antimicrobials or antimicrobials administered for 2, 5, or 8 d). The tree included probabilities for the distribution of etiologies (gram-positive, gram-negative, or no growth), bacteriological cure, and recurrence. The economic consequences of mastitis included costs of diagnosis and initial treatment, additional treatments, labor, discarded milk, milk production losses due to clinical and subclinical mastitis, culling, and transmission of infection to other cows (only for CM caused by Staphylococcus aureus). Pathogen-specific estimates for bacteriological cure and milk losses were used. The economically optimal path for several scenarios was determined by comparison of expected monetary values. For most scenarios, the optimal economic strategy was to treat CM caused by gram-positive pathogens for 2 d and to avoid antimicrobials for CM cases caused by gram-negative pathogens or when no pathogen was recovered. Use of extended intramammary antimicrobial therapy (5 or 8 d) resulted in the least expected monetary values. PMID:21426977

Pinzón-Sánchez, C; Cabrera, V E; Ruegg, P L

2011-04-01

263

Types of Unintended Consequences Related to Computerized Provider Order Entry  

PubMed Central

Objective To identify types of clinical unintended adverse consequences resulting from computerized provider order entry (CPOE) implementation. Design An expert panel provided initial examples of adverse unintended consequences of CPOE. The authors, using qualitative methods, gathered and analyzed additional examples from five successful CPOE sites. Methods Using a card sort method, the authors developed a categorization scheme for the 79 unintended consequences initially identified and then iteratively modified the scheme to categorize 245 additional adverse consequences resulting from fieldwork. Because the focus centered on consequences requiring prevention or remedial action, the authors did not further analyze reported unintended beneficial (positive) consequences. Results Unintended adverse consequences (UACs) fell into nine major categories (in order of decreasing frequency): 1) more/new work for clinicians; 2) unfavorable workflow issues; 3) never ending system demands; 4) problems related to paper persistence; 5) untoward changes in communication patterns and practices; 6) negative emotions; 7) generation of new kinds of errors; 8) unexpected changes in the power structure; and 9) overdependence on the technology. Clinical decision support features introduced many of these unintended consequences. Conclusion Identifying and understanding the types and in some instances the causes of unintended adverse consequences associated with CPOE will enable system developers and implementers to better manage implementation and maintenance of future CPOE projects. PMID:16799128

Campbell, Emily M.; Sittig, Dean F.; Ash, Joan S.; Guappone, Kenneth P.; Dykstra, Richard H.

2006-01-01

264

Clinical decision making in a high-risk primary care environment: a qualitative study in the UK  

PubMed Central

Objective Examine clinical reasoning and decision making in an out of hours (OOH) primary care setting to gain insights into how general practitioners (GPs) make clinical decisions and manage risk in this environment. Design Semi-structured interviews using open-ended questions. Setting A 2-month qualitative interview study conducted in Oxfordshire, UK. Participants 21 GPs working in OOH primary care. Results The most powerful themes to emerge related to dealing with urgent potentially high-risk cases, keeping patients safe and responding to their needs, while trying to keep patients out of hospital and the concept of ‘fire fighting’. There were a number of well-defined characteristics that GPs reported making presentations easy or difficult to deal with. Severely ill patients were straightforward, while the older people, with complex multisystem diseases, were often difficult. GPs stopped collecting clinical information and came to clinical decisions when high-risk disease and severe illness requiring hospital attention has been excluded; they had responded directly to the patient's needs and there was a reliable safety net in place. Learning points that GPs identified as important for trainees in the OOH setting included the importance of developing rapport in spite of time pressures, learning to deal with uncertainty and learning about common presentations with a focus on critical cues to exclude severe illness. Conclusions The findings support suggestions that improvements in primary care OOH could be achieved by including automated and regular timely feedback system for GPs and individual peer and expert clinician support for GPs with regular meetings to discuss recent cases. In addition, trainee support and mentoring to focus on clinical skills, knowledge and risk management issues specific to OOH is currently required. Investigating the stopping rules used for diagnostic closure may provide new insights into the root causes of clinical error in such a high-risk setting. PMID:22318661

Heneghan, Carl; Thompson, Matthew; Balla, Margaret

2012-01-01

265

Ten commandments for effective clinical decision support for imaging: enabling evidence-based practice to improve quality and reduce waste.  

PubMed

OBJECTIVE. We describe best practices for effective imaging clinical decision support (CDS) derived from firsthand experience, extending the Ten Commandments for CDS published a decade ago. Our collective perspective is used to set expectations for providers, health systems, policy makers, payers, and health information technology developers. CONCLUSION. Highlighting unique attributes of effective imaging CDS will help radiologists to successfully lead and optimize the value of the substantial federal and local investments in health information technology in the United States. PMID:25341131

Khorasani, Ramin; Hentel, Keith; Darer, Jonathan; Langlotz, Curtis; Ip, Ivan K; Manaker, Scott; Cardella, John; Min, Robert; Seltzer, Steven

2014-11-01

266

Understanding patient decisions about clinical trials and the associated communication process: a preliminary report. | accrualnet.cancer.gov  

Cancer.gov

This article presents a conceptual model of factors affecting patient decisions about participating in clinical trials and describes videotaping methods for observing interactions between patients, physicians, and family members. Preliminary findings suggest that awareness of the camera during videotaped conversations does not significantly alter the behavior of participants. Further study of this model and methodology may produce results that can be incorporated into provider training.

267

Decision-making process in patients before entering phase III cancer clinical trials: a pilot study. | accrualnet.cancer.gov  

Cancer.gov

The findings of this pilot study with 14 cancer patients showed that patients, after receiving information from the medical oncologist, oncology nurse, or both, decided about participation in a clinical trial instantaneously. However, the information provided by the referring specialist may have been inadequate in the majority of cases. The emotional turmoil experienced after a cancer diagnosis may have contributed to the instantaneous decision making observed. Gathering further information and searching for alternatives should be encouraged.

268

"Many miles to go ...": a systematic review of the implementation of patient decision support interventions into routine clinical practice  

PubMed Central

Background Two decades of research has established the positive effect of using patient-targeted decision support interventions: patients gain knowledge, greater understanding of probabilities and increased confidence in decisions. Yet, despite their efficacy, the effectiveness of these decision support interventions in routine practice has yet to be established; widespread adoption has not occurred. The aim of this review was to search for and analyze the findings of published peer-reviewed studies that investigated the success levels of strategies or methods where attempts were made to implement patient-targeted decision support interventions into routine clinical settings. Methods An electronic search strategy was devised and adapted for the following databases: ASSIA, CINAHL, Embase, HMIC, Medline, Medline-in-process, OpenSIGLE, PsycINFO, Scopus, Social Services Abstracts, and the Web of Science. In addition, we used snowballing techniques. Studies were included after dual independent assessment. Results After assessment, 5322 abstracts yielded 51 articles for consideration. After examining full-texts, 17 studies were included and subjected to data extraction. The approach used in all studies was one where clinicians and their staff used a referral model, asking eligible patients to use decision support. The results point to significant challenges to the implementation of patient decision support using this model, including indifference on the part of health care professionals. This indifference stemmed from a reported lack of confidence in the content of decision support interventions and concern about disruption to established workflows, ultimately contributing to organizational inertia regarding their adoption. Conclusions It seems too early to make firm recommendations about how best to implement patient decision support into routine practice because approaches that use a ‘referral model’ consistently report difficulties. We sense that the underlying issues that militate against the use of patient decision support and, more generally, limit the adoption of shared decision making, are under-investigated and under-specified. Future reports from implementation studies could be improved by following guidelines, for example the SQUIRE proposals, and by adopting methods that would be able to go beyond the ‘barriers’ and ‘facilitators’ approach to understand more about the nature of professional and organizational resistance to these tools. The lack of incentives that reward the use of these interventions needs to be considered as a significant impediment. PMID:24625083

2013-01-01

269

Computerized training management system  

DOEpatents

A Computerized Training Management System (CTMS) is disclosed for providing a procedurally defined process that is employed to develop accreditable performance based training programs for job classifications that are sensitive to documented regulations and technical information. CTMS is a database that links information needed to maintain a five-phase approach to training-analysis, design, development, implementation, and evaluation independent of training program design. CTMS is designed using R-Base{trademark}, an-SQL compliant software platform. Information is logically entered and linked in CTMS. Each task is linked directly to a performance objective, which, in turn, is linked directly to a learning objective; then, each enabling objective is linked to its respective test items. In addition, tasks, performance objectives, enabling objectives, and test items are linked to their associated reference documents. CTMS keeps all information up to date since it automatically sorts, files and links all data; CTMS includes key word and reference document searches. 18 figs.

Rice, H.B.; McNair, R.C.; White, K.; Maugeri, T.

1998-08-04

270

Computerized training management system  

DOEpatents

A Computerized Training Management System (CTMS) for providing a procedurally defined process that is employed to develop accreditable performance based training programs for job classifications that are sensitive to documented regulations and technical information. CTMS is a database that links information needed to maintain a five-phase approach to training-analysis, design, development, implementation, and evaluation independent of training program design. CTMS is designed using R-Base.RTM., an-SQL compliant software platform. Information is logically entered and linked in CTMS. Each task is linked directly to a performance objective, which, in turn, is linked directly to a learning objective; then, each enabling objective is linked to its respective test items. In addition, tasks, performance objectives, enabling objectives, and test items are linked to their associated reference documents. CTMS keeps all information up to date since it automatically sorts, files and links all data; CTMS includes key word and reference document searches.

Rice, Harold B. (Franklin Furnace, OH); McNair, Robert C. (East Setauket, NY); White, Kenneth (Shirley, NY); Maugeri, Terry (Wading River, NY)

1998-08-04

271

An Analysis and Recommendations for Multidisciplinary Computerized Handoff Applications in Hospitals  

PubMed Central

In healthcare, patient handoffs are a common practice that is implemented by most clinicians who carry the responsibility of patient care. Ineffective handoffs have been associated with the occurrence of adverse clinical events. With the inception of the Joint Commissions’ National Patient Safety Goal (NSPG) 2E on handoff communication, computerized clinical handoff applications are emerging in hospitals. Computerized clinical handoff applications are intended to assist the clinicians in conducting effective handoffs by providing easy access to accurate clinical information and reducing the burden of handoff report upkeep. The purpose of this paper is to identify various types of computerized clinical handoff tools that are used in hospitals and perform a comparison of application characteristics, review clinical and business advantages and disadvantages in implementing computerized clinical handoff applications, and give recommendations for improvement. PMID:22195114

Hunt, Sevgin; Staggers, Nancy

2011-01-01

272

Helping patients make better decisions: how to apply behavioral economics in clinical practice  

PubMed Central

Clinicians are committed to effectively educating patients and helping them to make sound decisions concerning their own health care. However, how do clinicians determine what is effective education? How do they present information clearly and in a manner that patients understand and can use to make informed decisions? Behavioral economics (BE) is a subfield of economics that can assist clinicians to better understand how individuals actually make decisions. BE research can help guide interactions with patients so that information is presented and discussed in a more deliberate and impactful way. We can be more effective providers of care when we understand the factors that influence how our patients make decisions, factors of which we may have been largely unaware. BE research that focuses on health care and medical decision making is becoming more widely known, and what has been reported suggests that BE interventions can be effective in the medical realm. The purpose of this article is to provide clinicians with an overview of BE decision science and derived practice strategies to promote more effective behavior change in patients. PMID:25378915

Courtney, Maureen Reni; Spivey, Christy; Daniel, Kathy M

2014-01-01

273

Evaluation of User Interface and Workflow Design of a Bedside Nursing Clinical Decision Support System  

PubMed Central

Background Clinical decision support systems (CDSS) are important tools to improve health care outcomes and reduce preventable medical adverse events. However, the effectiveness and success of CDSS depend on their implementation context and usability in complex health care settings. As a result, usability design and validation, especially in real world clinical settings, are crucial aspects of successful CDSS implementations. Objective Our objective was to develop a novel CDSS to help frontline nurses better manage critical symptom changes in hospitalized patients, hence reducing preventable failure to rescue cases. A robust user interface and implementation strategy that fit into existing workflows was key for the success of the CDSS. Methods Guided by a formal usability evaluation framework, UFuRT (user, function, representation, and task analysis), we developed a high-level specification of the product that captures key usability requirements and is flexible to implement. We interviewed users of the proposed CDSS to identify requirements, listed functions, and operations the system must perform. We then designed visual and workflow representations of the product to perform the operations. The user interface and workflow design were evaluated via heuristic and end user performance evaluation. The heuristic evaluation was done after the first prototype, and its results were incorporated into the product before the end user evaluation was conducted. First, we recruited 4 evaluators with strong domain expertise to study the initial prototype. Heuristic violations were coded and rated for severity. Second, after development of the system, we assembled a panel of nurses, consisting of 3 licensed vocational nurses and 7 registered nurses, to evaluate the user interface and workflow via simulated use cases. We recorded whether each session was successfully completed and its completion time. Each nurse was asked to use the National Aeronautics and Space Administration (NASA) Task Load Index to self-evaluate the amount of cognitive and physical burden associated with using the device. Results A total of 83 heuristic violations were identified in the studies. The distribution of the heuristic violations and their average severity are reported. The nurse evaluators successfully completed all 30 sessions of the performance evaluations. All nurses were able to use the device after a single training session. On average, the nurses took 111 seconds (SD 30 seconds) to complete the simulated task. The NASA Task Load Index results indicated that the work overhead on the nurses was low. In fact, most of the burden measures were consistent with zero. The only potentially significant burden was temporal demand, which was consistent with the primary use case of the tool. Conclusions The evaluation has shown that our design was functional and met the requirements demanded by the nurses’ tight schedules and heavy workloads. The user interface embedded in the tool provided compelling utility to the nurse with minimal distraction. PMID:23612350

Yuan, Michael Juntao; Finley, George Mike; Mills, Christy; Johnson, Ron Kim

2013-01-01

274

A national clinical decision support infrastructure to enable the widespread and consistent practice of genomic and personalized medicine  

PubMed Central

Background In recent years, the completion of the Human Genome Project and other rapid advances in genomics have led to increasing anticipation of an era of genomic and personalized medicine, in which an individual's health is optimized through the use of all available patient data, including data on the individual's genome and its downstream products. Genomic and personalized medicine could transform healthcare systems and catalyze significant reductions in morbidity, mortality, and overall healthcare costs. Discussion Critical to the achievement of more efficient and effective healthcare enabled by genomics is the establishment of a robust, nationwide clinical decision support infrastructure that assists clinicians in their use of genomic assays to guide disease prevention, diagnosis, and therapy. Requisite components of this infrastructure include the standardized representation of genomic and non-genomic patient data across health information systems; centrally managed repositories of computer-processable medical knowledge; and standardized approaches for applying these knowledge resources against patient data to generate and deliver patient-specific care recommendations. Here, we provide recommendations for establishing a national decision support infrastructure for genomic and personalized medicine that fulfills these needs, leverages existing resources, and is aligned with the Roadmap for National Action on Clinical Decision Support commissioned by the U.S. Office of the National Coordinator for Health Information Technology. Critical to the establishment of this infrastructure will be strong leadership and substantial funding from the federal government. Summary A national clinical decision support infrastructure will be required for reaping the full benefits of genomic and personalized medicine. Essential components of this infrastructure include standards for data representation; centrally managed knowledge repositories; and standardized approaches for leveraging these knowledge repositories to generate patient-specific care recommendations at the point of care. PMID:19309514

2009-01-01

275

Decisions to Withhold Diagnostic Investigations in Nursing Home Patients with a Clinical Suspicion of Venous Thromboembolism  

PubMed Central

Background This study aimed to gather insights in physicians' considerations for decisions to either refer for- or to withhold additional diagnostic investigations in nursing home patients with a suspicion of venous thromboembolism. Methods Our study was nested in an observational study on diagnostic strategies for suspected venous thromboembolism in nursing home patients. Patient characteristics, bleeding-complications and mortality were related to the decision to withhold investigations. For a better understanding of the physicians' decisions, 21 individual face-to-face in-depth interviews were performed and analysed using the grounded theory approach. Results Referal for additional diagnostic investigations was forgone in 126/322 (39.1%) patients with an indication for diagnostic work-up. ‘Blind’ anticoagulant treatment was initiated in 95 (75.4%) of these patients. The 3month mortality rates were higher for patients in whom investigations were withheld than in the referred patients, irrespective of anticoagulant treatment (odds ratio 2.45; 95% confidence interval 1.40 to 4.29) but when adjusted for the probability of being referred (i.e. the propensity score), there was no relation of non-diagnosis decisions to mortality (odds ratio 1.75; 0.98 to 3.11). In their decisions to forgo diagnostic investigations, physicians incorporated the estimated relative impact of the potential disease; the potential net-benefits of diagnostic investigations and whether performing investigations agreed with established management goals in advance care planning. Conclusion Referral for additional diagnostic investigations is withheld in almost 40% of Dutch nursing home patients with suspected venous thromboembolism and an indication for diagnostic work-up. We propose that, given the complexity of these decisions and the uncertainty regarding their indirect effects on patient outcome, more attention should be focused on the decision to either use or withhold additional diagnostic tests. PMID:24614754

Schouten, Henrike J.; Koek, Huiberdina L.; Kruisman-Ebbers, Marije; Geersing, Geert-Jan; Oudega, Ruud; Kars, Marijke C.; Moons, Karel G. M.; van Delden, Johannes J. M.

2014-01-01

276

Multicenter Validation of a Computer-Based Clinical Decision Support Tool for Glucose Control in Adult and Pediatric Intensive Care Units  

PubMed Central

Introduction Hyperglycemia during critical illness is common, and intravenous insulin therapy (IIT) to normalize blood glucose improves outcomes in selected populations. Methods differ widely in complexity, insulin dosing approaches, efficacy, and rates of hypoglycemia. We developed a simple bedside-computerized decision support protocol (eProtocol-insulin) that yields promising results in the development center. We examined the effectiveness and safety of this tool in six adult and five pediatric intensive care units (ICUs) in other centers. Methods We required attending physicians of eligible patients to independently intend to use intravenous insulin to normalize blood glucose. We used eProtocol-insulin for glucose control for a duration determined by the clinical caregivers. Adults had an anticipated length of stay of 3 or more days. In pediatric ICUs, we also required support or intended support with mechanical ventilation for greater than 24 hours or with a vasoactive infusion. We recorded all instances in which eProtocol-insulin instructions were not accepted and all blood glucose values. An independent data safety and monitoring board monitored study results and subject safety. Bedside nurses were selected randomly to complete a paper survey describing their perceptions of quality of care and workload related to eProtocol-insulin use. Results Clinicians accepted 93% of eProtocol-insulin instructions (11,773/12,645) in 100 adult and 48 pediatric subjects. Forty-eight percent of glucose values were in the target range. Both of these results met a priori-defined efficacy thresholds. Only 0.18% of glucose values were ?40 mg/dl. This is lower than values reported in prior IIT studies. Although nurses reported eProtocol-insulin required as much work as managing a mechanical ventilator, most nurses felt eProtocol-insulin had a low impact on their ability to complete non-IIT nursing activities. Conclusions A multicenter validation demonstrated that eProtocol-insulin is a valid, exportable tool that can assist clinicians in achieving control of glucose in critically ill adults and children. PMID:19885199

Thompson, B. Taylor; Orme, James F.; Zheng, Hui; Luckett, Peter M.; Truwit, Jonathon D.; Willson, Douglas F.; Duncan Hite, R.; Brower, Roy G.; Bernard, Gordon R.; Curley, Martha A. Q.; Steingrub, Jay S.; Sorenson, Dean K.; Sward, Kathy; Hirshberg, Ellie; Morris, Alan H.

2008-01-01

277

Improving allergy alerting in a computerized physician order entry system.  

PubMed

Computerized physician order entry has been shown to reduce the frequency of serious medication errors. Decision support tools such as alerting functions for patient medication allergy are a key part of these applications. However, optimal performance requires iterative refinement. As systems become increasingly complex, mechanisms to monitor their performance become increasingly critical. We analyzed trend data obtained over a five-year period that showed decreasing compliance to allergy alert functions within computerized order entry. Many medication-allergy pairs were being consistently overridden. Renewal policies affecting reordering narcotics also contributed heavily to this trend. Each factor revealed a system-wide trend that could result in suggestions for policy or software change. Monitoring trends such as these is very important to maintain software correctness and ensure user trust in alerting systems, so users remain responsive to computerized alerts. PMID:11080034

Abookire, S A; Teich, J M; Sandige, H; Paterno, M D; Martin, M T; Kuperman, G J; Bates, D W

2000-01-01

278

78 FR 35937 - Food and Drug Administration Decisions for Investigational Device Exemption Clinical...  

Federal Register 2010, 2011, 2012, 2013

...applicable to other clinical investigations as...providing feedback on a clinical study protocol as...allowing for more complete and meaningful feedback...Decisional IDE. In such cases, FDA should acknowledge...Pre-Decisional IDE to complete FDA feedback, inclusive...the initiation of clinical trials, such...

2013-06-14

279

Evaluation and certification of computerized provider order entry systems.  

PubMed

Computerized physician order entry (CPOE) is an application that is used to electronically write physician orders either in the hospital or in the outpatient setting. It is used in about 15% of U.S. Hospitals and a smaller percentage of ambulatory clinics. It is linked with clinical decision support, which provides much of the value of implementing it. A number of studies have assessed the impact of CPOE with respect to a variety of parameters, including costs of care, medication safety, use of guidelines or protocols, and other measures of the effectiveness or quality of care. Most of these studies have been undertaken at CPOE exemplar sites with homegrown clinical information systems. With the increasing implementation of commercial CPOE systems in various settings of care has come evidence that some implementation approaches may not achieve previously published results or may actually cause new errors or even harm. This has lead to new initiatives to evaluate CPOE systems, which have been undertaken by both vendors and other groups who evaluate vendors, focused on CPOE vendor capabilities and effective approaches to implementation that can achieve benefits seen in published studies. In addition, an electronic health record (EHR) vendor certification process is ongoing under the province of the Certification Commission for Health Information Technology (CCHIT) (which includes CPOE) that will affect the purchase and use of these applications by hospitals and clinics and their participation in public and private health insurance programs. Large employers have also joined this focus by developing flight simulation tools to evaluate the capabilities of these CPOE systems once implemented, potentially linking the results of such programs to reimbursement through pay for performance programs. The increasing role of CPOE systems in health care has invited much more scrutiny about the effectiveness of these systems in actual practice which has the potential to improve their ultimate performance. PMID:17077453

Classen, David C; Avery, Anthony J; Bates, David W

2007-01-01

280

Computerized Physician Order Entry in the Critical Care Environment: A Review of Current Literature  

Microsoft Academic Search

The implementation of health information technology (HIT) is accelerating, driven in part by a growing interest in computerized physician order entry (CPOE) as a tool for improving the quality and safety of patient care. Computerized physician order entry could have a substantial impact on patients in intensive care, where the potential for medical error is high, and the clinical workflow

David M. Maslove; Norman Rizk; Henry J. Lowe

2011-01-01

281

Bias-Free Computerized Testing.  

National Technical Information Service (NTIS)

Summarized in this report is research from a project designed to investigate the utility of item characteristic curve theory and computerized adaptive testing as means of measuring and reducing ethnic bias and unfairness in ability tests. During the theor...

S. M. Pine, D. J. Weiss

1979-01-01

282

Computerized international geothermal information systems  

SciTech Connect

The computerized international geothermal energy information system is reviewed. The review covers establishment of the Italy - United States linked data centers by the NATO Committee on Challenges of Modern Society, through a bilateral agreement, and up to the present time. The result of the information exchange project is given as the bibliographic and numerical data available from the data centers. Recommendations for the exchange of computerized geothermal information at the international level are discussed.

Phillips, S.L.; Lawrence, J.D.; Lepman, S.R.

1980-03-01

283

Ambulatory Computerized Physician Order Entry Implementation  

PubMed Central

As part of a broader effort to identify success factors for implementing computerized physician order entry (CPOE), factors specific to the ambulatory setting were investigated in the field at Kaiser Permanente Northwest. A multidisciplinary team of five qualitative researchers spent seven months at four clinics conducting observations, interviews, and focus groups. The team analyzed the data using a combination of template and grounded theory approaches. The result is a description of fourteen themes, clustered into technology, organizational, personal, and environmental categories. While similar to inpatient study results in many respects, this outpatient CPO investigation generated subtly different themes. PMID:16778992

Ash, Joan S.; Chin, Homer L.; Sittig, Dean F.; Dykstra, Richard

2005-01-01

284

Understanding the decisions of cancer clinical trial participants to enter research studies: factors associated with informed consent, patient satisfaction, and decisional regret. | accrualnet.cancer.gov  

Cancer.gov

This study shows that participants who enroll in clinical trials quickly (early signers) may not believe they fully understand the implications of participation. In general, participants who do not believe they fully understand the implications of trial participation, or who are less satisfied with their decision to enroll in the trial, may ultimately feel regret about their decision to participate.

285

A Privacy-Preserving Framework for Distributed Clinical Decision Support George Mathew, Zoran Obradovic  

E-print Network

) Systems in connection with the practice of Evidence-based Medicine was to "develop maintainable technical facilitates knowledge building using statistics based on patient data from multiple sites that satisfy and methodological foundations for computer-based decision support" [1]. Also, medical domain is "characterized

Obradovic, Zoran

286

Thinking Processes in Social Workers' Use of a Clinical Decision Support System: A Qualitative Study  

ERIC Educational Resources Information Center

The authors examined the thinking processes in the use of a decision support system (DSS) by social workers in a human services agency to determine whether they used the system to improve their case reasoning. Information was obtained from in-depth interviews with eight social workers who used a DSS in their work and from content analysis of…

Monnickendam, Menachem; Savaya, Riki; Waysman, Mark

2005-01-01

287

Building a Normative Decision Support System for Clinical and Operational Risk Management in Hemodialysis  

Microsoft Academic Search

This paper describes the design and implementation of a decision support system for risk management in hemodialysis (HD) departments. The proposed system exploits a domain ontology to formalize the problem as a Bayesian network. It also relies on a software tool, able to automatically collect HD data, to learn the network conditional probabilities. By merging prior knowledge and the available

Chiara Cornalba; Roberto G. Bellazzi; Riccardo Bellazzi

2008-01-01

288

Computerized Anesthesia Personnel System.  

PubMed

CAPS, (Computerized Anesthesia Personnel System), is a personnel management system for a large anesthesia department. It is written in BASIC for the IBM PC or IBM-compatible computer using 2 or more 5 1/4 inch disk drives or a hard disk. CAPS is designed to facilitate assignment of up to 30 attending anesthesiologists, 40 residents, 15 CRNAs, 5 interns, 5 anesthesia assistants, and up to 15 medical students to the operating room schedule. The system supports part-time personnel, regular laboratory/office/reading days, and resident rotations inside the operating suite, outside the operating suite, and to secondary hospitals. CAPS generates an availability list each day, listing all persons available for the operating room and the rotations and call days assigned. It then lists all persons not available that day and the reason for the absence. CAPS also tracts vacation, meeting, administrative and compensatory time for all members of the department, and maintains an absence record for each person listing sick times and all other absences. CAPS generates a weekly staffing list showing days each person is available to the operating room and the total number of attendings, residents, CRNAs, and assistants available each day. This article discusses why the program was developed, how it was designed, and how well it has met the objectives of the designers. PMID:3397611

Holley, H S; Heller, F

1988-01-01

289

Competency in health care management: a training model in epidemiologic methods for assessing and improving the quality of clinical practice through evidence-based decision making.  

PubMed

This article describes a training model that focuses on health care management by applying epidemiologic methods to assess and improve the quality of clinical practice. The model's uniqueness is its focus on integrating clinical evidence-based decision making with fundamental principles of resource management to achieve attainable, cost-effective, high-quality health outcomes. The target students are current and prospective clinical and administrative executives who must optimize decision making at the clinical and managerial levels of health care organizations. PMID:10176406

Hudak, R P; Jacoby, I; Meyer, G S; Potter, A L; Hooper, T I; Krakauer, H

1997-01-01

290

A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma  

Microsoft Academic Search

Study Objective: We sought to determine the prevalence of thoracic injuries in children sustaining blunt torso trauma and to develop a clinical prediction rule to identify children with these injuries. Methods: We prospectively enrolled pediatric patients (<16 years) who presented to the emergency department of a Level I trauma center with blunt torso trauma and underwent chest radiography. Clinical findings

James F. Holmes; Peter E. Sokolove; William E. Brant; Nathan Kuppermann

2002-01-01

291

How to translate therapeutic recommendations in clinical practice guidelines into rules for critiquing physician prescriptions? Methods and application to five guidelines  

Microsoft Academic Search

BACKGROUND: Clinical practice guidelines give recommendations about what to do in various medical situations, including therapeutical recommendations for drug prescription. An effective way to computerize these recommendations is to design critiquing decision support systems, i.e. systems that criticize the physician's prescription when it does not conform to the guidelines. These systems are commonly based on a list of \\

Jean-Baptiste Lamy; Vahid Ebrahiminia; Christine Riou; Brigitte Seroussi; Jacques Bouaud; Christian Simon; Stéphane Dubois; Antoine Butti; Gérard Simon; Madeleine Favre; Hector Falcoff; Alain Venot

2010-01-01

292

Clinical decision making involved in secluding and restraining an adult psychiatric patient: an integrative literature review.  

PubMed

The purpose of this integrative literature review was to describe different factors involved in the decision-making process of using seclusion or restraint, and to discuss the process in practice. The data used in this review were systematically retrieved from the following databases: CINAHL, Medline and PsycINFO. Manual data retrieval was conducted from the reference lists of the papers that came up in the original database search. A total of 32 studies were selected. Results suggest that the situations that lead to the use of seclusion or restraint are always dynamic and circumstantial. During the decision-making process staff observe a patient's behaviour, assesses risk and chooses and uses interventions that aim to de-escalate the situation. This process is affected by the previous experiences and history of staff as well as the behaviour and previous experience of the patient. PMID:23217004

Laiho, T; Kattainen, E; Astedt-Kurki, P; Putkonen, H; Lindberg, N; Kylmä, J

2013-11-01

293

The MacCAT-T: a clinical tool to assess patients' capacities to make treatment decisions  

Microsoft Academic Search

OBJECTIVE: The feasibility, reliability, and validity of a new instrument, the MacArthur Competence Assessment Tool-Treatment (MacCAT-T), which was developed for use by clinicians, was tested. The instrument assesses patients' competence to make treatment decisions by examining their capacities in four areas--understanding information relevant to their condition and the recommended treatment, reasoning about the potential risks and benefits of their choices,

Thomas Grisso; Paul S. Appelbaum; Carolyn Hill-Fotouhi

1997-01-01

294

Decision-Making in Frontotemporal Dementia: Clinical, Theoretical and Legal Implications  

Microsoft Academic Search

Background: The behavioral variant of frontotemporal dementia (bvFTD) is characterized by progressive changes in personality and social interaction, loss of empathy, disinhibition and impulsivity, most of which generally precede the onset of cognitive deficits. In this study, we investigated decision-making cognition in a group of patients with an early bvFTD diagnosis whose standard neuropsychological performance was within normal range for

Facundo Manes; Teresa Torralva; Agustín Ibáñez; María Roca; Tristán Bekinschtein; Ezequiel Gleichgerrcht

2011-01-01

295

Ethically Justified, Clinically Applicable Criteria for Physician Decision-Making in Psychopharmacological Enhancement  

Microsoft Academic Search

Advances in psychopharmacology raise the prospects of enhancing neurocognitive functions of humans by improving attention,\\u000a memory, or mood. While general ethical reflections on psychopharmacological enhancement have been increasingly published in\\u000a the last years, ethical criteria characterizing physicians’ role in neurocognitive enhancement and guiding their decision-making\\u000a still remain highly unclear. Here it will be argued that also in the medical domain

Matthis Synofzik

2009-01-01

296

What Factors Influence Parental Decisions to Participate in Clinical Research: Consenters versus Non-consenters  

PubMed Central

Objective To determine factors associated with parental consent for their child’s participation in a randomized, placebo-controlled trial. Design Cross-sectional survey. Setting 7 Children’s Hospitals participating in a randomized trial evaluating management of children with vesicoureteral reflux; July 2008 to May 2011. Participants Parents asked to provide consent for their child’s participation in the trial were invited to complete an anonymous online survey about factors influencing their decision. 120 (44%) of the 271 invited, completed the survey: 58 of 125 (46%) had provided and 62 of 144 (43%) had declined consent. Outcome Measures 60-question survey examining: child, parent, and study characteristics; parental perception of the study; understanding of design; external influences; and decision-making process. Results Having graduated from college and private health insurance were associated with lower likelihood of providing consent. Parents who perceived the trial as having low degree of risk, resulting in greater benefit to their child and other children, causing little interference with standard care or exhibiting potential for enhanced care or who perceived the researcher as professional were significantly more likely to consent to participate. Higher levels of understanding of randomization process, blinding, and right to withdraw were significantly associated with consent to participate. Conclusions Parents who declined consent had a relatively higher socioeconomic status, had more anxiety about their decision and found it harder to make their decision compared with consenting parents, who had higher levels of trust and altruism, perceived the potential for enhanced care, reflected better understanding of randomization, and exhibited low decisional uncertainty. PMID:23546617

Hoberman, Alejandro; Shaikh, Nader; Bhatnagar, Sonika; Haralam, Mary Ann; Kearney, Diana H.; Colborn, D. Kathleen; Kienholz, Michelle L.; Wang, Li; Bunker, Clareann H.; Keren, Ron; Carpenter, Myra A.; Greenfield, Saul P.; Pohl, Hans G.; Mathews, Ranjiv; Moxey-Mims, Marva; Chesney, Russell W.

2013-01-01

297

Bayesian decision theoretic two-stage design in Phase II clinical trials with survival endpoint  

PubMed Central

SUMMARY In this paper, we consider two-stage designs with failure-time endpoints in single arm phase II trials. We propose designs in which stopping rules are constructed by comparing the Bayes risk of stopping at stage one to the expected Bayes risk of continuing to stage two using both the observed data in stage one and the predicted survival data in stage two. Terminal decision rules are constructed by comparing the posterior expected loss of a rejection decision versus an acceptance decision. Simple threshold loss functions are applied to time-to-event data modelled either parametrically or non-parametrically, and the cost parameters in the loss structure are calibrated to obtain desired Type I error and power. We ran simulation studies to evaluate design properties including type I&II errors, probability of early stopping, expected sample size and expected trial duration, and compared them with the Simon two-stage designs and a design which is an extension of the Simon’s designs with time-to-event endpoints. An example based on a recently conducted phase II sarcoma trial illustrates the method. PMID:22359354

Zhao, Lili; Taylor, Jeremy M.G.; Schuetze, Scott M

2014-01-01

298

Recommendations for standardizing glucose reporting and analysis to optimize clinical decision making in diabetes: the ambulatory glucose profile.  

PubMed

Underutilization of glucose data and lack of easy and standardized glucose data collection, analysis, visualization, and guided clinical decision making are key contributors to poor glycemic control among individuals with type 1 diabetes mellitus. An expert panel of diabetes specialists, facilitated by the International Diabetes Center and sponsored by the Helmsley Charitable Trust, met in 2012 to discuss recommendations for standardizing the analysis and presentation of glucose monitoring data, with the initial focus on data derived from continuous glucose monitoring systems. The panel members were introduced to a universal software report, the Ambulatory Glucose Profile, and asked to provide feedback on its content and functionality, both as a research tool and in clinical settings. This article provides a summary of the topics and issues discussed during the meeting and presents recommendations from the expert panel regarding the need to standardize glucose profile summary metrics and the value of a uniform glucose report to aid clinicians, researchers, and patients. PMID:23567014

Bergenstal, Richard M; Ahmann, Andrew J; Bailey, Timothy; Beck, Roy W; Bissen, Joan; Buckingham, Bruce; Deeb, Larry; Dolin, Robert H; Garg, Satish K; Goland, Robin; Hirsch, Irl B; Klonoff, David C; Kruger, Davida F; Matfin, Glenn; Mazze, Roger S; Olson, Beth A; Parkin, Christopher; Peters, Anne; Powers, Margaret A; Rodriguez, Henry; Southerland, Phil; Strock, Ellie S; Tamborlane, William; Wesley, David M

2013-01-01

299

Recommendations for standardizing glucose reporting and analysis to optimize clinical decision making in diabetes: the Ambulatory Glucose Profile (AGP).  

PubMed

Abstract Underutilization of glucose data and lack of easy and standardized glucose data collection, analysis, visualization, and guided clinical decision making are key contributors to poor glycemic control among individuals with type 1 diabetes. An expert panel of diabetes specialists, facilitated by the International Diabetes Center and sponsored by the Helmsley Charitable Trust, met in 2012 to discuss recommendations for standardization of analysis and presentation of glucose monitoring data, with the initial focus on data derived from CGM systems. The panel members were introduced to a universal software report, the Ambulatory Glucose Profile (AGP), and asked to provide feedback on its content and functionality, both as a research tool and in clinical settings. This paper provides a summary of the topics and issues discussed during the meeting and presents recommendations from the expert panel regarding the need to standardize glucose profile summary metrics and the value of a uniform glucose report to aid clinicians, researchers, and patients. PMID:23448694

Bergenstal, Richard M; Ahmann, Andrew J; Bailey, Timothy; Beck, Roy W; Bissen, Joan; Buckingham, Bruce; Deeb, Larry; Dolin, Robert H; Garg, Satish K; Goland, Robin; Hirsch, Irl B; Klonoff, David C; Kruger, Davida F; Matfin, Glenn; Mazze, Roger S; Olson, Beth A; Parkin, Christopher; Peters, Anne; Powers, Margaret A; Rodriguez, Henry; Southerland, Phil; Strock, Ellie S; Tamborlane, William; Wesley, David M

2013-03-01

300

Development and psychometric properties of a five-language multiperspective instrument to assess clinical decision making style in the treatment of people with severe mental illness (CDMS)  

PubMed Central

Background The aim of this study was to develop and evaluate psychometric properties of the Clinical Decision Making Style (CDMS) scale which measures general preferences for decision making as well as preferences regarding the provision of information to the patient from the perspectives of people with severe mental illness and staff. Methods A participatory approach was chosen for instrument development which followed 10 sequential steps proposed in a current guideline of good practice for the translation and cultural adaptation of measures. Following item analysis, reliability, validity, and long-term stability of the CDMS were examined using Spearman correlations in a sample of 588 people with severe mental illness and 213 mental health professionals in 6 European countries (Germany, UK, Italy, Denmark, Hungary, and Switzerland). Results In both patient and staff versions, the two CDMS subscales “Participation in Decision Making” and “Information” reliably measure distinct characteristics of decision making. Validity could be demonstrated to some extent, but needs further investigation. Conclusions Together with two other five-language patient- and staff-rated measures developed in the CEDAR study (ISRCTN75841675) – “Clinical Decision Making in Routine Care” and “Clinical Decision Making Involvement and Satisfaction” – the CDMS allows empirical investigation of the complex relation between clinical decision making and outcome in the treatment of people with severe mental illness across Europe. PMID:23379280

2013-01-01

301

Mixed results in the safety performance of computerized physician order entry.  

PubMed

Computerized physician order entry is a required feature for hospitals seeking to demonstrate meaningful use of electronic medical record systems and qualify for federal financial incentives. A national sample of sixty-two hospitals voluntarily used a simulation tool designed to assess how well safety decision support worked when applied to medication orders in computerized order entry. The simulation detected only 53 percent of the medication orders that would have resulted in fatalities and 10-82 percent of the test orders that would have caused serious adverse drug events. It is important to ascertain whether actual implementations of computerized physician order entry are achieving goals such as improved patient safety. PMID:20368595

Metzger, Jane; Welebob, Emily; Bates, David W; Lipsitz, Stuart; Classen, David C

2010-04-01

302

Decision tree-based method for integrating gene expression, demographic, and clinical data to determine disease endotypes  

PubMed Central

Background Complex diseases are often difficult to diagnose, treat and study due to the multi-factorial nature of the underlying etiology. Large data sets are now widely available that can be used to define novel, mechanistically distinct disease subtypes (endotypes) in a completely data-driven manner. However, significant challenges exist with regard to how to segregate individuals into suitable subtypes of the disease and understand the distinct biological mechanisms of each when the goal is to maximize the discovery potential of these data sets. Results A multi-step decision tree-based method is described for defining endotypes based on gene expression, clinical covariates, and disease indicators using childhood asthma as a case study. We attempted to use alternative approaches such as the Student’s t-test, single data domain clustering and the Modk-prototypes algorithm, which incorporates multiple data domains into a single analysis and none performed as well as the novel multi-step decision tree method. This new method gave the best segregation of asthmatics and non-asthmatics, and it provides easy access to all genes and clinical covariates that distinguish the groups. Conclusions The multi-step decision tree method described here will lead to better understanding of complex disease in general by allowing purely data-driven disease endotypes to facilitate the discovery of new mechanisms underlying these diseases. This application should be considered a complement to ongoing efforts to better define and diagnose known endotypes. When coupled with existing methods developed to determine the genetics of gene expression, these methods provide a mechanism for linking genetics and exposomics data and thereby accounting for both major determinants of disease. PMID:24188919

2013-01-01

303

Electronic health record: integrating evidence-based information at the point of clinical decision making.  

PubMed

The authors created two tools to achieve the goals of providing physicians with a way to review alternative diagnoses and improving access to relevant evidence-based library resources without disrupting established workflows. The “diagnostic decision support tool” lifted terms from standard, coded fields in the electronic health record and sent them to Isabel, which produced a list of possible diagnoses. The physicians chose their diagnoses and were presented with the “knowledge page,” a collection of evidence-based library resources. Each resource was automatically populated with search results based on the chosen diagnosis. Physicians responded positively to the “knowledge page.” PMID:24415920

Fowler, Susan A; Yaeger, Lauren H; Yu, Feliciano; Doerhoff, Dwight; Schoening, Paul; Kelly, Betsy

2014-01-01

304

Electronic health record: integrating evidence-based information at the point of clinical decision making*  

PubMed Central

The authors created two tools to achieve the goals of providing physicians with a way to review alternative diagnoses and improving access to relevant evidence-based library resources without disrupting established workflows. The “diagnostic decision support tool” lifted terms from standard, coded fields in the electronic health record and sent them to Isabel, which produced a list of possible diagnoses. The physicians chose their diagnoses and were presented with the “knowledge page,” a collection of evidence-based library resources. Each resource was automatically populated with search results based on the chosen diagnosis. Physicians responded positively to the “knowledge page.” PMID:24415920

Fowler, Susan A.; Yaeger, Lauren H.; Yu, Feliciano; Doerhoff, Dwight; Schoening, Paul; Kelly, Betsy

2014-01-01

305

An information retrieval service to support clinical decision-making at the point of care.  

PubMed Central

The information retrieval systems currently available in general practice, such as Medline, and web search engines are passive and relatively difficult to access during consultations. Emergent technologies, including the National Electronic Library for Health, offer opportunities for more active decision support. We examine the extent to which information retrieval could support primary care consultations by examining the impact of the new technology at different stages of the consultation. We advocate a system whereby professional organisations concerned with quality of care, such as the Royal College of General Practitioners, might contribute the the process. PMID:10824349

Sullivan, F; Gardner, M; van Rijsbergen, K

1999-01-01

306

Computerized financial systems in the ambulatory care marketplace.  

PubMed

In summary, there are literally hundreds of vendor financial system product offerings that combine a confusing array of application areas, hardware features, and data processing approaches to support the medical marketplace. Ambulatory health care managers will make better decisions regarding investments in computerized financial information systems by objectively comparing the many diverse features and functions of various systems, identifying the desirable hardware capabilities needed to effectively support the systems, and understanding the differences between data processing approaches. PMID:10271110

Cook, M J

1985-05-01

307

An HL7-CDA wrapper for facilitating semantic interoperability to rule-based Clinical Decision Support Systems.  

PubMed

The success of Clinical Decision Support Systems (CDSS) greatly depends on its capability of being integrated in Health Information Systems (HIS). Several proposals have been published up to date to permit CDSS gathering patient data from HIS. Some base the CDSS data input on the HL7 reference model, however, they are tailored to specific CDSS or clinical guidelines technologies, or do not focus on standardizing the CDSS resultant knowledge. We propose a solution for facilitating semantic interoperability to rule-based CDSS focusing on standardized input and output documents conforming an HL7-CDA wrapper. We define the HL7-CDA restrictions in a HL7-CDA implementation guide. Patient data and rule inference results are mapped respectively to and from the CDSS by means of a binding method based on an XML binding file. As an independent clinical document, the results of a CDSS can present clinical and legal validity. The proposed solution is being applied in a CDSS for providing patient-specific recommendations for the care management of outpatients with diabetes mellitus. PMID:23199936

Sáez, Carlos; Bresó, Adrián; Vicente, Javier; Robles, Montserrat; García-Gómez, Juan Miguel

2013-03-01

308

Removal of C-spine protection by A&E triage nurses: a prospective trial of a clinical decision making instrument  

Microsoft Academic Search

Objective: To investigate if triage nurses could safely apply a set of clinical criteria, removing hard collars and spinal boards at initial triage assessment.Methods: The Nexus clinical decision rules were applied by trained triage nurses to patients who attended the department with cervical collars and \\/or on spinal boards. Patients were excluded if they were felt to be in need

E Pitt; D K Pedley; A Nelson; M Cumming; M Johnston

2006-01-01

309

Calibrating for Comorbidity: Clinical Decision-Making in Youth Depression and Anxiety  

ERIC Educational Resources Information Center

Comorbidity in clinical youth populations is more the rule than the exception, yet few established guidelines exist to help practicing clinicians manage complex diagnostic profiles. The current paper reviews efforts within the treatment development literature to handle comorbidity in depressed and anxious children and adolescents, including…

Chu, Brian C.; Merson, Rachel A.; Zandberg, Laurie J.; Areizaga, Margaret

2012-01-01

310

Lesson of the week Playing the odds in clinical decision making  

E-print Network

improved over- night, becoming persistent and centred behind the left eye. Ten days later he noticed drooping of his left eye- lid and double vision. Clinical examination revealed a left, complete, oculomotor subtraction angio- graphy revealed a left 8 mm posterior communicating Fig 1 Case 1: magnetic resonance

Penny, Will

311

A UMLS-Based Knowledge Acquisition Tool for Rule-Based Clinical Decision Support Systems Construction  

E-print Network

: Knowledge Engineering, Domain Ontology, Arden Syntax, and Blood Transfusion. #12;3 I. Introduction Clinical browser, the explicit domain ontology. The expert is then guided in creating the knowledge base according to the pre- established domain ontology and condition-action rule templates that are well adapted to several

Dojat, Michel

312

Ten commandments for effective clinical decision support: makingthe practice of evidence-based medicine a reality  

Microsoft Academic Search

While evidence-based medicine has increasingly broad-based support\\u000d\\u000a\\u0009in health care, it remains difficult to get physicians to actually\\u000d\\u000a\\u0009practice it. Across most domains in medicine, practice has lagged\\u000d\\u000a\\u0009behind knowledge by at least several years. The authors believe that\\u000d\\u000a\\u0009the key tools for closing this gap will be information systems that\\u000d\\u000a\\u0009provide decision support to users at the time they

DAVID W. BATES; G ILAD J. KUPERMAN; Samuel Wang; Tejal Gandhi; Anne Kittler; Lynn Volk; Cynthia Spurr; Ramin Khorasani; Milenko Tanasijevic; Blackford Middleton

2003-01-01

313

Cervical Spine Computed Tomography Imaging Artifact Affecting Clinical Decision-Making in the Traumatized Patient  

PubMed Central

CT scanning is an important tool in the evaluation of trauma patients. We review a case involving a trauma patient in which a cervical spine computed tomography (CT) artifact affected decision-making by physicians. The CT artifact mimicked bilateral dislocated facets (51-B1.1). On the basis of CT findings, the patient was transferred to a different hospital for evaluation. Discrepancy between the primary CT scan and patient physical exam prompted secondary CT scans and X-ray evaluation; neither of these studies showed osseous abnormalities. This case reinforces the necessity for physicians to formulate their diagnosis based upon multiple areas of information including physical examination, plain x-ray and subsequent advanced imaging, rather than relying solely on advanced imaging. PMID:25352931

Coats, Aaron C; Nies, Matthew S; Rispler, David

2014-01-01

314

Development and initial evaluation of a treatment decision dashboard  

PubMed Central

Background For many healthcare decisions, multiple alternatives are available with different combinations of advantages and disadvantages across several important dimensions. The complexity of current healthcare decisions thus presents a significant barrier to informed decision making, a key element of patient-centered care. Interactive decision dashboards were developed to facilitate decision making in Management, a field marked by similarly complicated choices. These dashboards utilize data visualization techniques to reduce the cognitive effort needed to evaluate decision alternatives and a non-linear flow of information that enables users to review information in a self-directed fashion. Theoretically, both of these features should facilitate informed decision making by increasing user engagement with and understanding of the decision at hand. We sought to determine if the interactive decision dashboard format can be successfully adapted to create a clinically realistic prototype patient decision aid suitable for further evaluation and refinement. Methods We created a computerized, interactive clinical decision dashboard and performed a pilot test of its clinical feasibility and acceptability using a multi-method analysis. The dashboard summarized information about the effectiveness, risks of side effects and drug-drug interactions, out-of-pocket costs, and ease of use of nine analgesic treatment options for knee osteoarthritis. Outcome evaluations included observations of how study participants utilized the dashboard, questionnaires to assess usability, acceptability, and decisional conflict, and an open-ended qualitative analysis. Results The study sample consisted of 25 volunteers - 7 men and 18 women - with an average age of 51 years. The mean time spent interacting with the dashboard was 4.6 minutes. Mean evaluation scores on scales ranging from 1 (low) to 7 (high) were: mechanical ease of use 6.1, cognitive ease of use 6.2, emotional difficulty 2.7, decision-aiding effectiveness 5.9, clarification of values 6.5, reduction in decisional uncertainty 6.1, and provision of decision-related information 6.0. Qualitative findings were similarly positive. Conclusions Interactive decision dashboards can be adapted for clinical use and have the potential to foster informed decision making. Additional research is warranted to more rigorously test the effectiveness and efficiency of patient decision dashboards for supporting informed decision making and other aspects of patient-centered care, including shared decision making. PMID:23601912

2013-01-01

315

CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury  

PubMed Central

Background There is controversy about which children with minor head injury need to undergo computed tomography (CT). We aimed to develop a highly sensitive clinical decision rule for the use of CT in children with minor head injury. Methods For this multicentre cohort study, we enrolled consecutive children with blunt head trauma presenting with a score of 13–15 on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. For each child, staff in the emergency department completed a standardized assessment form before any CT. The main outcomes were need for neurologic intervention and presence of brain injury as determined by CT. We developed a decision rule by using recursive partitioning to combine variables that were both reliable and strongly associated with the outcome measures and thus to find the best combinations of predictor variables that were highly sensitive for detecting the outcome measures with maximal specificity. Results Among the 3866 patients enrolled (mean age 9.2 years), 95 (2.5%) had a score of 13 on the Glasgow Coma Scale, 282 (7.3%) had a score of 14, and 3489 (90.2%) had a score of 15. CT revealed that 159 (4.1%) had a brain injury, and 24 (0.6%) underwent neurologic intervention. We derived a decision rule for CT of the head consisting of four high-risk factors (failure to reach score of 15 on the Glasgow coma scale within two hours, suspicion of open skull fracture, worsening headache and irritability) and three additional medium-risk factors (large, boggy hematoma of the scalp; signs of basal skull fracture; dangerous mechanism of injury). The high-risk factors were 100.0% sensitive (95% CI 86.2%–100.0%) for predicting the need for neurologic intervention and would require that 30.2% of patients undergo CT. The medium-risk factors resulted in 98.1% sensitivity (95% CI 94.6%–99.4%) for the prediction of brain injury by CT and would require that 52.0% of patients undergo CT. Interpretation The decision rule developed in this study identifies children at two levels of risk. Once the decision rule has been prospectively validated, it has the potential to standardize and improve the use of CT for children with minor head injury. PMID:20142371

Osmond, Martin H.; Klassen, Terry P.; Wells, George A.; Correll, Rhonda; Jarvis, Anna; Joubert, Gary; Bailey, Benoit; Chauvin-Kimoff, Laurel; Pusic, Martin; McConnell, Don; Nijssen-Jordan, Cheri; Silver, Norm; Taylor, Brett; Stiell, Ian G.

2010-01-01

316

Clinical decision-making in hypertension using an automated (BpTRU™) measurement device  

Microsoft Academic Search

Mercury sphygmomanometers are being removed from clinical practice in the United States due to environmental concerns about mercury toxicity. Accurate blood pressure measurement is central to high-quality hypertension management. In this study of 106 patients, the BpTRUTM device was compared to nurse blood pressure measurements that complied with all the JNC VII\\/American Heart Association guidelines in evaluation of a random

J W Graves; C Nash; K Burger; K Bailey; S G Sheps

2003-01-01

317

Value of fine needle aspiration biopsy of salivary gland masses in clinical decision-making.  

PubMed

The accuracy of fine needle aspiration biopsy (FNAB) in the diagnosis of salivary tumors has been well established. This study was undertaken to determine the impact of FNAB on patient management. One hundred one patients underwent FNAB of major salivary gland masses. The physician's initial clinical impression was compared with the FNAB diagnosis and the final diagnosis in each case. Forty patients had solitary masses thought to be benign tumors other than Warthin's tumors. FNAB in 13 of these patients (33%) yielded a diagnosis permitting modification of the planned procedure. The diagnosis of Warthin's tumor was suspected clinically in 23 patients. In nine of these patients (39%), FNAB resulted in a different diagnosis. Of the 10 patients believed to have malignant tumors, using FNAB, 1 was found to have sialadenitis and 1 a lymphoma. Overall, FNAB resulted in a change in the clinical approach to 35% of the patients. We recommend the performance of FNAB in almost all patients with salivary masses. PMID:1463121

Heller, K S; Dubner, S; Chess, Q; Attie, J N

1992-12-01

318

Key principles for a national clinical decision support knowledge sharing framework: synthesis of insights from leading subject matter experts  

PubMed Central

Objective To identify key principles for establishing a national clinical decision support (CDS) knowledge sharing framework. Materials and methods As part of an initiative by the US Office of the National Coordinator for Health IT (ONC) to establish a framework for national CDS knowledge sharing, key stakeholders were identified. Stakeholders' viewpoints were obtained through surveys and in-depth interviews, and findings and relevant insights were summarized. Based on these insights, key principles were formulated for establishing a national CDS knowledge sharing framework. Results Nineteen key stakeholders were recruited, including six executives from electronic health record system vendors, seven executives from knowledge content producers, three executives from healthcare provider organizations, and three additional experts in clinical informatics. Based on these stakeholders' insights, five key principles were identified for effectively sharing CDS knowledge nationally. These principles are (1) prioritize and support the creation and maintenance of a national CDS knowledge sharing framework; (2) facilitate the development of high-value content and tooling, preferably in an open-source manner; (3) accelerate the development or licensing of required, pragmatic standards; (4) acknowledge and address medicolegal liability concerns; and (5) establish a self-sustaining business model. Discussion Based on the principles identified, a roadmap for national CDS knowledge sharing was developed through the ONC's Advancing CDS initiative. Conclusion The study findings may serve as a useful guide for ongoing activities by the ONC and others to establish a national framework for sharing CDS knowledge and improving clinical care. PMID:22865671

Hongsermeier, Tonya; Wright, Adam; Lewis, Janet; Bell, Douglas S; Middleton, Blackford

2013-01-01

319

Clinical Characteristics and Surgical Decision Making for Infants with Metopic Craniosynostosis in Conjunction with Other Congenital Anomalies  

PubMed Central

Background: Metopic craniosynostosis can occur in isolation or in conjunction with other congenital anomalies. The surgical decision making and outcomes between these 2 groups are analyzed. Methods: A retrospective review of all children evaluated in the craniofacial clinic at Seattle Children’s Hospital for metopic craniosynostosis between 2004 and 2009 was performed. Physical examination and CT scan characteristics were analyzed as were the treatment decisions and surgical outcomes. Results: From 2004 to 2009, 282 patients were evaluated and 100 were determined to have metopic craniosynostosis. Of these, 19 patients were found to have additional congenital anomalies. Review of these patients’ CT scans revealed 13 with classic trigonencephaly, 3 with microcephaly, and 3 with narrow frontal bones, abnormal orbits, and small anterior fossa. Patients (90%) with isolated metopic craniosynostosis underwent cranial vault expansion, whereas only 63% of the complex group did so. The complex metopic group had a longer hospital stay (5 d vs 3.4 d), more intraoperative complications, and required more repeat surgery. Conclusion: Patients with metopic craniosynostosis and additional anomalies require special consideration when deciding upon surgical intervention and should be cared for by a multidisciplinary team to address their additional needs.

Heike, Carrie L.; Saltzman, Babette S.; Hing, Anne V.

2013-01-01

320

Total Library Computerization for Windows.  

ERIC Educational Resources Information Center

Presents a general review of features of version 2.1 of Total Library Computerization (TLC) for Windows from On Point, Inc. Includes information about pricing, hardware and operating systems, modules/functions available, user interface, security, on-line catalog functions, circulation, cataloging, and documentation and online help. A table…

Combs, Joseph, Jr.

1999-01-01

321

Ionospheric imaging using computerized tomography  

Microsoft Academic Search

Computerized tomography (CT) techniques can be used to produce a two-dimensional image of the electron density in the ionosphere. The CT problem requires that the measured data be the line integral through the medium of the unknown parameter; transionospheric satellite beacon total electron content data recorded simultaneously at multiple ground stations fulfill this requirement. In this paper the CT problem

Jeffrey R. Austen; Steven J. Franke; C. H. Liu

1988-01-01

322

Computerized Proof Techniques for Undergraduates  

ERIC Educational Resources Information Center

The use of computer algebra systems such as Maple and Mathematica is becoming increasingly important and widespread in mathematics learning, teaching and research. In this article, we present computerized proof techniques of Gosper, Wilf-Zeilberger and Zeilberger that can be used for enhancing the teaching and learning of topics in discrete…

Smith, Christopher J.; Tefera, Akalu; Zeleke, Aklilu

2012-01-01

323

Regulatory decision strategy for entry of a novel biological therapeutic with a clinically unmonitorable toxicity into clinical trials: pre-IND meetings and a case example.  

PubMed

The following material was derived from a synthesis of case histories taken from investigational new drug (IND) applications and drug sponsors' experiences, utilizing fictionalized data to avoid any resemblance to any proprietary information; any such resemblance is accidental. These examples are used as an instructional scenario to illustrate appropriate handling of a difficult toxicology issue. In this scenario, a drug caused a toxicity in animals that was detected only by histopathologic analysis; if it were to develop in patients, no conventional clinical methods could be identified to monitor for it. It is not unusual for a firm to cancel clinical development plans for a lead drug candidate that causes such a toxicity, especially if such a drug is intended for use as a chronic therapeutic in a population of patients with a chronic disease. This case synthesis was inspired by a Food and Drug Administration (FDA) agreement to allow such a product to proceed into clinical trials after substantive pre-IND discussions and agreement on well-considered toxicology program designs. The scientists most closely involved in the strategy development included the sponsor's toxicologist, veterinary toxicologic pathologist, and pharmacokineticist, as well as the FDA's reviewing pharmacologist. The basis of this decision was thorough toxicity characterization (1-month studies in 2 species); correlating toxicities with a particular cumulative area under the curve (AUC) in both species; identification of the most sensitive species (the species that showed the lower AUC correlating with toxicity); allometric assessment of clearance of the drug in 3 nonhuman species; construction of a model of human kinetics (based on extrapolation from animal kinetics); and finally, estimation of clinical safety factors (ratios of the human estimated cumulative AUC at the proposed clinical doses, over the animal cumulative AUC that correlated with the no adverse effect levels). Industry and FDA scientists negotiated a joint assessment of risk and benefit in patients, resulting in the FDA permitting such a compound to enter into clinical trials for a serious autoimmune disease. Such constructive, early communication starts with the pre-IND meeting, and the conduct and planning for this meeting can be very important in establishing smooth scientific and regulatory groundwork for the future of a drug under IND investigation. PMID:10367668

Black, L E; Bendele, A M; Bendele, R A; Zack, P M; Hamilton, M

1999-01-01

324

Evaluating the value of a web-based natural medicine clinical decision tool at an academic medical center  

PubMed Central

Background Consumer use of herbal and natural products (H/NP) is increasing, yet physicians are often unprepared to provide guidance due to lack of educational training. This knowledge deficit may place consumers at risk of clinical complications. We wished to evaluate the impact that a natural medicine clinical decision tool has on faculty attitudes, practice experiences, and needs with respect to H/NP. Methods All physicians and clinical staff (nurse practitioners, physicians assistants) (n = 532) in departments of Pediatrics, Family and Community Medicine, and Internal Medicine at our medical center were invited to complete 2 electronic surveys. The first survey was completed immediately before access to a H/NP clinical-decision tool was obtained; the second survey was completed the following year. Results Responses were obtained from 89 of 532 practitioners (16.7%) on the first survey and 87 of 535 (16.3%) clinicians on the second survey. Attitudes towards H/NP varied with gender, age, time in practice, and training. At baseline, before having an evidence-based resource available, nearly half the respondents indicated that they rarely or never ask about H/NP when taking a patient medication history. The majority of these respondents (81%) indicated that they would like to learn more about H/NP, but 72% admitted difficulty finding evidence-based information. After implementing the H/NP tool, 63% of database-user respondents indicated that they now ask patients about H/NP when taking a drug history. Compared to results from the baseline survey, respondents who used the database indicated that the tool significantly increased their ability to find reliable H/NP information (P < 0.0001), boosted their knowledge of H/NP (p < 0.0001), and increased their confidence in providing accurate H/NP answers to patients and colleagues (P < 0.0001). Conclusions Our results demonstrate healthcare provider knowledge and confidence with H/NP can be improved without costly and time-consuming formal H/NP curricula. Yet, it will be challenging to make providers aware of such resources. PMID:22011398

2011-01-01

325

Potential Cost-Effectiveness of a New Infant Tuberculosis Vaccine in South Africa - Implications for Clinical Trials: A Decision Analysis  

PubMed Central

Novel tuberculosis vaccines are in varying stages of pre-clinical and clinical development. This study seeks to estimate the potential cost-effectiveness of a BCG booster vaccine, while accounting for costs of large-scale clinical trials, using the MVA85A vaccine as a case study for estimating potential costs. We conducted a decision analysis from the societal perspective, using a 10-year time frame and a 3% discount rate. We predicted active tuberculosis cases and tuberculosis-related costs for a hypothetical cohort of 960,763 South African newborns (total born in 2009). We compared neonatal vaccination with bacille Calmette-Guérin alone to vaccination with bacille Calmette-Guérin plus a booster vaccine at 4 months. We considered booster efficacy estimates ranging from 40% to 70%, relative to bacille Calmette-Guérin alone. We accounted for the costs of Phase III clinical trials. The booster vaccine was assumed to prevent progression to active tuberculosis after childhood infection, with protection decreasing linearly over 10 years. Trial costs were prorated to South Africa's global share of bacille Calmette-Guérin vaccination. Vaccination with bacille Calmette-Guérin alone resulted in estimated tuberculosis-related costs of $89.91 million 2012 USD, and 13,610 tuberculosis cases in the birth cohort, over the 10 years. Addition of the booster resulted in estimated cost savings of $7.69–$16.68 million USD, and 2,800–4,160 cases averted, for assumed efficacy values ranging from 40%–70%. A booster tuberculosis vaccine in infancy may result in net societal cost savings as well as fewer active tuberculosis cases, even if efficacy is relatively modest and large scale Phase III studies are required. PMID:24454706

Ditkowsky, Jared B.; Schwartzman, Kevin

2014-01-01

326

AN ADDITIONAL CAUSE OF HEALTH CARE DISPARITIES--THE VARIABLE CLINICAL DECISIONS OF PRIMARY CARE DOCTORS  

PubMed Central

Rationale, Aims and Objectives Decades of work on health disparities have culminated in identification of three contributors to variability in diagnosis and management of disease: 1) patient attributes, 2) physician characteristics, and 3) organizational. Understanding the relative influence of different contributors to variability in diagnosis and management of diabetes is important to improving quality and reducing disparities. This study was designed to examine the influence of patient, provider, and organizational factors on the diagnosis and management of a major chronic disease: diabetes. Method A factorial experiment using video vignettes was conducted among n=192 primary care physicians. Physicians were interviewed after viewing vignettes of (1) a “patient” with symptoms strongly suggestive of diabetes and (2) an already diagnosed diabetes “patient” with emerging peripheral neuropathy. Results 60.9 percent of physicians identified diabetes as the correct diagnosis, with significant variations depending on the patients’ race/ethnicity. Many physicians offered competing diagnoses with high levels of certainty. For the “patient” with emerging peripheral neuropathy, 42.2 percent of physicians would do all essential components of a foot examination, while 21.9 percent would do none. Conclusions That half of all diabetes in the US remains undiagnosed is unsurprising given only 60.9 percent of physicians would diagnose it when the condition is strongly suggested, and nearly one quarter suspecting diabetes would not order tests necessary to confirm it. The diagnosis of diabetes is significantly influenced by a patient’s race/ethnicity and clinical management (specifically for foot neuropathy), is influenced by patient SES, physician gender, and access to clinical guidelines. PMID:23216876

McKinlay, John; Piccolo, Rebecca; Marceau, Lisa

2013-01-01

327

Evaluating patients' health using a hierarchical multi-attribute decision model.  

PubMed

Evaluation of a patient's health status is an essential part of the healthcare process. For this purpose, Henderson's model of basic living activities (BLA) is often proposed as a set of criteria to be used in nursing. Despite its clarity and theoretical background, the model is only partially used in clinical practice. In this paper, we present the methodology for a hierarchical multi-attribute decision model to increase the practical efficiency of the BLA model. The result is a computerized model for the evaluation of a patient's health status. This model was tested in clinical practice by 17 nurses in two health centres in Slovenia and a strengths, weaknesses, opportunities and threats (SWOT) analysis was carried out. The strengths included providing a holistic understanding of the nature and level of the nursing problems, enriching the documentation and reducing the possibility of overlooking something important. As a part of electronic documentation, this computerized model supports systematic patient data gathering and evaluation. PMID:19930874

Sustersic, O; Rajkovic, U; Dinevski, D; Jereb, E; Rajkovic, Vladislav

2009-01-01

328

Detection of clinical mastitis with sensor data from automatic milking systems is improved by using decision-tree induction.  

PubMed

The objective was to develop and validate a clinical mastitis (CM) detection model by means of decision-tree induction. For farmers milking with an automatic milking system (AMS), it is desirable that the detection model has a high level of sensitivity (Se), especially for more severe cases of CM, at a very high specificity (Sp). In addition, an alert for CM should be generated preferably at the quarter milking (QM) at which the CM infection is visible for the first time. Data were collected from 9 Dutch dairy herds milking automatically during a 2.5-yr period. Data included sensor data (electrical conductivity, color, and yield) at the QM level and visual observations of quarters with CM recorded by the farmers. Visual observations of quarters with CM were combined with sensor data of the most recent automatic milking recorded for that same quarter, within a 24-h time window before the visual assessment time. Sensor data of 3.5 million QM were collected, of which 348 QM were combined with a CM observation. Data were divided into a training set, including two-thirds of all data, and a test set. Cows in the training set were not included in the test set and vice versa. A decision-tree model was trained using only clear examples of healthy (n=24,717) or diseased (n=243) QM. The model was tested on 105 QM with CM and a random sample of 50,000 QM without CM. While keeping the Se at a level comparable to that of models currently used by AMS, the decision-tree model was able to decrease the number of false-positive alerts by more than 50%. At an Sp of 99%, 40% of the CM cases were detected. Sixty-four percent of the severe CM cases were detected and only 12.5% of the CM that were scored as watery milk. The Se increased considerably from 40% to 66.7% when the time window increased from less than 24h before the CM observation, to a time window from 24h before to 24h after the CM observation. Even at very wide time windows, however, it was impossible to reach an Se of 100%. This indicates the inability to detect all CM cases based on sensor data alone. Sensitivity levels varied largely when the decision tree was validated per herd. This trend was confirmed when decision trees were trained using data from 8 herds and tested on data from the ninth herd. This indicates that when using the decision tree as a generic CM detection model in practice, some herds will continue having difficulties in detecting CM using mastitis alert lists, whereas others will perform well. PMID:20655431

Kamphuis, C; Mollenhorst, H; Heesterbeek, J A P; Hogeveen, H

2010-08-01

329

Computerized Health Assessment and Education for Adolescent HIV and STD Prevention in Health Care Settings and Schools  

Microsoft Academic Search

This report summarizes a number of computer applications from a decade of experience with computerized adolescent health assessments and automated health education in a large health maintenance organization, military adolescent clinics, detention facilities, health fairs, and public schools. Feedback from over 5,000 adolescents is given for patient responses to and acceptance of computerized health assessments and preferences for automated health

David M. N. Paperny

1997-01-01

330

Evaluation of the Pressure Ulcer Prevention Clinical Decision Report for Bedside Nurses in Acute Care Hospitals  

PubMed Central

Background Hospital stays for patients with pressure ulcers (PU) increased nearly 80% from 1992 to 2006. Most PU’s developed during an admission, often despite preventive efforts from clinical staff. Data from Electronic medical records (EMR’s) were used to prepare daily patient risk factor and PU information for nurses to help prevent PU development and exacerbations. Objectives The objectives of this study were to determine whether: 1) dissemination of an automated daily report with patient risk and current status of pressure ulcers (“PU Daily”) helps prevent the development of pressure ulcers, and 2) using the PU Daily information impacts the severity of pressure ulcers that develop in an acute care setting. Methods A pre-post study with four control units was designed to determine the impact of the PU Daily in intensive care units (ICU) in a large medical center. The control units included ICU’s using the same EMR and similar complexity of cases with a high risk of developing a PU. The pre-post study took place over a six month period (March – August 2009). Results A total of 6,735 cases were included in the study. The intervention unit showed a significant decrease (p = 0.004) in PU’s at post-evaluation; none of the four comparison units showed a decrease at the p<0.05 level. The intervention led to a significant reduction in the total number of PU’s documented (p <0.000) and the number of Stage II PU’s (p = 0.046). Conclusion The intervention with the PU Daily showed a significant decrease in the total PU’s and severity of PU’s and allowed for implementation of interventions that help prevent the development of PU’s. As EMR’s become more widely available, this intervention showed a reduction in PU’s. Future studies should further develop this intervention and include multiple institutions and patient populations. PMID:23616892

Talsma, A.; Tschannen, D.; Guo, Y.; Kazemi, J.

2011-01-01

331

[Computerized analysis of esophageal manometry].  

PubMed

Computerized analysis of esophageal manometry should consider the following objectives: a) objectivation of data acquisition; b) precision in calculating the various parameters; c) speed of analysis; d) an easy-to-read and promptly understandable graphic display of the manometric data; e) computation of new parameters capable of defining normal and pathologic function. It is with these objectives in mind that we launched our research project. Five normal subjects and 10 patients, of whom 5 presented esophageal achalasia and 5 gastroesophageal reflux disease, underwent computerized esophageal manometry and were evaluated on the basis of both traditional and innovative parameters, of our own inception. Among the various indexes tested, the "Esophageal transport" parameter, calculated as the ratio of momentum (dp*dT) over speed of propagation of the esophageal contractions, gave rise to particular interest. In our opinion, this parameter can be used as an index of the dynamic function of the organ. PMID:2067691

Spigno, L; Pandolfo, N; Guiddo, G; Calci, G; Mattioli, G; De Salvo, L

1991-04-15

332

Evaluation of Drug Interactions in a Large Sample of Psychiatric Inpatients: A Data Interface for Mass Analysis With Clinical Decision Support Software  

Microsoft Academic Search

In order to improve medication safety, more epidemiological data on the prevalence and clinical relevance of drug interactions are required. We developed an interface for mass analysis using the Clinical Decision Support Software (CDSS) MediQ and a multidimensional classification (Zurich Interaction System (ZHIAS)) incorporating the Operational Classification of Drug Interactions (ORCA). These were applied to 359,207 cross-sectional prescriptions from 84,607

P Haueis; W Greil; M Huber; R Grohmann; G A Kullak-Ublick; S Russmann

2011-01-01

333

CAT (Computerized Axial Tomography) scans  

NSDL National Science Digital Library

This web page about CAT (computerized axial tomography) scans gives a brief overview of this imaging technique. CAT (or CT) scanning captures a lot of 2-dimensional X-rays that a computer then joins together to generate 3-dimensional images of internal structures. As part of a set of materials about brain scanning technologies, this page mentions what researchers can learn about the brain from CAT scans. Copyright 2005 Eisenhower National Clearinghouse

Productions, David G.; York, Thirteen/wnet N.

2001-01-01

334

Optimal insemination and replacement decisions to minimize the cost of pathogen-specific clinical mastitis in dairy cows.  

PubMed

Mastitis is a serious production-limiting disease, with effects on milk yield, milk quality, and conception rate, and an increase in the risk of mortality and culling. The objective of this study was 2-fold: (1) to develop an economic optimization model that incorporates all the different types of pathogens that cause clinical mastitis (CM) categorized into 8 classes of culture results, and account for whether the CM was a first, second, or third case in the current lactation and whether the cow had a previous case or cases of CM in the preceding lactation; and (2) to develop this decision model to be versatile enough to add additional pathogens, diseases, or other cow characteristics as more information becomes available without significant alterations to the basic structure of the model. The model provides economically optimal decisions depending on the individual characteristics of the cow and the specific pathogen causing CM. The net returns for the basic herd scenario (with all CM included) were $507/cow per year, where the incidence of CM (cases per 100 cow-years) was 35.6, of which 91.8% of cases were recommended for treatment under an optimal replacement policy. The cost per case of CM was $216.11. The CM cases comprised (incidences, %) Staphylococcus spp. (1.6), Staphylococcus aureus (1.8), Streptococcus spp. (6.9), Escherichia coli (8.1), Klebsiella spp. (2.2), other treated cases (e.g., Pseudomonas; 1.1), other not treated cases (e.g., Trueperella pyogenes; 1.2), and negative culture cases (12.7). The average cost per case, even under optimal decisions, was greatest for Klebsiella spp. ($477), followed by E. coli ($361), other treated cases ($297), and other not treated cases ($280). This was followed by the gram-positive pathogens; among these, the greatest cost per case was due to Staph. aureus ($266), followed by Streptococcus spp. ($174) and Staphylococcus spp. ($135); negative culture had the lowest cost ($115). The model recommended treatment for most CM cases (>85%); the range was 86.2% (Klebsiella spp.) to 98.5% (Staphylococcus spp.). In general, the optimal recommended time for replacement was up to 5 mo earlier for cows with CM compared with cows without CM. Furthermore, although the parameter estimates implemented in this model are applicable to the dairy farms in this study, the parameters may be altered to be specific to other dairy farms. Cow rankings and values based on disease status, pregnancy status, and milk production can be extracted; these provide guidance when determining which cows to keep or cull. PMID:24534495

Cha, E; Kristensen, A R; Hertl, J A; Schukken, Y H; Tauer, L W; Welcome, F L; Gröhn, Y T

2014-04-01

335

Training family physicians and residents in family medicine in shared decision making to improve clinical decisions regarding the use of antibiotics for acute respiratory infections: protocol for a clustered randomized controlled trial  

PubMed Central

Background To explore ways to reduce the overuse of antibiotics for acute respiratory infections (ARIs), we conducted a pilot clustered randomized controlled trial (RCT) to evaluate DECISION+, a training program in shared decision making (SDM) for family physicians (FPs). This pilot project demonstrated the feasibility of conducting a large clustered RCT and showed that DECISION+ reduced the proportion of patients who decided to use antibiotics immediately after consulting their physician. Consequently, the objective of this study is to evaluate, in patients consulting for ARIs, if exposure of physicians to a modified version of DECISION+, DECISION+2, would reduce the proportion of patients who decide to use antibiotics immediately after consulting their physician. Methods/design The study is a multi-center, two-arm, parallel clustered RCT. The 12 family practice teaching units (FPTUs) in the network of the Department of Family Medicine and Emergency Medicine of Université Laval will be randomized to a DECISION+2 intervention group (experimental group) or to a no-intervention control group. These FPTUs will recruit patients consulting family physicians and residents in family medicine enrolled in the study. There will be two data collection periods: pre-intervention (baseline) including 175 patients with ARIs in each study arm, and post-intervention including 175 patients with ARIs in each study arm (total n = 700). The primary outcome will be the proportion of patients reporting a decision to use antibiotics immediately after consulting their physician. Secondary outcome measures include: 1) physicians and patients' decisional conflict; 2) the agreement between the parties' decisional conflict scores; and 3) perception of patients and physicians that SDM occurred. Also in patients, at 2 weeks follow-up, adherence to the decision, consultation for the same reason, decisional regret, and quality of life will be assessed. Finally, in both patients and physicians, intention to engage in SDM in future clinical encounters will be assessed. Intention-to-treat analyses will be applied and account for the nested design of the trial will be taken into consideration. Discussion DECISION+2 has the potential to reduce antibiotics use for ARIs by priming physicians and patients to share decisional process and empowering patients to make informed, value-based decisions. Trial Registration ClinicalTrials.gov: NCT01116076 PMID:21269509

2011-01-01

336

The level of knowledge of respiratory physiology articulated by intensive care nurses to provide rationale for their clinical decision-making.  

PubMed

The combination of intensive care knowledge, and the ability to articulate analytical decision-making processes to the interdisciplinary team, enhances the clinical credibility of the intensive care unit (ICU) nurse. The objective of this paper is to outline a study firstly, assessing ICU nurses' ability in articulating respiratory physiology to provide rationale for their clinical decision-making and secondly, the barriers that limit the articulation of this knowledge. Using an evaluation methodology, multiple methods were employed to collect data from 27 ICU nurses who had completed an ICU education programme and were working in one of two tertiary ICUs in New Zealand. Quantitative analysis showed that nurses articulated a low to medium level of knowledge of respiratory physiology. Thematic analysis identified the barriers limiting this use of respiratory physiology as being inadequate coverage of concepts in some ICU programmes; limited discussion of concepts in clinical practice; lack of clinical support; lack of individual professional responsibility; nurses' high reliance on intuitive knowledge; lack of collaborative practice; availability of medical expertise; and the limitations of clinical guidelines and protocols. These issues need to be addressed if nurses' articulation of respiratory physiology to provide rationale for their clinical decision-making is to be improved. PMID:17419057

Pirret, Alison M

2007-06-01

337

Computerized dermatopathologic diagnosis.  

PubMed

A practical, transferable microcomputer system for differential diagnosis in dermatopathology, called TEGUMENT, has been developed for use by dermatologists on the standard IBM PC, Compaq, and other compatible personal microcomputers. In an interactive computer program a set of information is abstracted from the microscopic study of each specimen by a dermatologist, to compare with a structured knowledge base. The process leads through a relevant sequence of descriptive phrases until the findings can be allocated to a disease class. The microscopic description and diagnosis are then combined with clinical information by the computer and printed, optionally, as a pathology report. The identification and diagnosis of each case are preserved in permanent memory to enable future search and sorting. The results of independent validation are that a pathologist made the same diagnosis as the machine or a similar differential diagnosis in 91.8%, disagreed in 4.8%, and was unable to make a diagnosis from the description furnished by the machine in 3.4% of 147 actual cases. We conclude that a certain critical minimum of information is required for objective diagnosis; more information is needed for definitive than for differential diagnosis; a characteristic feature is necessary to distinguish between differential diagnoses; an objective description may admit of more than one diagnosis; ambiguity may be reduced by presenting for consideration all distinguishing features that characterize closely related diagnoses; and the personal microcomputer, programmed in this way, is of considerable assistance to the dermatologist in the histopathologic diagnosis of diseases and neoplasms of the skin. PMID:3301922

Potter, B; Ronan, S G

1987-07-01

338

The Development and Validation of a Tool to Measure Self-Confidence and Anxiety in Nursing Students While Making Clinical Decisions  

ERIC Educational Resources Information Center

Clinical decision making (CDM) is a cornerstone skill for nurses. Self-confidence and anxiety are two affective influences that impact the learning and adeptness of CDM. Currently, no instruments exist that measure perceived self-confidence and anxiety level of undergraduate nursing students related to CDM. The purpose of this research was to…

White, Krista Alaine

2011-01-01

339

A Critical Comparison of Clinical Decision Instruments for Computed Tomographic Scanning in Mild Closed Traumatic Brain Injury in Adolescents and Adults  

Microsoft Academic Search

Study objective: A number of clinical decision aids have been introduced to limit unnecessary computed tomographic scans in patients with mild traumatic brain injury. These aids differ in the risk factors they use to recommend a scan. We compare the instruments according to their sensitivity and specificity and recommend ones based on incremental benefit of correctly classifying patients as having

Sherman C. Stein; Andrea Fabbri; Franco Servadei; Henry A. Glick

340

Measuring plasma paracetamol concentrations in all patients with drug overdoses; development of a clinical decision rule and clinicians willingness to use it  

Microsoft Academic Search

Objectives: The study proposed a clinical decision rule: In patients who have taken a deliberate overdose, but deny taking paracetamol or paracetamol containing compounds, who have a GCS of 15, understand English well, and have not taken excessive alcohol, there is no need to take blood for paracetamol estimation.Methods: 307 consecutive emergency department patients were followed up, and the history

K Hartington; J Hartley; M Clancy

2002-01-01

341

Clinical utility of ImPACT assessment for postconcussion return-to-play counseling: Psychometric issues  

Microsoft Academic Search

Computerized neuropsychological testing is commonly utilized in the management of sport-related concussion. In particular, the Immediate Postconcussion Assessment and Cognitive Testing 2.0 program (ImPACT) is widely used to assess the cognitive functioning of athletes before and after a concussion. We review the evidence for the clinical utility of this program in terms of validity, reliability, and use in return-to-play decisions.

Lester B. Mayers; Thomas S. Redick

2012-01-01

342

Clinical utility of ImPACT assessment for postconcussion return-to-play counseling: Psychometric issues  

Microsoft Academic Search

Computerized neuropsychological testing is commonly utilized in the management of sport-related concussion. In particular, the Immediate Postconcussion Assessment and Cognitive Testing 2.0 program (ImPACT) is widely used to assess the cognitive functioning of athletes before and after a concussion. We review the evidence for the clinical utility of this program in terms of validity, reliability, and use in return-to-play decisions.

Lester B. Mayers; Thomas S. Redick

2011-01-01

343

Improving risk assessment of violence among military Veterans: An evidence-based approach for clinical decision-making  

PubMed Central

Despite increased media attention on violent acts against others committed by military Veterans, few models have been developed to systematically guide violence risk assessment among Veterans. Ideally, a model would identify which Veterans are most at risk for violence and increased attention could then be turned to determining what could be done to prevent violent behavior. This article suggests how empirical approaches to risk assessment used successfully in civilian populations can be applied to Veterans. A review was conducted of the scientific literature on Veteran populations regarding factors related to interpersonal violence generally and to domestic violence specifically. A list was then generated of empirically-supported risk factors for clinicians to consider in practice. To conceptualize how these known risk factors relate to a Veteran’s violence potential, risk assessment scholarship was utilized to develop an evidence-based method to guide mental health professionals. The goals of this approach are to integrate science into practice, overcome logistical barriers, and permit more effective assessment, monitoring, and management of violence risk for clinicians working with Veterans, both in Veteran Administration settings and in the broader community. It is likely that the use of a systematic, empirical framework could lead to improved clinical decision-making in the area of risk assessment, and help reduce violence among Veterans. PMID:20627387

Elbogen, Eric B.; Fuller, Sara; Johnson, Sally C.; Brooks, Stephanie; Kinneer, Patricia; Calhoun, Patrick; Beckham, Jean C.

2010-01-01

344

GOAL: an inverse toxicity-related algorithm for daily clinical practice decision making in advanced kidney cancer.  

PubMed

Metastatic renal cell carcinoma (mRCC), considered almost an orphan disease only six years ago, appears today a very dynamic pathology. The recently switch to the actual overcrowded scenario defined by seven active drugs has driven physicians to an incertitude status, due to difficulties in defining the best possible treatment strategy. This situation is mainly related to the absence of predictive biomarkers for any available or new therapy. Such issue, associated with the nearly absence of published face-to-face studies, draws a complex picture frame. In order to solve this dilemma, decisional algorithms tailored on drug efficacy data and patient profile are recognized as very useful tools. These approaches try to select the best therapy suitable for every patient profile. On the contrary, the present review has the "goal" to suggest a reverse approach: basing on the pivotal studies, post-marketing surveillance reports and our experience, we defined the polarizing toxicity (the most frequent toxicity in the light of clinical experience) for every single therapy, creating a new algorithm able to identify the patient profile, mainly comorbidities, unquestionably unsuitable for each single agent presently available for either the first- or the second-line therapy. The GOAL inverse decision-making algorithm, proposed at the end of this review, allows to select the best therapy for mRCC by reducing the risk of limiting toxicities. PMID:24309065

Bracarda, Sergio; Sisani, Michele; Marrocolo, Francesca; Hamzaj, Alketa; del Buono, Sabrina; De Simone, Valeria

2014-03-01

345

Integrating Arden-Syntax-based clinical decision support with extended presentation formats into a commercial patient data management system.  

PubMed

The purpose of this study was to introduce clinical decision support (CDS) that exceeds conventional alerting at tertiary care intensive care units. We investigated physicians' functional CDS requirements in periodic interviews, and analyzed technical interfaces of the existing commercial patient data management system (PDMS). Building on these assessments, we adapted a platform that processes Arden Syntax medical logic modules (MLMs). Clinicians demanded data-driven, user-driven and time-driven execution of MLMs, as well as multiple presentation formats such as tables and graphics. The used PDMS represented a black box insofar as it did not provide standardized interfaces for event notification and external access to patient data; enabling CDS thus required periodically exporting datasets for making them accessible to the invoked Arden engine. A client-server-architecture with a simple browser-based viewer allows users to activate MLM execution and to access CDS results, while an MLM library generates hypertext for diverse presentation targets. The workaround that involves a periodic data replication entails a trade-off between the necessary computational resources and a delay of generated alert messages. Web technologies proved serviceable for reconciling Arden-based CDS functions with alternative presentation formats, including tables, text formatting, graphical outputs, as well as list-based overviews of data from several patients that the native PDMS did not support. PMID:23354988

Kraus, Stefan; Castellanos, Ixchel; Toddenroth, Dennis; Prokosch, Hans-Ulrich; Bürkle, Thomas

2014-10-01

346

Computerized building energy simulation handbook  

SciTech Connect

This book provides practical, down-to-earth coverage of the non-software aspects of using computerized building energy simulation. While software is the principal tool in the process, the focus of this presentation is on the data needed to build a model, how to build a model, examining the results, diagnosing problems with a model, and calibrating them to reality. For those who have been frustrated trying to build faithful models of existing buildings, or have become skeptical of the efficacy of building simulation -- or are just trying to do a better job simulating buildings -- this book will offer welcome assistance.

Waltz, J.P.

1999-09-01

347

Ionospheric imaging using computerized tomography  

SciTech Connect

Computerized tomography (CT) techniques can be used to produce a two-dimensional image of the electron density in the ionosphere. The CT problem requires that the measured data be the line integral through the medium of the unknown parameter; transionospheric satellite beacon total electron content data recorded simultaneously at multiple ground stations fulfill this requirement. In this paper the CT problem is formulated as it applies to ionospheric imaging and limitations of the technique are investigated. Simulations are performed assuming a 1000-km-altitude polar-orbiting satellite and both five and three ground stations; the results demonstrate the feasibility of this technique. 14 references.

Austen, J.R.; Franke, S.J.; Liu, C.H.

1988-06-01

348

Informing the design of clinical decision support services for evaluation of children with minor blunt head trauma in the emergency department: a sociotechnical analysis.  

PubMed

Integration of clinical decision support services (CDSS) into electronic health records (EHRs) may be integral to widespread dissemination and use of clinical prediction rules in the emergency department (ED). However, the best way to design such services to maximize their usefulness in such a complex setting is poorly understood. We conducted a multi-site cross-sectional qualitative study whose aim was to describe the sociotechnical environment in the ED to inform the design of a CDSS intervention to implement the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rules for children with minor blunt head trauma. Informed by a sociotechnical model consisting of eight dimensions, we conducted focus groups, individual interviews and workflow observations in 11 EDs, of which 5 were located in academic medical centers and 6 were in community hospitals. A total of 126 ED clinicians, information technology specialists, and administrators participated. We clustered data into 19 categories of sociotechnical factors through a process of thematic analysis and subsequently organized the categories into a sociotechnical matrix consisting of three high-level sociotechnical dimensions (workflow and communication, organizational factors, human factors) and three themes (interdisciplinary assessment processes, clinical practices related to prediction rules, EHR as a decision support tool). Design challenges that emerged from the analysis included the need to use structured data fields to support data capture and re-use while maintaining efficient care processes, supporting interdisciplinary communication, and facilitating family-clinician interaction for decision-making. PMID:23892207

Sheehan, Barbara; Nigrovic, Lise E; Dayan, Peter S; Kuppermann, Nathan; Ballard, Dustin W; Alessandrini, Evaline; Bajaj, Lalit; Goldberg, Howard; Hoffman, Jeffrey; Offerman, Steven R; Mark, Dustin G; Swietlik, Marguerite; Tham, Eric; Tzimenatos, Leah; Vinson, David R; Jones, Grant S; Bakken, Suzanne

2013-10-01

349

Protocol for the Quick Clinical study: a randomised controlled trial to assess the impact of an online evidence retrieval system on decision-making in general practice  

PubMed Central

Background Online information retrieval systems have the potential to improve patient care but there are few comparative studies of the impact of online evidence on clinicians' decision-making behaviour in routine clinical work. Methods/design A randomized controlled parallel design is employed to assess the effectiveness of an online evidence retrieval system, Quick Clinical (QC) in improving clinical decision-making processes in general practice. Eligible clinicians are randomised either to receive access or not to receive access to QC in their consulting rooms for 12 months. Participants complete pre- and post trial surveys. Two-hundred general practitioners are recruited. Participants must be registered to practice in Australia, have a computer with Internet access in their consulting room and use electronic prescribing. Clinicians planning to retire or move to another practice within 12 months or participating in any other clinical trial involving electronic extraction of prescriptions data are excluded from the study. The primary end-points for the study is clinician acceptance and use of QC and the resulting change in decision-making behaviour. The study will examine prescribing patterns related to frequently prescribed medications where there has been a recent significant shift in recommendations regarding their use based upon new evidence. Secondary outcome measures include self-reported changes in diagnosis, patient education, prescriptions written, investigations and referrals. Discussion A trial under experimental conditions is an effective way of examining the impact of using QC in routine general practice consultations. PMID:16928282

Coiera, Enrico; Magrabi, Farah; Westbrook, Johanna I; Kidd, Michael R; Day, Richard O

2006-01-01

350

Clinical Effectiveness and Cost-Effectiveness of HIV Pre-Exposure Prophylaxis in Men Who Have Sex with Men: Risk Calculators for Real-World Decision-Making  

PubMed Central

Background Oral pre-exposure prophylaxis (PrEP) can be clinically effective and cost-effective for HIV prevention in high-risk men who have sex with men (MSM). However, individual patients have different risk profiles, real-world populations vary, and no practical tools exist to guide clinical decisions or public health strategies. We introduce a practical model of HIV acquisition, including both a personalized risk calculator for clinical management and a cost-effectiveness calculator for population-level decisions. Methods We developed a decision-analytic model of PrEP for MSM. The primary clinical effectiveness and cost-effectiveness outcomes were the number needed to treat (NNT) to prevent one HIV infection, and the cost per quality-adjusted life-year (QALY) gained. We characterized patients according to risk factors including PrEP adherence, condom use, sexual frequency, background HIV prevalence and antiretroviral therapy use. Results With standard PrEP adherence and national epidemiologic parameters, the estimated NNT was 64 (95% uncertainty range: 26, 176) at a cost of $160,000 (cost saving, $740,000) per QALY – comparable to other published models. With high (35%) HIV prevalence, the NNT was 35 (21, 57), and cost per QALY was $27,000 (cost saving, $160,000), and with high PrEP adherence, the NNT was 30 (14, 69), and cost per QALY was $3,000 (cost saving, $200,000). In contrast, for monogamous, serodiscordant relationships with partner antiretroviral therapy use, the NNT was 90 (39, 157) and cost per QALY was $280,000 ($14,000, $670,000). Conclusions PrEP results vary widely across individuals and populations. Risk calculators may aid in patient education, clinical decision-making, and cost-effectiveness evaluation. PMID:25285793

Chen, Anders; Dowdy, David W.

2014-01-01

351

45 CFR 307.5 - Mandatory computerized support enforcement systems.  

Code of Federal Regulations, 2013 CFR

...Mandatory computerized support enforcement systems. 307.5 Section 307.5 Public...SERVICES COMPUTERIZED SUPPORT ENFORCEMENT SYSTEMS § 307.5 Mandatory computerized support enforcement systems. (a) Basic requirement....

2013-10-01

352

An Analysis of the Usability of Inpatient Insulin Ordering in Three Computerized Provider Order Entry Systems  

PubMed Central

Background Insulin is a highly scrutinized drug in hospitals since it is both frequently used and high risk. As the insulin ordering process makes a transition from pen and paper to computerized provider order entry (CPOE) systems, the effective design of these systems becomes critical. There are fundamental usability principles in the field of human–computer interaction design, which help make interfaces that are effective, efficient, and satisfying. To our knowledge, there has not been a study that specifically looks at how these principles have been applied in the design of insulin orders in a CPOE system. Method We analyzed the usability of inpatient insulin ordering in three widely deployed CPOE systems—two commercially marketed systems and the U.S. Department of Veterans Affairs VistA Computerized Patient Record System. We performed a usability analysis using aspects of three different methods. Our first goal was to note each instance where a usability principle was either upheld or not upheld. Our second goal was to discover ways in which CPOE designers could exploit usability principles to make insulin ordering safer and more intuitive in the future. Results Commonly encountered usability principles included constraints, obviousness/self-evidence, natural mapping, feedback, and affordance. The three systems varied in their adherence to these principles, and each system had varying strengths and weaknesses. Conclusion Adherence to usability principles is important when building a CPOE system, yet designers observe them to varying degrees. A well-designed CPOE interface allows a clinician to focus more of his or her mental energy on clinical decisions rather than on deciphering the system itself. In the future, intelligent design of CPOE insulin orders can be used to help optimize and modernize management of hyperglycemia in the hospital. PMID:22226260

Neinstein, Aaron; Cucina, Russ

2011-01-01

353

Computerized Adaptive Testing under Nonparametric IRT Models  

ERIC Educational Resources Information Center

Nonparametric item response models have been developed as alternatives to the relatively inflexible parametric item response models. An open question is whether it is possible and practical to administer computerized adaptive testing with nonparametric models. This paper explores the possibility of computerized adaptive testing when using…

Xu, Xueli; Douglas, Jeff

2006-01-01

354

A First Life with Computerized Business Simulations  

ERIC Educational Resources Information Center

The author discusses the theoretical lens, origins, and environment of his work on computerized business simulations. Key ideas that inform his work include the two dimensions (control and interaction) of computerized simulation, the two ways of representing a natural process (phenotypical and genotypical) in a simulation, which he defines as a…

Thavikulwat, Precha

2011-01-01

355

The Evaluation of SISMAKOM (Computerized SDI Project).  

ERIC Educational Resources Information Center

A survey of 88 users of SISMAKOM, a computerized selective dissemination of information (SDI) and document delivery service provided by the Universiti Sains Malaysia and four other Malaysian universities, was conducted in August 1982 in order to collect data about SISMAKOM and to assess the value of a computerized SDI service in a developing…

University of Science, Penang (Malaysia).

356

Year 2000 Computerized Farm Project. Final Report.  

ERIC Educational Resources Information Center

An ongoing project was funded to develop and demonstrate a computerized approach to operation and management of a commercial-sized farm. Other project objectives were to facilitate the demonstration of the computerized farm to the public and to develop individual software packages and make them available to the public. Project accomplishments…

McGrann, James M.; Lippke, Lawrence A.

357

Comparison of an effect-model-law-based method versus traditional clinical practice guidelines for optimal treatment decision-making: application to statin treatment in the French population.  

PubMed

Healthcare authorities make difficult decisions about how to spend limited budgets for interventions that guarantee the best cost-efficacy ratio. We propose a novel approach for treatment decision-making, OMES-in French: Objectif thérapeutique Modèle Effet Seuil (in English: Therapeutic Objective-Threshold-Effect Model; TOTEM). This approach takes into consideration results from clinical trials, adjusted for the patients' characteristics in treatment decision-making. We compared OMES with the French clinical practice guidelines (CPGs) for the management of dyslipidemia with statin in a computer-generated realistic virtual population, representing the adult French population, in terms of the number of all-cause deaths avoided (number of avoided events: NAEs) under treatment and the individual absolute benefit. The total budget was fixed at the annual amount reimbursed by the French social security for statins. With the CPGs, the NAEs was 292 for an annual cost of 122.54 M€ compared with 443 with OMES. For a fixed NAEs, OMES reduced costs by 50% (60.53 M€ yr(-1)). The results demonstrate that OMES is at least as good as, and even better than, the standard CPGs when applied to the same population. Hence the OMES approach is a practical, useful alternative which will help to overcome the limitations of treatment decision-making based uniquely on CPGs. PMID:25209407

Kahoul, Riad; Gueyffier, François; Amsallem, Emmanuel; Haugh, Margaret; Marchant, Ivanny; Boissel, François-Henri; Boissel, Jean-Pierre

2014-11-01

358

Developing an electronic clinical decision support system to promote guideline adherence for healthy weight management and cardiovascular risk reduction in children: a progress update  

Microsoft Academic Search

Overweight and obesity are common challenges facing pediatric clinicians. Electronic health records (EHRs) can impact clinician\\u000a behavior through the presentation of relevant, patient-specific information during clinical encounters, potentially improving\\u000a clinician recognition and management of overweight\\/obesity in children. Little research has been published evaluating the\\u000a impact of EHR-facilitated decision support on the treatment of obesity in children. The main objectives of

Sara M Naureckas; Rachel Zweigoron; K Susan Haverkamp; Erin O’Brien Kaleba; Shannon J Pohl; Adolfo J Ariza

2011-01-01

359

Development and evaluation of a comprehensive clinical decision support taxonomy: comparison of front-end tools in commercial and internally developed electronic health record systems  

Microsoft Academic Search

BackgroundClinical decision support (CDS) is a valuable tool for improving healthcare quality and lowering costs. However, there is no comprehensive taxonomy of types of CDS and there has been limited research on the availability of various CDS tools across current electronic health record (EHR) systems.ObjectiveTo develop and validate a taxonomy of front-end CDS tools and to assess support for these

Adam Wright; Dean F Sittig; Joan S Ash; Joshua Feblowitz; Seth Meltzer; Carmit McMullen; Ken Guappone; Jim Carpenter; Joshua Richardson; Linas Simonaitis; R Scott Evans; W Paul Nichol; Blackford Middleton

2011-01-01

360

Multi-National, Multi-Institutional Analysis of Clinical Decision Support Data Needs to Inform Development of the HL7 Virtual Medical Record Standard.  

PubMed

An important barrier to the widespread dissemination of clinical decision support (CDS) is the heterogeneity of information models and terminologies used across healthcare institutions, health information systems, and CDS resources such as knowledge bases. To address this problem, the Health Level 7 (HL7) Virtual Medical Record project (an open, international standards development effort) is developing community consensus on the clinical information exchanged between CDS engines and clinical information systems. As a part of this effort, the HL7 CDS Work Group embarked on a multinational, collaborative effort to identify a representative set of clinical data elements required for CDS. Based on an analysis of CDS systems from 20 institutions representing 4 nations, 131 data elements were identified as being currently utilized for CDS. These findings will inform the development of the emerging HL7 Virtual Medical Record standard and will facilitate the achievement of scalable, standards-based CDS. PMID:21347004

Kawamoto, Kensaku; Del Fiol, Guilherme; Strasberg, Howard R; Hulse, Nathan; Curtis, Clayton; Cimino, James J; Rocha, Beatriz H; Maviglia, Saverio; Fry, Emory; Scherpbier, Harm J; Huser, Vojtech; Redington, Patrick K; Vawdrey, David K; Dufour, Jean-Charles; Price, Morgan; Weber, Jens H; White, Thomas; Hughes, Kevin S; McClay, James C; Wood, Carla; Eckert, Karen; Bolte, Scott; Shields, David; Tattam, Peter R; Scott, Peter; Liu, Zhijing; McIntyre, Andrew K

2010-01-01

361

Computerized provider documentation: findings and implications of a multisite study of clinicians and administrators  

PubMed Central

Objective Clinical documentation is central to the medical record and so to a range of healthcare and business processes. As electronic health record adoption expands, computerized provider documentation (CPD) is increasingly the primary means of capturing clinical documentation. Previous CPD studies have focused on particular stakeholder groups and sites, often limiting their scope and conclusions. To address this, we studied multiple stakeholder groups from multiple sites across the USA. Methods We conducted 14 focus groups at five Department of Veterans Affairs facilities with 129 participants (54 physicians or practitioners, 34 nurses, and 37 administrators). Investigators qualitatively analyzed resultant transcripts, developed categories linked to the data, and identified emergent themes. Results Five major themes related to CPD emerged: communication and coordination; control and limitations in expressivity; information availability and reasoning support; workflow alteration and disruption; and trust and confidence concerns. The results highlight that documentation intertwines tightly with clinical and administrative workflow. Perceptions differed between the three stakeholder groups but remained consistent within groups across facilities. Conclusions CPD has dramatically changed documentation processes, impacting clinical understanding, decision-making, and communication across multiple groups. The need for easy and rapid, yet structured and constrained, documentation often conflicts with the need for highly reliable and retrievable information to support clinical reasoning and workflows. Current CPD systems, while better than paper overall, often do not meet the needs of users, partly because they are based on an outdated ‘paper-chart’ paradigm. These findings should inform those implementing CPD systems now and future plans for more effective CPD systems. PMID:23355462

Embi, Peter J; Weir, Charlene; Efthimiadis, Efthimis N; Thielke, Stephen M; Hedeen, Ashley N; Hammond, Kenric W

2013-01-01

362

Use Of Clinical Decision Analysis In Predicting The Efficacy Of Newer Radiological Imaging Modalities: Radioscintigraphy Versus Single Photon Transverse Section Emission Computed Tomography  

NASA Astrophysics Data System (ADS)

Sensitivity, specificity, and predictive accuracy have been shown to be useful measures of the clinical efficacy of diagnostic tests and can be used to predict the potential improvement in diagnostic certitude resulting from the introduction of a competing technology. This communication demonstrates how the informal use of clinical decision analysis may guide health planners in the allocation of resources, purchasing decisions, and implementation of high technology. For didactic purposes the focus is on a comparison between conventional planar radioscintigraphy (RS) and single photon transverse section emission conputed tomography (SPECT). For example, positive predictive accuracy (PPA) for brain RS in a specialist hospital with a 50% disease prevalance is about 95%. SPECT should increase this predicted accuracy to 96%. In a primary care hospital with only a 15% disease prevalance the PPA is only 77% and SPECT may increase this accuracy to about 79%. Similar calculations based on published data show that marginal improvements are expected with SPECT in the liver. It is concluded that: a) The decision to purchase a high technology imaging modality such as SPECT for clinical purposes should be analyzed on an individual organ system and institutional basis. High technology may be justified in specialist hospitals but not necessarily in primary care hospitals. This is more dependent on disease prevalance than procedure volume; b) It is questionable whether SPECT imaging will be competitive with standard RS procedures. Research should concentrate on the development of different medical applications.

Prince, John R.

1982-12-01

363

An automated Computerized Severity Index.  

PubMed Central

The Computerized Severity Index (CSI) is a commercially available scoring system for hospital inpatients. Trained abstractors review the patient's paper medical record and enter the diagnoses and relevant physiological attributes. The HELP (Health Evaluation through Logical Processing) System at LDS Hospital stores patient data in discrete codes. This paper describes the development of an automatic interface between the standalone, personal-computer-based severity system and the mainframe-based hospital information system. The interface scores patient severity without the need for manual chart review. Severity scores from the automated and manual methods were identical for 70% of 222 general medical patients scored retrospectively. An evaluation of the causes for differing scores between the two methods is presented. PMID:7949945

Gibson, R. F.; Haug, P. J.

1994-01-01

364

Support and Assessment for Fall Emergency Referrals (SAFER 1): Cluster Randomised Trial of Computerised Clinical Decision Support for Paramedics  

PubMed Central

Objective To evaluate effectiveness, safety and cost-effectiveness of Computerised Clinical Decision Support (CCDS) for paramedics attending older people who fall. Design Cluster trial randomised by paramedic; modelling. Setting 13 ambulance stations in two UK emergency ambulance services. Participants 42 of 409 eligible paramedics, who attended 779 older patients for a reported fall. Interventions Intervention paramedics received CCDS on Tablet computers to guide patient care. Control paramedics provided care as usual. One service had already installed electronic data capture. Main Outcome Measures Effectiveness: patients referred to falls service, patient reported quality of life and satisfaction, processes of care. Safety Further emergency contacts or death within one month. Cost-Effectiveness Costs and quality of life. We used findings from published Community Falls Prevention Trial to model cost-effectiveness. Results 17 intervention paramedics used CCDS for 54 (12.4%) of 436 participants. They referred 42 (9.6%) to falls services, compared with 17 (5.0%) of 343 participants seen by 19 control paramedics [Odds ratio (OR) 2.04, 95% CI 1.12 to 3.72]. No adverse events were related to the intervention. Non-significant differences between groups included: subsequent emergency contacts (34.6% versus 29.1%; OR 1.27, 95% CI 0.93 to 1.72); quality of life (mean SF12 differences: MCS ?0.74, 95% CI ?2.83 to +1.28; PCS ?0.13, 95% CI ?1.65 to +1.39) and non-conveyance (42.0% versus 36.7%; OR 1.13, 95% CI 0.84 to 1.52). However ambulance job cycle time was 8.9 minutes longer for intervention patients (95% CI 2.3 to 15.3). Average net cost of implementing CCDS was £208 per patient with existing electronic data capture, and £308 without. Modelling estimated cost per quality-adjusted life-year at £15,000 with existing electronic data capture; and £22,200 without. Conclusions Intervention paramedics referred twice as many participants to falls services with no difference in safety. CCDS is potentially cost-effective, especially with existing electronic data capture. Trial Registration ISRCTN Register ISRCTN10538608 PMID:25216281

Snooks, Helen Anne; Carter, Ben; Dale, Jeremy; Foster, Theresa; Humphreys, Ioan; Logan, Philippa Anne; Lyons, Ronan Anthony; Mason, Suzanne Margaret; Phillips, Ceri James; Sanchez, Antonio; Wani, Mushtaq; Watkins, Alan; Wells, Bridget Elizabeth; Whitfield, Richard; Russell, Ian Trevor

2014-01-01

365

End-of-Life Decision Making for Cancer Patients in Different Clinical Settings and the Impact of the LCP  

Microsoft Academic Search

Differences in the general focus of care among hospitals, nursing homes, and homes may affect the adequacy of end-of-life decision making for the dying. We studied end-of-life decision-making practices for cancer patients who died in each of these settings and assessed the impact of the Liverpool Care Pathway for the Dying Patient (LCP), a template for care in the dying phase.

Agnes van der Heide; Laetitia Veerbeek; Siebe Swart; Carin van der Rijt; Paul J. van der Maas; Lia van Zuylen

2010-01-01

366

Computerized neurocognitive testing in the management of sport-related concussion: an update.  

PubMed

Since the late nineties, computerized neurocognitive testing has become a central component of sport-related concussion (SRC) management at all levels of sport. In 2005, a review of the available evidence on the psychometric properties of four computerized neuropsychological test batteries concluded that the tests did not possess the necessary criteria to warrant clinical application. Since the publication of that review, several more computerized neurocognitive tests have entered the market place. The purpose of this review is to summarize the body of published studies on psychometric properties and clinical utility of computerized neurocognitive tests available for use in the assessment of SRC. A review of the literature from 2005 to 2013 was conducted to gather evidence of test-retest reliability and clinical validity of these instruments. Reviewed articles included both prospective and retrospective studies of primarily sport-based adult and pediatric samples. Summaries are provided regarding the available evidence of reliability and validity for the most commonly used computerized neurocognitive tests in sports settings. PMID:24306287

Resch, Jacob E; McCrea, Michael A; Cullum, C Munro

2013-12-01

367

Development and evaluation of a comprehensive clinical decision support taxonomy: comparison of front-end tools in commercial and internally developed electronic health record systems  

PubMed Central

Background Clinical decision support (CDS) is a valuable tool for improving healthcare quality and lowering costs. However, there is no comprehensive taxonomy of types of CDS and there has been limited research on the availability of various CDS tools across current electronic health record (EHR) systems. Objective To develop and validate a taxonomy of front-end CDS tools and to assess support for these tools in major commercial and internally developed EHRs. Study design and methods We used a modified Delphi approach with a panel of 11 decision support experts to develop a taxonomy of 53 front-end CDS tools. Based on this taxonomy, a survey on CDS tools was sent to a purposive sample of commercial EHR vendors (n=9) and leading healthcare institutions with internally developed state-of-the-art EHRs (n=4). Results Responses were received from all healthcare institutions and 7 of 9 EHR vendors (response rate: 85%). All 53 types of CDS tools identified in the taxonomy were found in at least one surveyed EHR system, but only 8 functions were present in all EHRs. Medication dosing support and order facilitators were the most commonly available classes of decision support, while expert systems (eg, diagnostic decision support, ventilator management suggestions) were the least common. Conclusion We developed and validated a comprehensive taxonomy of front-end CDS tools. A subsequent survey of commercial EHR vendors and leading healthcare institutions revealed a small core set of common CDS tools, but identified significant variability in the remainder of clinical decision support content. PMID:21415065

Sittig, Dean F; Ash, Joan S; Feblowitz, Joshua; Meltzer, Seth; McMullen, Carmit; Guappone, Ken; Carpenter, Jim; Richardson, Joshua; Simonaitis, Linas; Evans, R Scott; Nichol, W Paul; Middleton, Blackford

2011-01-01

368

Computerized grading of anatomy laboratory practical examinations.  

PubMed

At the Medical College of Wisconsin, a procedure was developed to allow computerized grading and grade reporting of laboratory practical examinations in the Clinical Human Anatomy course. At the start of the course, first year medical students were given four Lists of Structures. On these lists, numbered items were arranged alphabetically; the items were anatomical structures that could be tagged on a given lab practical examination. Each lab exam featured an anatomy laboratory component and a computer laboratory component. For the anatomy lab component, students moved from one question station to another at timed intervals and identified tagged anatomical structures. As students identified a tagged structure, they referred to a copy of the list (provided with their answer sheet) and wrote the number corresponding to the structure on their answer sheet. Immediately after the anatomy lab component, students were escorted to a computer instruction laboratory where they typed their answer numbers into a secured testing component of a learning management system that recorded their answers for automatic grading. After a brief review of examination scores and item analysis by faculty, exam scores were reported to students electronically. Adding this brief computer component to each lab exam greatly reduced faculty grading time, reduced grading errors and provided faster performance feedback for students without changing overall student performance. PMID:19177415

Krippendorf, Beth B; Bolender, David L; Kolesari, Gary L

2008-01-01

369

Computerized maintenance boosts reliability, trims costs  

SciTech Connect

A natural gas-fired combined-cycle power plant has operated successfully for the past three years at the 3800-acre Pitchess Honor Rancho jail complex in Saugus, Calif. One of the reasons for the plant's success has been its computerized maintenance system. This paper reports that utilization of the computerized plant maintenance system program, in conjunction with several data base programs, has increased the plant's reliability and trimmed costs. As we learned at Pitchess, a computerized maintenance program provides two key advantages over the traditional breakdown maintenance approach: minimal equipment breakdown, and a reduction in operations and maintenance man-hours.

Hammer, K. (County of Los Angeles, CA (US)); Egleston, P.C.; Steinert, M.P.; Goldstein, M. (Charles T. Main Inc. (US))

1992-01-01

370

Computerized Neurocognitive Test Performance in Schizophrenia: A Lifespan Analysis  

PubMed Central

Objective Computerized neurocognitive batteries based on advanced behavioral neuroscience methods are increasingly used in large-scale clinical and genomic studies. Favorable construct validity in younger schizophrenia patients has been reported, but not in older patients. New variables afforded by computerized assessments were used to clarify age-associated cognitive impairment across the lifespan. Methods 624 patients with schizophrenia and 624 healthy comparison (HC) subjects aged 16–75 completed a 1–2 hour computerized neurocognitive battery (CNB) that assessed abstraction and mental flexibility, attention, working memory, recognition memory (verbal, facial, spatial), language, visuospatial and emotion processing. Linear mixed effects models tested for group differences in accuracy, response time, and efficiency scores. Contrasts were stratified by age. Results 91% of older (45+) and 94% of younger (<45) groups provided “good” data quality. After controlling for parental education and project, there were significant three-way interactions for diagnosis x domain x age group on all three outcome variables. Patients performed worse than HC across all neurocognitive domains, except in the oldest group of 60+ patients. Age-stratified analyses did not show differences between younger (16–45) and older patients (45–60, 60+), except for the attention domain. Older patients’ reduced working memory efficiency was due to worse speed, not accuracy. Older patients were quicker than younger patients in processing emotions. Conclusions Computerized assessments are feasible in large cohorts of schizophrenia patients. There is stable and generalized neurocognitive dysfunction across the lifespan in schizophrenia, albeit with fewer differences in some domains between older patients and HC after age 60. Speed-accuracy tradeoff strategies suggest deceleration of some frontal networks and improvements in speed of emotional processing. PMID:22183011

Irani, Farzin; Brensinger, Colleen M.; Richard, Jan; Calkins, Monica E.; Moberg, Paul J.; Bilker, Waren; Gur, Raquel E.; Gur, Ruben C.

2011-01-01

371

The CAD-MDD: A Computerized Adaptive Diagnostic Screening Tool for Depression  

PubMed Central

Objective To develop a computerized adaptive diagnostic (CAD) screening tool for depression that decreases patient and clinician burden and increases sensitivity and specificity for clinician-based DSM-IV diagnosis of major depressive disorder (MDD). Method 656 individuals with and without minor and major depression were recruited from a psychiatric clinic, community mental health center, and through public announcements (controls without depression). The item bank consists of 88 depression scale items drawn from 73 depression measures. The focus of this study was the development of the CAD-MDD diagnostic screening tool based on a decision-theoretic approach (random forests and decision trees). Sensitivity and specificity for predicting clinician-based SCID DSM-IV diagnoses of MDD were the primary outcomes. Diagnostic screening accuracy was then compared to the PHQ-9. Results An average of 4 items per participant was required (maximum of 6 items). Overall sensitivity and specificity were 0.95 and 0.87 respectively. For the PHQ-9, sensitivity was 0.70 and specificity was 0.91. Conclusion High sensitivity and reasonable specificity for a clinician-based DSM-IV diagnosis of depression can be obtained using an average of 4 adaptively administered self-report items in less than one minute. Relative to the currently used PHQ-9, the CAD-MDD dramatically increased sensitivity while maintaining similar specificity. As such, the CAD-MDD will identify more true positives (lower false negative rate) than the PHQ-9 using half the number of items. Inexpensive (relative to clinical assessment), efficient and accurate screening of depression in primary care settings, psychiatric epidemiology, molecular genetics, and global health are all direct applications of the current system. PMID:23945443

Gibbons, Robert D.; Hooker, Giles; Finkelman, Matthew D.; Weiss, David J.; Pilkonis, Paul A.; Frank, Ellen; Moore, Tara; Kupfer, David J.

2014-01-01

372

Computerized Bus Routing in San Francisco.  

ERIC Educational Resources Information Center

A computerized routing and scheduling system for the San Francisco Public Schools includes the batch processing of bus route assignments and schedules for all schools and the online terminal processing of daily changes. (Author/MLF)

Caswell, Peter J.; Jungherr, J. Anton

1979-01-01

373

Local Computerized Safeguards System for THTR-300.  

National Technical Information Service (NTIS)

The paper describes a possible way of realizing the safeguards approach for the THTR-300 pebble bed reactor by means of a computerized monitoring system. The system structure is presented and also the appropriate safeguards instrumentation. The concept of...

F. Arning, H. Reuters, H. Bueker, S. Nicolai

1982-01-01

374

Graphical Models and Computerized Adaptive Testing.  

ERIC Educational Resources Information Center

Considers computerized adaptive testing from the perspective of graphical modeling (GM). GM provides methods for making inferences about multifaceted skills and knowledge and for extracting data from complex performances. Provides examples from language-proficiency assessment. (SLD)

Almond, Russell G.; Mislevy, Robert J.

1999-01-01

375

HUMAN RELIABILITY ANALYSIS FOR COMPUTERIZED PROCEDURES  

SciTech Connect

This paper provides a characterization of human reliability analysis (HRA) issues for computerized procedures in nuclear power plant control rooms. It is beyond the scope of this paper to propose a new HRA approach or to recommend specific methods or refinements to those methods. Rather, this paper provides a review of HRA as applied to traditional paper-based procedures, followed by a discussion of what specific factors should additionally be considered in HRAs for computerized procedures. Performance shaping factors and failure modes unique to computerized procedures are highlighted. Since there is no definitive guide to HRA for paper-based procedures, this paper also serves to clarify the existing guidance on paper-based procedures before delving into the unique aspects of computerized procedures.

Ronald L. Boring; David I. Gertman; Katya Le Blanc

2011-09-01

376

The Computerized Reference Department: Buying the Future.  

ERIC Educational Resources Information Center

Basis for systematic computerization of academic research library's reference, collection development, and collection management functions emphasizes productivity enhancement for librarians and support staff. Use of microcomputer and university's mainframe computer to develop applications of database management systems, electronic spreadsheets,…

Kriz, Harry M.; Kok, Victoria T.

1985-01-01

377

The integrated modeling and framework of clinical pathway adaptive workflow management system based on Extended Workflow-nets (EWF-nets)  

Microsoft Academic Search

At present, the clinical pathways (CP) is developed and implemented manually by filling predefined paper. Computerization and automatic or semi-automatic implementation of CP based on workflow is one of the possible solutions. By introducing the rule places based on object-oriented Petri net, we build the CP workflow model to solve the workflow route decision-making. However, there are still some unavoidable

Gang Du; Zhibin Jiang; Xiaodi Diao

2008-01-01

378

Comparison of robustness against missing values of alternative decision tree and multiple logistic regression for predicting clinical data in primary breast cancer.  

PubMed

Nomogram based on multiple logistic regression (MLR) is a standard technique for predicting diagnostic and treatment outcomes in medical fields. However, the applicability of MLR to data mining of clinical information is limited. To overcome these issues, we have developed prediction models using ensembles of alternative decision trees (ADTree). Here, we compare the performance of MLR and ADTree models in terms of robustness against missing values. As a case study, we employ datasets including pathological complete response (pCR) of neoadjuvant therapy, one of the most important decision-making factors in the diagnosis and treatment of primary breast cancer. Ensembled ADTree models are more robust against missing values than MLR. Sufficient robustness is attained at low boosting and ensemble number, and is compromised as these numbers increase. PMID:24110372

Sugimoto, Masahiro; Takada, Masahiro; Toi, Masakazu

2013-01-01

379

Ionospheric imaging using computerized tomography  

SciTech Connect

Computerized tomography (CT) techniques can be used to produce a two-dimensional image of the electron density in the ionosphere. The necessary data are transionospheric satellite beacon total electron content (TEC) data recorded simultaneously at multiple ground stations. The ionospheric imaging case presents a difficult problem due to large amounts of missing data. This is a consequence of the locations of the transmitter (in orbit) and receivers (ground-based) and causes the reconstruction algorithm to fail to correctly reconstruct the background density profile. Despite this limitation, a method has been developed which successfully reconstructs the irregularities and variations in the profile. A computer program simulates the data collection and image reconstruction process. This allows the method to be tested with several electron density models, transmitter and receiver locations, and noniterative and iterative reconstruction algorithms. Simulations are performed assuming a 1,000-km-altitude polar-orbiting satellite and several ground stations. The imaged region is 3,500 km wide by 800 km high. A new algorithm, which is a modification of the discrete backprojection algorithm, is developed for use with nonuniform sampling geometries.

Austen, J.R.

1991-01-01

380

Real-time use of the iPad by third-year medical students for clinical decision support and learning: a mixed methods study  

PubMed Central

Purpose Despite widespread use of mobile technology in medical education, medical students’ use of mobile technology for clinical decision support and learning is not well understood. Three key questions were explored in this extensive mixed methods study: 1) how medical students used mobile technology in the care of patients, 2) the mobile applications (apps) used and 3) how expertise and time spent changed overtime. Methods This year-long (July 2012–June 2013) mixed methods study explored the use of the iPad, using four data collection instruments: 1) beginning and end-of-year questionnaires, 2) iPad usage logs, 3) weekly rounding observations, and 4) weekly medical student interviews. Descriptive statistics were generated for the questionnaires and apps reported in the usage logs. The iPad usage logs, observation logs, and weekly interviews were analyzed via inductive thematic analysis. Results Students predominantly used mobile technology to obtain real-time patient data via the electronic health record (EHR), to access medical knowledge resources for learning, and to inform patient care. The top four apps used were Epocrates®, PDF Expert®, VisualDx®, and Micromedex®. The majority of students indicated that their use (71%) and expertise (75%) using mobile technology grew overtime. Conclusions This mixed methods study provides substantial evidence that medical students used mobile technology for clinical decision support and learning. Integrating its use into the medical student's daily workflow was essential for achieving these outcomes. Developing expertise in using mobile technology and various apps was critical for effective and efficient support of real-time clinical decisions. PMID:25317266

Nuss, Michelle A.; Hill, Janette R.; Cervero, Ronald M.; Gaines, Julie K.; Middendorf, Bruce F.

2014-01-01

381

Reflecting on the ethical administration of computerized medical records  

NASA Astrophysics Data System (ADS)

This presentation examines the ethical issues raised by computerized image management and communication systems (IMAC), the ethical principals that should guide development of policies, procedures and practices for IMACS systems, and who should be involved in developing a hospital's approach to these issues. The ready access of computerized records creates special hazards of which hospitals must beware. Hospitals must maintain confidentiality of patient's records while making records available to authorized users as efficiently as possible. The general conditions of contemporary health care undermine protecting the confidentiality of patient record. Patients may not provide health care institutions with information about themselves under conditions of informed consent. The field of information science must design sophisticated systems of computer security that stratify access, create audit trails on data changes and system use, safeguard patient data from corruption, and protect the databases from outside invasion. Radiology professionals must both work with information science experts in their own hospitals to create institutional safeguards and include the adequacy of security measures as a criterion for evaluating PACS systems. New policies and procedures on maintaining computerized patient records must be developed that obligate all members of the health care staff, not just care givers. Patients must be informed about the existence of computerized medical records, the rules and practices that govern their dissemination and given the opportunity to give or withhold consent for their use. Departmental and hospital policies on confidentiality should be reviewed to determine if revisions are necessary to manage computer-based records. Well developed discussions of the ethical principles and administrative policies on confidentiality and informed consent and of the risks posed by computer-based patient records systems should be included in initial and continuing staff system training. Administration should develop ways to monitor staff compliance with confidentiality policies and should assess diligence in maintaining patient record confidentiality as part of staff annual performance evaluations. Ethical management of IMAC systems is the business of all members of the health care team. Computerized patient records management (including IMAC) should be scrutinized as any other clinical medial ethical issue. If hospitals include these processes in their planning for RIS, IMACS, and HIS systems, they should have time to develop institutional expertise on these questions before and as systems are installed rather than only as ethical dilemmas develop during their use.

Collmann, Jeff R.

1995-05-01

382

Quality of ethical guidelines and ethical content in clinical guidelines: the example of end-of-life decision-making  

Microsoft Academic Search

BackgroundWhile there are many guidelines on how to make ethical decisions at the end of life, there is little evidence regarding the quality of this sort of ethical guidelines.ObjectivesFirst, this study aims to demonstrate the conceptual transferability of the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument for the quality assessment of ethical guidelines. Second, it aims to illustrate

Daniel Strech; Jan Schildmann

2011-01-01

383

Computerized Adaptive Personality Testing: A Review and Illustration With the MMPI-2 Computerized Adaptive Version.  

ERIC Educational Resources Information Center

Computerized adaptive testing in personality assessment can improve efficiency by significantly reducing the number of items administered to answer an assessment question. Two approaches have been explored for adaptive testing in computerized personality assessment: item response theory and the countdown method. In this article, the authors…

Forbey, Johnathan D.; Ben-Porath, Yossef S.

2007-01-01

384

A Randomized Experiment to Compare Conventional, Computerized, and Computerized Adaptive Administration of Ordinal Polytomous Attitude Items  

ERIC Educational Resources Information Center

A total of 520 high school students were randomly assigned to a paper-and-pencil test (PPT), a computerized standard test (CST), or a computerized adaptive test (CAT) version of the Dutch School Attitude Questionnaire (SAQ), consisting of ordinal polytomous items. The CST administered items in the same order as the PPT. The CAT administered all…

Hol, A. Michiel; Vorst, Harrie C. M.; Mellenbergh, Gideon J.

2005-01-01

385

Impacts of Computerized Physician Documentation in a Teaching Hospital: Perceptions of Faculty and Resident Physicians  

Microsoft Academic Search

ObjectiveComputerized physician documentation (CPD) has been implemented throughout the nation's Veterans Affairs Medical Centers (VAMCs) and is likely to increasingly replace handwritten documentation in other institutions. The use of this technology may affect educational and clinical activities, yet little has been reported in this regard. The authors conducted a qualitative study to determine the perceived impacts of CPD among faculty

Peter J Embi; Thomas R Yackel; Judith R Logan; Judith L Bowen; Thomas G Cooney; Paul N Gorman

2004-01-01

386

Comparing Assessments of Students' Knowledge by Computerized Open-Ended and Multiple-Choice Tests.  

ERIC Educational Resources Information Center

Interactive computerized tests accepting unrestricted natural-language input were used to assess knowledge of clinical biophysics at the State University of New York at Buffalo. Comparison of responses to open-ended sequential questions and multiple-choice questions on the same material found the two formats test different aspects of competence.…

Anbar, Michael

1991-01-01

387

SYN-OP-SYS™: A Computerized Management Information System for Quality Assurance and Risk Management  

PubMed Central

SYN·OP·SYS™ is a computerized management information system for quality assurance and risk management. Computer software for the efficient collection and analysis of “occurrences” and the clinical data associated with these kinds of patient events is described. The system is evaluated according to certain computer design criteria, and the system's implementation is assessed.

Thomas, David J.; Weiner, Jayne; Lippincott, Ronald C.

1985-01-01

388

The Impact of Interactive, Computerized Educational Modules on Preclinical Medical Education  

ERIC Educational Resources Information Center

Interactive computerized modules have been linked to improved retention of material in clinical medicine. This study examined the effects of a new series of interactive learning modules for preclinical medical education, specifically in the areas of quiz performance, perceived difficulty of concepts, study time, and perceived stress level. We…

Bryner, Benjamin S.; Saddawi-Konefka, Daniel; Gest, Thomas R.

2008-01-01

389

Reliability and validity of a computerized neurocognitive test battery, CNS Vital Signs  

Microsoft Academic Search

CNS Vital Signs (CNSVS) is a computerized neurocognitive test battery that was developed as a routine clinical screening instrument. It is comprised of seven tests: verbal and visual memory, finger tapping, symbol digit coding, the Stroop Test, a test of shifting attention and the continuous performance test. Because CNSVS is a battery of well-known neuropsychological tests, one should expect its

C. Thomas Gualtieri; Lynda G Johnson

2006-01-01

390

Computerized Versus Motivational Interviewing Alcohol Interventions: Impact on Discrepancy, Motivation, and Drinking  

Microsoft Academic Search

The authors conducted two randomized clinical trials with ethnically diverse samples of college student drinkers in order to determine (a) the relative efficacy of two popular computerized interventions versus a more comprehensive motivational interview approach (BASICS) and (b) the mechanisms of change associated with these interventions. In Study 1, heavy drinking participants recruited from a student health center (N =

James G. Murphy; Ashley A. Dennhardt; Jessica R. Skidmore; Matthew P. Martens; Meghan E. McDevitt-Murphy

2010-01-01

391

78 FR 17940 - Certain Computerized Orthopedic Surgical Devices, Software, Implants, and Components Thereof...  

Federal Register 2010, 2011, 2012, 2013

...Computerized Orthopedic Surgical Devices, Software, Implants, and Components Thereof...Computerized Orthopedic Surgical Devices, Software, Implants, and Components Thereof...computerized orthopedic surgical devices, software, implants, and components...

2013-03-25

392

Expert System Shells for Rapid Clinical Decision Support Module Development: An ESTA Demonstration of a Simple Rule-Based System for the Diagnosis of Vaginal Discharge  

PubMed Central

Objectives This study demonstrates the feasibility of using expert system shells for rapid clinical decision support module development. Methods A readily available expert system shell was used to build a simple rule-based system for the crude diagnosis of vaginal discharge. Pictures and 'canned text explanations' are extensively used throughout the program to enhance its intuitiveness and educational dimension. All the steps involved in developing the system are documented. Results The system runs under Microsoft Windows and is available as a free download at http://healthcybermap.org/vagdisch.zip (the distribution archive includes both the program's executable and the commented knowledge base source as a text document). The limitations of the demonstration system, such as the lack of provisions for assessing uncertainty or various degrees of severity of a sign or symptom, are discussed in detail. Ways of improving the system, such as porting it to the Web and packaging it as an app for smartphones and tablets, are also presented. Conclusions An easy-to-use expert system shell enables clinicians to rapidly become their own 'knowledge engineers' and develop concise evidence-based decision support modules of simple to moderate complexity, targeting clinical practitioners, medical and nursing students, as well as patients, their lay carers and the general public (where appropriate). In the spirit of the social Web, it is hoped that an online repository can be created to peer review, share and re-use knowledge base modules covering various clinical problems and algorithms, as a service to the clinical community. PMID:23346475

2012-01-01

393

Comparison between Dichotomous and Polytomous Scoring of Innovative Items in a Large-Scale Computerized Adaptive Test  

ERIC Educational Resources Information Center

This study explored the impact of partial credit scoring of one type of innovative items (multiple-response items) in a computerized adaptive version of a large-scale licensure pretest and operational test settings. The impacts of partial credit scoring on the estimation of the ability parameters and classification decisions in operational test…

Jiao, Hong; Liu, Junhui; Haynie, Kathleen; Woo, Ada; Gorham, Jerry

2012-01-01

394

Computerization of school administration: impact on the principal's role - a case study  

Microsoft Academic Search

Changes in the principal’s role, resulting from the computerization of a high-school’s instruction-administration subsystem (i.e. a significant technological change), occurred in six major categories: accountability, instruction evaluation, supervision, feedback, frequency of meetings, and shared decision-making. The principal’s interrelations with department heads, homeroom teachers and teachers, tightened significantly. The principal’s interrelations with the school computer administrator (a new role created as

Moshe Telem

2001-01-01

395

The Impact of Computerized Physician Order Entry on Medication Error Prevention  

Microsoft Academic Search

BackgroundMedication errors are common, and while most such errors have little potential for harm they cause substantial extra work in hospitals. A small proportion do have the potential to cause injury, and some cause preventable adverse drug events.ObjectiveTo evaluate the impact of computerized physician order entry (POE) with decision support in reducing the number of medication errors.DesignProspective time series analysis,

David W Bates; J ONATHAN M. TEICH; JOSHUA LEE; Diane Seger; Gilad J Kuperman; Nell MaLuf; Deborah Boyle; Lucian Leape

1999-01-01

396

Clinical terminology.  

PubMed

This chapter gives an educational overview of: * What a clinical terminology is * How clinical terminology is constructed and used * The concept of mapping terminologies * Why clinical terminology is an essential component of electronic health records and clinical decision support systems * The issues that relate to good use of terminologies and the need for governance and standardisation to support health information quality and the linkage to safe/consistent clinical decision support. PMID:20407153

Grain, Heather

2010-01-01

397

An fMRI study of visual lexical decision in patients with schizophrenia and clinical high-risk individuals.  

PubMed

Disturbances in semantic and phonological aspects of language processing are indicated in patients with schizophrenia, and in high-risk individuals for schizophrenia. To uncover neural correlates of the disturbances, a previous functional magnetic resonance imaging (fMRI) study using a visual lexical decision task in block design reported less leftward lateralization in the inferior frontal cortices, in patients with schizophrenia and individuals with high genetic risk for psychosis compared with normal control subjects. However, to our knowledge, no previous study has investigated contrasts between word and non-word processing that allow dissociation between semantic and phonological processing using event-related design visual lexical decision fMRI tasks in subjects with ultra-high-risk for psychosis (UHR) and patients with schizophrenia. In the current study, 20 patients with schizophrenia, 11 UHR, and 20 demographically matched controls underwent lexical decision fMRI tasks. Compared with controls, both schizophrenia and UHR groups showed significantly decreased activity in response to non-words compared with words in the inferior frontal regions. Additionally, decreased leftward lateralization in the non-word compared with word activity contrast was found in subjects with UHR compared with controls, which was not evident in patients with schizophrenia. The present findings suggest neural correlates of difficulty in phonological aspects of language processing during non-word processing in contrast to word, which at least partially commonly underlies the pathophysiology of schizophrenia and UHR. Together with a previous study in genetic high-risk subjects, the current results also suggest that reduced functional lateralization in the language-related frontal cortex may be a vulnerability marker for schizophrenia. Furthermore, the current result may suggest that the genetic basis of psychosis is presumed to be related to the evolution of the language capacity characteristic of humans. PMID:24893907

Natsubori, Tatsunobu; Hashimoto, Ryu-Ichiro; Yahata, Noriaki; Inoue, Hideyuki; Takano, Yosuke; Iwashiro, Norichika; Koike, Shinsuke; Gonoi, Wataru; Sasaki, Hiroki; Takao, Hidemasa; Abe, Osamu; Kasai, Kiyoto; Yamasue, Hidenori

2014-08-01

398

Ontology-based Modeling of Clinical Practice Guidelines: A Clinical Decision Support System for Breast Cancer Follow-up Interventions at Primary Care Settings  

E-print Network

for Breast Cancer Follow-up Interventions at Primary Care Settings Samina R. Abidi, Syed SR. Abidi, Sajjad, Canada Abstract Breast cancer follow-up care can be provided by family phy- sicians after specialists complete the primary treatment. Can- cer Care Nova Scotia has developed a breast cancer follow- up Clinical

Abidi, Syed Sibte Raza

399

A Hybrid Architecture for a Preoperative Decision Support System Using a Rule Engine and a Reasoner on a Clinical Ontology  

NASA Astrophysics Data System (ADS)

We report on a preventive care software system for preoperative risk assessment of patient undergoing elective surgery. The system combines a rule engine and a reasoner which uses a decision support ontology developed with a logic based knowledge representation formalism. We specifically discuss our experience of using a representation of a patient’s medical history in OWL, combined with a reasoning tool to suggest appropriate preoperative tests based on an implementation of preoperative assessment guidelines. We illustrate the reasoning functionalities of the system with a number of practical examples.

Bouamrane, Matt-Mouley; Rector, Alan; Hurrell, Martin

400

An ontology model for clinical documentation templates  

E-print Network

There are various kinds of clinical documents used in a hospital or clinic setting. With the emergence of Electronic Medical Records, efforts are being made to computerize these documents in a structured fashion in order ...

George, Joyce, S.M. Massachusetts Institute of Technology

2005-01-01

401

The effects of knowledge, attitudes, and significant others on decisions to enroll in a clinical trial on osteoporosis: implications for recruitment of older African-American women.  

PubMed Central

This preliminary study explored the roles of knowledge, attitudes, and significant others on decisions of older African-American women to enroll in a clinical trial involving estrogen and osteoporosis. Sixteen older African-American women (average age 75 years) participated in three focus groups. Twelve of the women had enrolled in the clinical trial and four, although eligible, refused to enroll. Discussions revealed that knowledge of osteoporosis and estrogen and expectations of personal rewards and group benefits from medical research appear to differentiate the women who participated in the clinical trial from those who refused. The women who participated also perceived the research institution as accessible. In addition, assuring full disclosure of testing procedures and test results eased their apprehensions about participation. However, the women who refused to enroll saw no personal benefit and were unwilling to expose themselves, in part because of their age, to the risks of taking estrogen and the uncertain outcomes of the clinical trial. The study illustrates how focus groups can be used to develop multiple strategies to enable recruitment of older African-American women with different demographic characteristics, levels of knowledge, and attitudes toward a disease and medical research. PMID:11688920

Unson, C. G.; Dunbar, N.; Curry, L.; Kenyon, L.; Prestwood, K.

2001-01-01

402

Application of Information Technology: Costs Associated with Developing and Implementing a Computerized Clinical Decision Support System for Medication Dosing for Patients with Renal Insufficiency in the Long-term Care Setting  

Microsoft Academic Search

A team of physicians, pharmacists, and informatics professionals developed a CDSS added to a commercial electronic medical record system to provide prescribers with patient-specific maximum dosing recommendations based on renal function. We tracked the time spent by team members and used US national averages of relevant hourly wages to estimate costs. The team required 924.5 hours and $48,668.57 in estimated

Terry S. Field; Paula Rochon; Monica Lee; Linda Gavendo; Sujha Subramanian; Sonia Hoover; Joann L. Baril; Jerry H. Gurwitz

2008-01-01

403

Managing health care decisions and improvement through simulation modeling.  

PubMed

Simulation modeling is a way to test changes in a computerized environment to give ideas for improvements before implementation. This article reviews research literature on simulation modeling as support for health care decision making. The aim is to investigate the experience and potential value of such decision support and quality of articles retrieved. A literature search was conducted, and the selection criteria yielded 59 articles derived from diverse applications and methods. Most met the stated research-quality criteria. This review identified how simulation can facilitate decision making and that it may induce learning. Furthermore, simulation offers immediate feedback about proposed changes, allows analysis of scenarios, and promotes communication on building a shared system view and understanding of how a complex system works. However, only 14 of the 59 articles reported on implementation experiences, including how decision making was supported. On the basis of these articles, we proposed steps essential for the success of simulation projects, not just in the computer, but also in clinical reality. We also presented a novel concept combining simulation modeling with the established plan-do-study-act cycle for improvement. Future scientific inquiries concerning implementation, impact, and the value for health care management are needed to realize the full potential of simulation modeling. PMID:21192204

Forsberg, Helena Hvitfeldt; Aronsson, Håkan; Keller, Christina; Lindblad, Staffan

2011-01-01

404

Research on Instructional Decision Models. Final Report.  

ERIC Educational Resources Information Center

Optimization procedures for a computer-assisted instruction (CAI) system were developed using iterative development and tests of a series of instructional decision models (IDM). The result was a total systems effort in which the instruction was carried on by a dialogue between a computerized tutor and the student. A profile of the student, student…

Seidel, Robert J.

405

Validation of a self-administered computerized system to detect cognitive impairment in older adults.  

PubMed

There is increasing interest in the development of economical and accurate approaches to identifying persons in the community who have mild, undetected cognitive impairments. Computerized assessment systems have been suggested as a viable approach to identifying these persons. The validity of a computerized assessment system for identification of memory and executive deficits in older individuals was evaluated in the current study. Volunteers (N = 235) completed a 3-hr battery of neuropsychological tests and a computerized cognitive assessment system. Participants were classified as impaired (n = 78) or unimpaired (n = 157) on the basis of the Mini Mental State Exam, Wechsler Memory Scale-III and the Trail Making Test (TMT), Part B. All six variables (three memory variables and three executive variables) derived from the computerized assessment differed significantly between groups in the expected direction. There was also evidence of temporal stability and concurrent validity. Application of computerized assessment systems for clinical practice and for identification of research participants is discussed in this article. PMID:25332303

Brinkman, Samuel D; Reese, Robert J; Norsworthy, Larry A; Dellaria, Donna K; Kinkade, Jacob W; Benge, Jared; Brown, Kimberly; Ratka, Anna; Simpkins, James W

2014-12-01

406

Building a web-based tool to support clinical decisions in the control of Chlamydia trachomatis and Neisseria gonorrhoeae infections  

PubMed Central

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the agents of two common, sexually transmitted diseases afflicting women in the United States (http://www.cdc.gov). We designed a novel web-based application that offers simple recommendations to help optimize medical outcomes with CT and GC prevention and control programs. This application takes population groups, prevalence rates, parameters for available screening assays and treatment regimens (costs, sensitivity, and specificity), as well as budget limits as inputs. Its output suggests optimal screening and treatment strategies for selected at-risk groups, commensurate with the clinic's budget allocation. Development of this tool illustrates how a clinical informatics application based on rigorous mathematics might have a significant impact on real-world clinical issues. PMID:24564848

2013-01-01

407

Evaluation of Heart Rate Assessment Timing, Communication, Accuracy, and Clinical Decision-Making during High Fidelity Simulation of Neonatal Resuscitation  

PubMed Central

Objective. Accurate heart rate (HR) determination during neonatal resuscitation (NR) informs subsequent NR actions. This study's objective was to evaluate HR determination timeliness, communication, and accuracy during high fidelity NR simulations that house officers completed during neonatal intensive care unit (NICU) rotations. Methods. In 2010, house officers in NICU rotations completed high fidelity NR simulation. We reviewed 80 house officers' videotaped performance on their initial high fidelity simulation session, prior to training and performance debriefing. We calculated the proportion of cases congruent with NR guidelines, using chi square analysis to evaluate performance across HR ranges relevant to NR decision-making: <60, 60–99, and ?100 beats per minute (bpm). Results. 87% used umbilical cord palpation, 57% initiated HR assessment within 30 seconds, 70% were accurate, and 74% were communicated appropriately. HR determination accuracy varied significantly across HR ranges, with 87%, 57%, and 68% for HR <60, 60–99, and ?100?bpm, respectively (P < 0.001). Conclusions. Timeliness, communication, and accuracy of house officers' HR determination are suboptimal, particularly for HR 60–100?bpm, which might lead to inappropriate decision-making and NR care. Training implications include emphasizing more accurate HR determination methods, better communication, and improved HR interpretation during NR. PMID:24883063

McAllister, Jennifer; Attar, Mohammad A.; Chapman, Rachel L.; Mullan, Patricia B.; Haftel, Hilary M.

2014-01-01

408

Evaluation of Heart Rate Assessment Timing, Communication, Accuracy, and Clinical Decision-Making during High Fidelity Simulation of Neonatal Resuscitation.  

PubMed

Objective. Accurate heart rate (HR) determination during neonatal resuscitation (NR) informs subsequent NR actions. This study's objective was to evaluate HR determination timeliness, communication, and accuracy during high fidelity NR simulations that house officers completed during neonatal intensive care unit (NICU) rotations. Methods. In 2010, house officers in NICU rotations completed high fidelity NR simulation. We reviewed 80 house officers' videotaped performance on their initial high fidelity simulation session, prior to training and performance debriefing. We calculated the proportion of cases congruent with NR guidelines, using chi square analysis to evaluate performance across HR ranges relevant to NR decision-making: <60, 60-99, and ?100 beats per minute (bpm). Results. 87% used umbilical cord palpation, 57% initiated HR assessment within 30 seconds, 70% were accurate, and 74% were communicated appropriately. HR determination accuracy varied significantly across HR ranges, with 87%, 57%, and 68% for HR <60, 60-99, and ?100?bpm, respectively (P < 0.001). Conclusions. Timeliness, communication, and accuracy of house officers' HR determination are suboptimal, particularly for HR 60-100?bpm, which might lead to inappropriate decision-making and NR care. Training implications include emphasizing more accurate HR determination methods, better communication, and improved HR interpretation during NR. PMID:24883063

Boon, Win; McAllister, Jennifer; Attar, Mohammad A; Chapman, Rachel L; Mullan, Patricia B; Haftel, Hilary M

2014-01-01

409

Decision Making Processes and Outcomes  

PubMed Central

The primary aim of this study was to examine the contributions of individual characteristics and strategic processing to the prediction of decision quality. Data were provided by 176 adults, ages 18 to 93 years, who completed computerized decision-making vignettes and a battery of demographic and cognitive measures. We examined the relations among age, domain-specific experience, working memory, and three measures of strategic information search to the prediction of solution quality using a 4-step hierarchical linear regression analysis. Working memory and two measures of strategic processing uniquely contributed to the variance explained. Results are discussed in terms of potential advances to both theory and intervention efforts. PMID:24282638

Hicks Patrick, Julie; Steele, Jenessa C.; Spencer, S. Melinda

2013-01-01

410