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Sample records for computerized clinical decision

  1. Computerized Clinical Decision Support: Contributions from 2014

    PubMed Central

    Koutkias, V.

    2015-01-01

    Summary Objective To summarize recent research and propose a selection of best papers published in 2014 in the field of computerized clinical decision support for the Decision Support section of the IMIA yearbook. Method A literature review was performed by searching two bibliographic databases for papers related to clinical decision support systems (CDSSs) and computerized provider order entry systems in order to select a list of candidate best papers to be then peer-reviewed by external reviewers. A consensus meeting between the two section editors and the editorial team was finally organized to conclude on the selection of best papers. Results Among the 1,254 returned papers published in 2014, the full review process selected four best papers. The first one is an experimental contribution to a better understanding of unintended uses of CDSSs. The second paper describes the effective use of previously collected data to tailor and adapt a CDSS. The third paper presents an innovative application that uses pharmacogenomic information to support personalized medicine. The fourth paper reports on the long-term effect of the routine use of a CDSS for antibiotic therapy. Conclusions As health information technologies spread more and more meaningfully, CDSSs are improving to answer users’ needs more accurately. The exploitation of previously collected data and the use of genomic data for decision support has started to materialize. However, more work is still needed to address issues related to the correct usage of such technologies, and to assess their effective impact in the long term. PMID:26293858

  2. Developing and implementing computerized protocols for standardization of clinical decisions.

    PubMed

    Morris, A H

    2000-03-01

    Humans have only a limited ability to incorporate information in decision making. In certain situations, the mismatch between this limitation and the availability of extensive information contributes to the varying performance and high error rate of clinical decision makers. Variation in clinical practice is due in part to clinicians' poor compliance with guidelines and recommended therapies. The use of decision-support tools is a response to both the information revolution and poor compliance. Computerized protocols used to deliver decision support can be configured to contain much more detail than textual guidelines or paper-based flow diagrams. Such protocols can generate patient-specific instructions for therapy that can be carried out with little interclinician variability; however, clinicians must be willing to modify personal styles of clinical management. Protocols need not be perfect. Several defensible and reasonable approaches are available for clinical problems. However, one of these reasonable approaches must be chosen and incorporated into the protocol to promote consistent clinical decisions. This reasoning is the basis of an explicit method of decision support that allows the rigorous evaluation of interventions, including use of the protocols themselves. Computerized protocols for mechanical ventilation and management of intravenous fluid and hemodynamic factors in patients with the acute respiratory distress syndrome provide case studies for this discussion. PMID:10691588

  3. Reducing inappropriate ESR testing with computerized clinical decision support

    PubMed Central

    Gottheil, Stephanie; Khemani, Ekta; Copley, Katherine; Keeney, Michael; Kinney, Jeff; Chin-Yee, Ian; Gob, Alan

    2016-01-01

    Laboratory test overutilization increases health care costs, leads to unwarranted investigations, and may have a negative impact on health outcomes. The American Society of Clinical Pathology, in its Choosing Wisely Campaign, advocates that inflammation be investigated with C-reactive protein (CRP) instead of Erythrocyte Sedimentation Rate (ESR). London Health Sciences Centre (LHSC), a tertiary care hospital organization in Ontario, Canada, set a goal to reduce inappropriate ESR orders by 50%. After developing appropriateness criteria for ESR, we used a series of PDSA cycles to reduce inappropriate ESR ordering and analyzed our results with an interrupted time series design. Our intervention began with an educational bulletin and moved to city-wide implementation of computerized Clinical Decision Support (CDS). After implementation, ESR orders decreased by 40% from 386 orders per week to 241 orders per week. Our results are supported by previous literature on the effectiveness of CDS in reducing overutilization and suggest that provider habit is a significant contributor to inappropriate ordering. PMID:27096092

  4. Reducing inappropriate ESR testing with computerized clinical decision support.

    PubMed

    Gottheil, Stephanie; Khemani, Ekta; Copley, Katherine; Keeney, Michael; Kinney, Jeff; Chin-Yee, Ian; Gob, Alan

    2016-01-01

    Laboratory test overutilization increases health care costs, leads to unwarranted investigations, and may have a negative impact on health outcomes. The American Society of Clinical Pathology, in its Choosing Wisely Campaign, advocates that inflammation be investigated with C-reactive protein (CRP) instead of Erythrocyte Sedimentation Rate (ESR). London Health Sciences Centre (LHSC), a tertiary care hospital organization in Ontario, Canada, set a goal to reduce inappropriate ESR orders by 50%. After developing appropriateness criteria for ESR, we used a series of PDSA cycles to reduce inappropriate ESR ordering and analyzed our results with an interrupted time series design. Our intervention began with an educational bulletin and moved to city-wide implementation of computerized Clinical Decision Support (CDS). After implementation, ESR orders decreased by 40% from 386 orders per week to 241 orders per week. Our results are supported by previous literature on the effectiveness of CDS in reducing overutilization and suggest that provider habit is a significant contributor to inappropriate ordering. PMID:27096092

  5. Evaluating the Effectiveness of Nurse-Focused Computerized Clinical Decision Support on Urinary Catheter Practice Guidelines

    ERIC Educational Resources Information Center

    Lang, Robin Lynn Neal

    2012-01-01

    A growing national emphasis has been placed on health information technology (HIT) with robust computerized clinical decision support (CCDS) integration into health care delivery. Catheter-associated urinary tract infection is the most frequent health care-associated infection in the United States and is associated with high cost, high volumes and…

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

    ERIC Educational Resources Information Center

    Kunisch, Joseph Martin

    2012-01-01

    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.…

  7. Evaluating the use of a computerized clinical decision support system for asthma by pediatric pulmonologists

    PubMed Central

    Lomotan, Edwin A.; Hoeksema, Laura J.; Edmonds, Diana E.; Ramírez-Garnica, Gabriela; Shiffman, Richard N.; Horwitz, Leora I.

    2012-01-01

    Purpose To investigate use of a new guideline-based, computerized clinical decision support (CCDS) system for asthma in a pediatric pulmonology clinic of a large academic medical center. Methods We conducted a qualitative evaluation including review of electronic data, direct observation, and interviews with all nine pediatric pulmonologists in the clinic. Outcome measures included patterns of computer use in relation to patient care, and themes surrounding the relationship between asthma care and computer use. Results The pediatric pulmonologists entered enough data to trigger the decision support system in 397/445 (89.2%) of all asthma visits from January 2009 to May 2009. However, interviews and direct observations revealed use of the decision support system was limited to documentation activities after clinic sessions ended. Reasons for delayed use reflected barriers common to general medical care and barriers specific to subspecialty care. Subspecialist-specific barriers included the perceived high complexity of patients, the impact of subject matter expertise on the types of decision support needed, and unique workflow concerns such as the need to create letters to referring physicians. Conclusions Pediatric pulmonologists demonstrated low use of a computerized decision support system for asthma care because of a combination of general and subspecialist-specific factors. Subspecialist-specific factors should not be underestimated when designing guideline-based, computerized decision support systems for the subspecialty setting. PMID:22204897

  8. Patient-oriented Computerized Clinical Guidelines for Mobile Decision Support in Gestational Diabetes

    PubMed Central

    Rigla, Mercedes; Martínez-Sarriegui, Iñaki; Shalom, Erez; Peleg, Mor; Broens, Tom; Pons, Belén; Caballero-Ruíz, Estefanía; Gómez, Enrique J.; Hernando, M. Elena

    2014-01-01

    The risks associated with gestational diabetes (GD) can be reduced with an active treatment able to improve glycemic control. Advances in mobile health can provide new patient-centric models for GD to create personalized health care services, increase patient independence and improve patients’ self-management capabilities, and potentially improve their treatment compliance. In these models, decision-support functions play an essential role. The telemedicine system MobiGuide provides personalized medical decision support for GD patients that is based on computerized clinical guidelines and adapted to a mobile environment. The patient’s access to the system is supported by a smartphone-based application that enhances the efficiency and ease of use of the system. We formalized the GD guideline into a computer-interpretable guideline (CIG). We identified several workflows that provide decision-support functionalities to patients and 4 types of personalized advice to be delivered through a mobile application at home, which is a preliminary step to providing decision-support tools in a telemedicine system: (1) therapy, to help patients to comply with medical prescriptions; (2) monitoring, to help patients to comply with monitoring instructions; (3) clinical assessment, to inform patients about their health conditions; and (4) upcoming events, to deal with patients’ personal context or special events. The whole process to specify patient-oriented decision support functionalities ensures that it is based on the knowledge contained in the GD clinical guideline and thus follows evidence-based recommendations but at the same time is patient-oriented, which could enhance clinical outcomes and patients’ acceptance of the whole system. PMID:24876573

  9. Patient-oriented Computerized Clinical Guidelines for Mobile Decision Support in Gestational Diabetes.

    PubMed

    García-Sáez, Gema; Rigla, Mercedes; Martínez-Sarriegui, Iñaki; Shalom, Erez; Peleg, Mor; Broens, Tom; Pons, Belén; Caballero-Ruíz, Estefanía; Gómez, Enrique J; Hernando, M Elena

    2014-03-01

    The risks associated with gestational diabetes (GD) can be reduced with an active treatment able to improve glycemic control. Advances in mobile health can provide new patient-centric models for GD to create personalized health care services, increase patient independence and improve patients' self-management capabilities, and potentially improve their treatment compliance. In these models, decision-support functions play an essential role. The telemedicine system MobiGuide provides personalized medical decision support for GD patients that is based on computerized clinical guidelines and adapted to a mobile environment. The patient's access to the system is supported by a smartphone-based application that enhances the efficiency and ease of use of the system. We formalized the GD guideline into a computer-interpretable guideline (CIG). We identified several workflows that provide decision-support functionalities to patients and 4 types of personalized advice to be delivered through a mobile application at home, which is a preliminary step to providing decision-support tools in a telemedicine system: (1) therapy, to help patients to comply with medical prescriptions; (2) monitoring, to help patients to comply with monitoring instructions; (3) clinical assessment, to inform patients about their health conditions; and (4) upcoming events, to deal with patients' personal context or special events. The whole process to specify patient-oriented decision support functionalities ensures that it is based on the knowledge contained in the GD clinical guideline and thus follows evidence-based recommendations but at the same time is patient-oriented, which could enhance clinical outcomes and patients' acceptance of the whole system. PMID:24876573

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

    PubMed Central

    2012-01-01

    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

  11. Early Experiences from a guideline-based computerized clinical decision support for stroke prevention in atrial fibrillation.

    PubMed

    Chen, Rong; Valladares, Carlos; Corbal, Iago; Anani, Nadim; Koch, Sabine

    2013-01-01

    Atrial fibrillation (AF) affects 1-2% of the population. Twenty percent of all strokes are caused by AF. In this study, we represented the clinical knowledge in the European Society of Cardiology guideline using Guideline Definition Language (GDL), a format that binds openEHR archetypes, rule languages, and reference terminologies together. The computerized guidelines are applied to electronic health record (EHR) data retrospectively in order to identify possible gaps between current clinical practice and optimal care recommended by the evidence-based guidelines. Treatment compliance is checked in two patient groups: one received treatment from a cardiologist who is responsible for AF treatment in the region (n=514) and the other was a much larger patient group from the whole region (n=8130). The compliance checking shows the cardiologist group has substantially higher percentage of compliant treatment compared with that of the general population group. Based on this important finding, we are now implementing at-point-of-care clinical decision support reusing the same computerized guideline knowledge in GDL format in order to increase the guideline adherence of the treatment. PMID:23920553

  12. The process of development of a prioritization tool for a clinical decision support build within a computerized provider order entry system: Experiences from St Luke's Health System.

    PubMed

    Wolf, Matthew; Miller, Suzanne; DeJong, Doug; House, John A; Dirks, Carl; Beasley, Brent

    2016-09-01

    To establish a process for the development of a prioritization tool for a clinical decision support build within a computerized provider order entry system and concurrently to prioritize alerts for Saint Luke's Health System. The process of prioritizing clinical decision support alerts included (a) consensus sessions to establish a prioritization process and identify clinical decision support alerts through a modified Delphi process and (b) a clinical decision support survey to validate the results. All members of our health system's physician quality organization, Saint Luke's Care as well as clinicians, administrators, and pharmacy staff throughout Saint Luke's Health System, were invited to participate in this confidential survey. The consensus sessions yielded a prioritization process through alert contextualization and associated Likert-type scales. Utilizing this process, the clinical decision support survey polled the opinions of 850 clinicians with a 64.7 percent response rate. Three of the top rated alerts were approved for the pre-implementation build at Saint Luke's Health System: Acute Myocardial Infarction Core Measure Sets, Deep Vein Thrombosis Prophylaxis within 4 h, and Criteria for Sepsis. This study establishes a process for developing a prioritization tool for a clinical decision support build within a computerized provider order entry system that may be applicable to similar institutions. PMID:25814483

  13. Feasibility of integrating a clinical decision support tool into an existing computerized physician order entry system to increase seasonal influenza vaccination in the emergency department.

    PubMed

    Venkat, Arvind; Chan-Tompkins, Noreen H; Hegde, Gajanan G; Chuirazzi, David M; Hunter, Roger; Szczesiul, Jillian M

    2010-08-23

    While emergency department (ED) seasonal influenza vaccination programs are feasible, reported implementation barriers include added staffing requirements to identify eligible patients and getting busy ED personnel to order and provide vaccination. We present a prospective, observational trial of integrating a clinical decision support tool into an existing ED computerized physician order entry (CPOE) system to increase ED seasonal influenza vaccination without added staffing resources, the operational barriers identified to program implementation, the revenue generated and data on opportunities for future quality improvement. Compared to the comparable pre-protocol period, ED influenza vaccination rose by 17.5% with a resultant profit margin of 34.5%. PMID:20620167

  14. Computerized Clinical Simulations.

    ERIC Educational Resources Information Center

    Reinecker, Lynn

    1985-01-01

    Describes technique involved in designing a clinical simulation problem for the allied health field of respiratory therapy; discusses the structure, content, and scoring categories of the simulation; and provides a sample program which illustrates a programming technique in BASIC, including a program listing and a sample flowchart. (MBR)

  15. Barriers to implementation of a computerized decision support system for depression: an observational report on lessons learned in "real world" clinical settings

    PubMed Central

    2009-01-01

    Background Despite wide promotion, clinical practice guidelines have had limited effect in changing physician behavior. Effective implementation strategies to date have included: multifaceted interventions involving audit and feedback, local consensus processes, marketing; reminder systems, either manual or computerized; and interactive educational meetings. In addition, there is now growing evidence that contextual factors affecting implementation must be addressed such as organizational support (leadership procedures and resources) for the change and strategies to implement and maintain new systems. Methods To examine the feasibility and effectiveness of implementation of a computerized decision support system for depression (CDSS-D) in routine public mental health care in Texas, fifteen study clinicians (thirteen physicians and two advanced nurse practitioners) participated across five sites, accruing over 300 outpatient visits on 168 patients. Results Issues regarding computer literacy and hardware/software requirements were identified as initial barriers. Clinicians also reported concerns about negative impact on workflow and the potential need for duplication during the transition from paper to electronic systems of medical record keeping. Conclusion The following narrative report based on observations obtained during the initial testing and use of a CDSS-D in clinical settings further emphasizes the importance of taking into account organizational factors when planning implementation of evidence-based guidelines or decision support within a system. PMID:19159458

  16. Computerized clinical decision support systems for primary preventive care: A decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes

    PubMed Central

    2011-01-01

    Background Computerized clinical decision support systems (CCDSSs) are claimed to improve processes and outcomes of primary preventive care (PPC), but their effects, safety, and acceptance must be confirmed. We updated our previous systematic reviews of CCDSSs and integrated a knowledge translation approach in the process. The objective was to review randomized controlled trials (RCTs) assessing the effects of CCDSSs for PPC on process of care, patient outcomes, harms, and costs. Methods We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews Database, Inspec, and other databases, as well as reference lists through January 2010. We contacted authors to confirm data or provide additional information. We included RCTs that assessed the effect of a CCDSS for PPC on process of care and patient outcomes compared to care provided without a CCDSS. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive. Results We added 17 new RCTs to our 2005 review for a total of 41 studies. RCT quality improved over time. CCDSSs improved process of care in 25 of 40 (63%) RCTs. Cumulative scientifically strong evidence supports the effectiveness of CCDSSs for screening and management of dyslipidaemia in primary care. There is mixed evidence for effectiveness in screening for cancer and mental health conditions, multiple preventive care activities, vaccination, and other preventive care interventions. Fourteen (34%) trials assessed patient outcomes, and four (29%) reported improvements with the CCDSS. Most trials were not powered to evaluate patient-important outcomes. CCDSS costs and adverse events were reported in only six (15%) and two (5%) trials, respectively. Information on study duration was often missing, limiting our ability to assess sustainability of CCDSS effects. Conclusions Evidence supports the

  17. Immediate financial impact of computerized clinical decision support for long-term care residents with renal insufficiency: a case study.

    PubMed

    Subramanian, Sujha; Hoover, Sonja; Wagner, Joann L; Donovan, Jennifer L; Kanaan, Abir O; Rochon, Paula A; Gurwitz, Jerry H; Field, Terry S

    2012-01-01

    In a randomized trial of a clinical decision support system for drug prescribing for residents with renal insufficiency in a large long-term care facility, analyses were conducted to estimate the system's immediate, direct financial impact. We determined the costs that would have been incurred if drug orders that triggered the alert system had actually been completed compared to the costs of the final submitted orders and then compared intervention units to control units. The costs incurred by additional laboratory testing that resulted from alerts were also estimated. Drug orders were conservatively assigned a duration of 30 days of use for a chronic drug and 10 days for antibiotics. It was determined that there were modest reductions in drug costs, partially offset by an increase in laboratory-related costs. Overall, there was a reduction in direct costs (US$1391.43, net 7.6% reduction). However, sensitivity analyses based on alternative estimates of duration of drug use suggested a reduction as high as US$7998.33 if orders for non-antibiotic drugs were assumed to be continued for 180 days. The authors conclude that the immediate and direct financial impact of a clinical decision support system for medication ordering for residents with renal insufficiency is modest and that the primary motivation for such efforts must be to improve the quality and safety of medication ordering. PMID:22101906

  18. Cassel Psych Center Computerized Biofeedback Clinic.

    ERIC Educational Resources Information Center

    Cassel, Russell N.

    1982-01-01

    Describes Cassel Psych Center, a computerized biofeedback clinic, where the "well" patient is a major concern, and where biofeedback instruments are used with computers to form a Computerized-Biofeedback Clinical Support System. The Center's activities are designed to parallel the services of the pathologist in a medical setting. (PAS)

  19. Computerized decision support system for kidney paired donation program.

    PubMed

    Chen, Yanhua; Song, Peter X-K

    2011-01-01

    In order to assist physicians and other health professionals for health care improvement, clinical decision support systems, through interactive computerized software, become very popular in clinical practice. The crisis associated with kidney organ shortage has triggered an innovative strategy, termed as Kidney Paired Donation (KPD) program, to address a rapidly expanding demand for donor kidneys. KPD program involves how to making optimal decision for allowing patients with incompatible living donors to receive compatible organs by best matching donors. Although some computerized optimization tools are being used in the current KPD program, there still lacks a general decision support system which enables us to evaluate and compare different kidney allocation strategies and effects of policy. In this paper, we discuss a general computer-based KPD decision model that appropriately reflects the real world clinical application. Also, the whole decision process is to be visualized by our Graphical User Interface (GUI) software, which offers a user friendly platform not only to provide a convenient interface for clinicians but also to assess different kidney exchange strategies of clinical importance. PMID:22255013

  20. Computerized clinical decision support for the early recognition and management of acute kidney injury: a qualitative evaluation of end-user experience

    PubMed Central

    Kanagasundaram, Nigel S.; Bevan, Mark T.; Sims, Andrew J.; Heed, Andrew; Price, David A.; Sheerin, Neil S.

    2016-01-01

    Background Although the efficacy of computerized clinical decision support (CCDS) for acute kidney injury (AKI) remains unclear, the wider literature includes examples of limited acceptability and equivocal benefit. Our single-centre study aimed to identify factors promoting or inhibiting use of in-patient AKI CCDS. Methods Targeting medical users, CCDS triggered with a serum creatinine rise of ≥25 μmol/L/day and linked to guidance and test ordering. User experience was evaluated through retrospective interviews, conducted and analysed according to Normalization Process Theory. Initial pilot ward experience allowed tool refinement. Assessments continued following CCDS activation across all adult, non-critical care wards. Results Thematic saturation was achieved with 24 interviews. The alert was accepted as a potentially useful prompt to early clinical re-assessment by many trainees. Senior staff were more sceptical, tending to view it as a hindrance. ‘Pop-ups’ and mandated engagement before alert dismissal were universally unpopular due to workflow disruption. Users were driven to close out of the alert as soon as possible to review historical creatinines and to continue with the intended workflow. Conclusions Our study revealed themes similar to those previously described in non-AKI settings. Systems intruding on workflow, particularly involving complex interactions, may be unsustainable even if there has been a positive impact on care. The optimal balance between intrusion and clinical benefit of AKI CCDS requires further evaluation. PMID:26798462

  1. Evaluation of medium-term consequences of implementing commercial computerized physician order entry and clinical decision support prescribing systems in two ‘early adopter’ hospitals

    PubMed Central

    Cresswell, Kathrin M; Bates, David W; Williams, Robin; Morrison, Zoe; Slee, Ann; Coleman, Jamie; Robertson, Ann; Sheikh, Aziz

    2014-01-01

    Objective To understand the medium-term consequences of implementing commercially procured computerized physician order entry (CPOE) and clinical decision support (CDS) systems in ‘early adopter’ hospitals. Materials and methods In-depth, qualitative case study in two hospitals using a CPOE or a CDS system for at least 2 years. Both hospitals had implemented commercially available systems. Hospital A had implemented a CPOE system (with basic decision support), whereas hospital B invested additional resources in a CDS system that facilitated order entry but which was integrated with electronic health records and offered more advanced CDS. We used a combination of documentary analysis of the implementation plans, audiorecorded semistructured interviews with system users, and observations of strategic meetings and systems usage. Results We collected 11 documents, conducted 43 interviews, and conducted a total of 21.5 h of observations. We identified three major themes: (1) impacts on individual users, including greater legibility of prescriptions, but also some accounts of increased workloads; (2) the introduction of perceived new safety risks related to accessibility and usability of hardware and software, with users expressing concerns that some problems such as duplicate prescribing were more likely to occur; and (3) realizing organizational benefits through secondary uses of data. Conclusions We identified little difference in the medium-term consequences of a CPOE and a CDS system. It is important that future studies investigate the medium- and longer-term consequences of CPOE and CDS systems in a wider range of hospitals. PMID:24431334

  2. Computerized decision support in adult and pediatric critical care

    PubMed Central

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

    2013-01-01

    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

  3. Clinical applications of computerized thermography

    NASA Technical Reports Server (NTRS)

    Anbar, Michael

    1988-01-01

    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.

  4. Usability and impact of a computerized clinical decision support intervention designed to reduce urinary catheter utilization and catheter-associated urinary tract infections

    PubMed Central

    Baillie, Charles A.; Epps, Mika; Hanish, Asaf; Fishman, Neil O.; French, Benjamin; Umscheid, Craig A.

    2015-01-01

    Objective To evaluate the usability and effectiveness of a computerized clinical decision support (CDS) intervention aimed at reducing the duration of urinary tract catheterizations. Design Retrospective cohort study. Setting Academic healthcare system. Patients All adult patients admitted from March 2009 through May 2012. Intervention A CDS intervention was integrated into a commercial electronic health record. Providers were prompted at order entry to specify the indication for urinary catheter insertion. Based on the indication chosen, providers were alerted to reassess the need for the urinary catheter if it was not removed within the recommended time. Three time periods were examined: baseline, after implementation of the first intervention (stock reminder), and after a second iteration (homegrown reminder). The primary endpoint was the usability of the intervention as measured by the proportion of reminders through which providers submitted a remove urinary catheter order. Secondary endpoints were the urinary catheter utilization ratio and the rate of hospital-acquired CAUTIs. Results The first intervention displayed limited usability with 2% of reminders resulting in a remove order. Usability improved to 15% with the revised reminder. The catheter utilization ratio declined over the three time periods (0.22, 0.20 and 0.19, respectively, p-value <0.001), as did CAUTI per 1,000 patient days (0.84, 0.70, 0.51, respectively, p-value <0.001). Conclusions A urinary catheter removal reminder system was successfully integrated within a healthcare system’s EHR. The usability of the reminder was highly dependent on its user interface, with a homegrown version of the reminder resulting in higher impact than a stock reminder. PMID:25111923

  5. Computerized Mastery Testing Using Fuzzy Set Decision Theory.

    ERIC Educational Resources Information Center

    Du, Yi; And Others

    1993-01-01

    A new computerized mastery test is described that builds on the Lewis and Sheehan procedure (sequential testlets) (1990), but uses fuzzy set decision theory to determine stopping rules and the Rasch model to calibrate items and estimate abilities. Differences between fuzzy set and Bayesian methods are illustrated through an example. (SLD)

  6. Physicians’ use of computerized clinical decision supports to improve medication management in the elderly – the Seniors Medication Alert and Review Technology intervention

    PubMed Central

    Alagiakrishnan, Kannayiram; Wilson, Patricia; Sadowski, Cheryl A; Rolfson, Darryl; Ballermann, Mark; Ausford, Allen; Vermeer, Karla; Mohindra, Kunal; Romney, Jacques; Hayward, Robert S

    2016-01-01

    Background Elderly people (aged 65 years or more) are at increased risk of polypharmacy (five or more medications), inappropriate medication use, and associated increased health care costs. The use of clinical decision support (CDS) within an electronic medical record (EMR) could improve medication safety. Methods Participatory action research methods were applied to preproduction design and development and postproduction optimization of an EMR-embedded CDS implementation of the Beers’ Criteria for medication management and the Cockcroft–Gault formula for estimating glomerular filtration rates (GFR). The “Seniors Medication Alert and Review Technologies” (SMART) intervention was used in primary care and geriatrics specialty clinics. Passive (chart messages) and active (order-entry alerts) prompts exposed potentially inappropriate medications, decreased GFR, and the possible need for medication adjustments. Physician reactions were assessed using surveys, EMR simulations, focus groups, and semi-structured interviews. EMR audit data were used to identify eligible patient encounters, the frequency of CDS events, how alerts were managed, and when evidence links were followed. Results Analysis of subjective data revealed that most clinicians agreed that CDS appeared at appropriate times during patient care. Although managing alerts incurred a modest time burden, most also agreed that workflow was not disrupted. Prevalent concerns related to clinician accountability and potential liability. Approximately 36% of eligible encounters triggered at least one SMART alert, with GFR alert, and most frequent medication warnings were with hypnotics and anticholinergics. Approximately 25% of alerts were overridden and ~15% elicited an evidence check. Conclusion While most SMART alerts validated clinician choices, they were received as valuable reminders for evidence-informed care and education. Data from this study may aid other attempts to implement Beers’ Criteria in

  7. Allied health applications of a computerized clinical log database system.

    PubMed

    Boyce, K E; Winn, J S; Anderson, S L; Bryant, B G

    1999-01-01

    Preliminary research in the development and use of computerized clinical log records began in 1987 in an allied health college at a midwestern academic health center. This article reviews development and implementation of a computerized system for managing clinical log records to improve and enhance allied health educational programs in the radiation sciences. These clinical log databases are used for quantitative and qualitative analyses of student participation in clinical procedures, and educational planning for each student. Collecting and recording data from clinical log records serves as a valuable instructional tool for students, with both clinical and didactic applications. PMID:10389054

  8. Using Computerized Clinical Nursing Data Bases for Nursing Research.

    ERIC Educational Resources Information Center

    Nail, Lillian M.; Lange, Linda L.

    1996-01-01

    Addresses the recognition of differences between clinical and research data in using computerized clinical nursing databases and the issues of privacy and confidentiality for patients whose records are involved. Describes procedures for assessing the quality and usability of these data for nursing research. (SK)

  9. Using a computerized patient record to reengineer an outpatient clinic.

    PubMed Central

    Borowitz, S. M.

    1994-01-01

    By employing process flow analysis and work redesign techniques during the design and implementation of a computerized patient record in the pediatric outpatient clinics at the University of Virginia Health Sciences Center, we have developed a database of clinical observations while simultaneously shortening the time that patients spend waiting in the pediatric clinics and decreasing the number of support staff employed within the clinics. PMID:7949936

  10. Evaluation of a Computerized Contraceptive Decision Aid for Adolescent Patients.

    ERIC Educational Resources Information Center

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

    1999-01-01

    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…

  11. Computerized clinical guidelines: current status & principles for future research.

    PubMed

    Kondylakis, Haridimos; Tsiknakis, Manolis

    2012-01-01

    Although it is widely accepted that the adoption of computerized clinical guidelines would improve the quality of the provided health care, their influence in the daily practice is limited. In this paper we provide insights on the core topics related to computer interpretable clinical guidelines and we present shortly the main approaches in the area. Then we discuss the current limitations, and we present three simple principles that according to our view should be adopted to enhance the penetration of computerized clinical guidelines in the health care organizations. The overall goal of this paper is not only to give readers a quick overview of the works in the area, but also to provide necessary insights for the practical understanding of the issues involved and draw directions for future research and development activities. PMID:22874227

  12. The effects of strategic decision making structure and computerization on organizational performance

    SciTech Connect

    Hoffman, J.J.; Carter, N.M.; Cullen, J.B.

    1993-12-31

    This study investigates whether the fit between computerization and strategic decision making predicts organizational performance. Results suggest that increased computerization along with the decentralization of strategic decisions leads to greater performance than increased computer usage and the centralization of strategic decisions. Findings indicate that the effects from a manager`s decision to computerize operations and change the organization`s strategic decision making structure are not immediately felt. These findings support the idea that performance needs to be measured on a long-term basis rather than on a short-term basis. The results also suggest that it may be erroneous to evaluated managers strictly on a short-term basis since the effects from strategic decisions may not be fully felt for one or more years. 64 refs.

  13. Shared clinical decision making

    PubMed Central

    AlHaqwi, Ali I.; AlDrees, Turki M.; AlRumayyan, Ahmad; AlFarhan, Ali I.; Alotaibi, Sultan S.; AlKhashan, Hesham I.; Badri, Motasim

    2015-01-01

    Objectives: To determine preferences of patients regarding their involvement in the clinical decision making process and the related factors in Saudi Arabia. Methods: This cross-sectional study was conducted in a major family practice center in King Abdulaziz Medical City, Riyadh, Saudi Arabia, between March and May 2012. Multivariate multinomial regression models were fitted to identify factors associated with patients preferences. Results: The study included 236 participants. The most preferred decision-making style was shared decision-making (57%), followed by paternalistic (28%), and informed consumerism (14%). The preference for shared clinical decision making was significantly higher among male patients and those with higher level of education, whereas paternalism was significantly higher among older patients and those with chronic health conditions, and consumerism was significantly higher in younger age groups. In multivariate multinomial regression analysis, compared with the shared group, the consumerism group were more likely to be female [adjusted odds ratio (AOR) =2.87, 95% confidence interval [CI] 1.31-6.27, p=0.008] and non-dyslipidemic (AOR=2.90, 95% CI: 1.03-8.09, p=0.04), and the paternalism group were more likely to be older (AOR=1.03, 95% CI: 1.01-1.05, p=0.04), and female (AOR=2.47, 95% CI: 1.32-4.06, p=0.008). Conclusion: Preferences of patients for involvement in the clinical decision-making varied considerably. In our setting, underlying factors that influence these preferences identified in this study should be considered and tailored individually to achieve optimal treatment outcomes. PMID:26620990

  14. [Computerized system validation of clinical researches].

    PubMed

    Yan, Charles; Chen, Feng; Xia, Jia-lai; Zheng, Qing-shan; Liu, Daniel

    2015-11-01

    Validation is a documented process that provides a high degree of assurance. The computer system does exactly and consistently what it is designed to do in a controlled manner throughout the life. The validation process begins with the system proposal/requirements definition, and continues application and maintenance until system retirement and retention of the e-records based on regulatory rules. The objective to do so is to clearly specify that each application of information technology fulfills its purpose. The computer system validation (CSV) is essential in clinical studies according to the GCP standard, meeting product's pre-determined attributes of the specifications, quality, safety and traceability. This paper describes how to perform the validation process and determine relevant stakeholders within an organization in the light of validation SOPs. Although a specific accountability in the implementation of the validation process might be outsourced, the ultimate responsibility of the CSV remains on the shoulder of the business process owner-sponsor. In order to show that the compliance of the system validation has been properly attained, it is essential to set up comprehensive validation procedures and maintain adequate documentations as well as training records. Quality of the system validation should be controlled using both QC and QA means. PMID:26911028

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

    ERIC Educational Resources Information Center

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

    2010-01-01

    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.…

  16. Diabetes Telehealth and Computerized Decision Support Systems: A Sound System with a Human Touch Is Needed

    PubMed Central

    Holmström, Inger

    2010-01-01

    Telehealth holds the promise of improved consistency and fast and equal access to care, and will have great impact on future care. To enhance its quality and safety, computerized decision support systems (CDSS) have been launched. This commentary focuses specifically on the impact of telehealth and CDSS on diabetes patient management. Ideally, clinical information should be linked to evidence based recommendations and guidelines in the CDSS to provide tailored recommendations at the moment of care. However, technical support such as CDSS is not enough. The human touch is essential. A named healthcare provider with access to telehealth and CDSS seems to promise a way of providing both patient-centered and evidence-based care. PMID:20663469

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

    PubMed Central

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

    2011-01-01

    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. Women reported that the decision aid was useful and provided much-needed privacy for making safety decisions. The majority (69%) reported severe to extreme danger in their relationship as scored by Danger Assessment (DA); only 60% reported having made a safety plan. After using the safety decision aid, the women felt more supported in their decision (p = .012) and had less total decisional conflict (p = .014). The study demonstrated that a computerized safety decision aid improved the safety planning process, as demonstrated by reduced decisional conflict after only one use in a sample of abused women. PMID:20040709

  18. [ Preventing adverse drug events using clinical decision support systems].

    PubMed

    Salili, Ali Reza; Hammann, Felix; Taegtmeyer, Anne B

    2015-12-01

    Adverse drug events pose a great risk to patients, are an everyday clinical problem and can have potential/ega/ consequences. Computerized physician order entry or computerized provider order entry (CPOE} in combination with clinical decision support systems {CDSS) are popular and aim to reduce prescribing errors as well as identifying potentially harmful drug drug interactions. The quantifiable benejit these systems bring to patients, has however, yet to be definitively proven. This article focusses on the current standpoint of CPOE-/CDSS, their risks and benefits, the potential for improvement and their perspectives for the future. PMID:26654813

  19. Diagnosis of functional psychoses. Comparison of clinical and computerized classifications.

    PubMed

    Scharfetter, C; Moerbt, H; Wing, J K

    1976-09-17

    The results of a comparison between the clinical diagnoses of 115 probands with functional psychoses, made on the basis of careful clinical history-taking, interviewing and examinations, and those made by computerized evaluation (CATEGO) on the basis of the present state examination (PSE) were presented. The clinical diagnoses of the project psychiatrist and the provisional classification resulting from the application of the CATEGO program to the PSE symptom profiles were in an overall concordance of 82%. In a second step the 20 cases with differences in diagnoses were reevaluated on the basis of the full history and psychopathology and a syndrome checklist was completed. This reevaluation led to a practically full diagnostic agreement. PMID:791196

  20. How clinical decisions are made

    PubMed Central

    Bate, Louise; Hutchinson, Andrew; Underhill, Jonathan; Maskrey, Neal

    2012-01-01

    There is much variation in the implementation of the best available evidence into clinical practice. These gaps between evidence and practice are often a result of multiple individual decisions. When making a decision, there is so much potentially relevant information available, it is impossible to know or process it all (so called ‘bounded rationality’). Usually, a limited amount of information is selected to reach a sufficiently satisfactory decision, a process known as satisficing. There are two key processes used in decision making: System 1 and System 2. System 1 involves fast, intuitive decisions; System 2 is a deliberate analytical approach, used to locate information which is not instantly recalled. Human beings unconsciously use System 1 processing whenever possible because it is quicker and requires less effort than System 2. In clinical practice, gaps between evidence and practice can occur when a clinician develops a pattern of knowledge, which is then relied on for decisions using System 1 processing, without the activation of a System 2 check against the best available evidence from high quality research. The processing of information and decision making may be influenced by a number of cognitive biases, of which the decision maker may be unaware. Interventions to encourage appropriate use of System 1 and System 2 processing have been shown to improve clinical decision making. Increased understanding of decision making processes and common sources of error should help clinical decision makers to minimize avoidable mistakes and increase the proportion of decisions that are better. PMID:22738381

  1. Computerized dental injection fear treatment: a randomized clinical trial.

    PubMed

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

    2013-07-01

    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. PMID:23690352

  2. Developing and testing a computerized decision support system for nurse-to-patient assignment: a multimethod study.

    PubMed

    van Oostveen, Catharina J; Braaksma, Aleida; Vermeulen, Hester

    2014-06-01

    Nurse-to-patient assignment is a frequently recurring, time-consuming, and complex process owing to the many considerations involved. Creating well-balanced, high-quality assignments is crucial to ensuring patient safety, quality of care, and job satisfaction for nurses. A computerized decision support system can assist (charge) nurses in the nurse-to-patient assignment process. In this two-phase multimethod study, a computerized decision support system was developed and evaluated. Three nursing wards in a 1000-bed Dutch university hospital participated. In the first phase of this study, considerations relevant to the assignment process--and their relative importance--were investigated in a literature review, focus group sessions with nurses, and a survey among nurses. Using information from the first phase, the computerized decision support system was developed based on an integer linear program. In the second phase, a before-and-after study was conducted to test and evaluate the computerized decision support system both quantitatively (duration of the assignment process) and qualitatively (survey on workload). Thirty-six measurements were performed to test the computerized decision support system. After implementation, a 30% time reduction was achieved in the nurse-to-patient assignments, and nurses (N = 138) experienced a lower workload. Therefore, the implementation of computerized decision support system would increase both the quality and safety of care as well as the nurses' job satisfaction and should be investigated rigorously in the coming years. PMID:24781813

  3. Computerized Tool to Manage Dental Anxiety: A Randomized Clinical Trial.

    PubMed

    Tellez, M; Potter, C M; Kinner, D G; Jensen, D; Waldron, E; Heimberg, R G; Myers Virtue, S; Zhao, H; Ismail, A I

    2015-09-01

    Anxiety regarding dental and physical health is a common and potentially distressing problem, for both patients and health care providers. Anxiety has been identified as a barrier to regular dental visits and as an important target for enhancement of oral health-related quality of life. The study aimed to develop and evaluate a computerized cognitive-behavioral therapy dental anxiety intervention that could be easily implemented in dental health care settings. A cognitive-behavioral protocol based on psychoeducation, exposure to feared dental procedures, and cognitive restructuring was developed. A randomized controlled trial was conducted (N = 151) to test its efficacy. Consenting adult dental patients who met inclusion criteria (e.g., high dental anxiety) were randomized to 1 of 2 groups: immediate treatment (n = 74) or a wait-list control (n = 77). Analyses of covariance based on intention-to-treat analyses were used to compare the 2 groups on dental anxiety, fear, avoidance, and overall severity of dental phobia. Baseline scores on these outcomes were entered into the analyses as covariates. Groups were equivalent at baseline but differed at 1-mo follow-up. Both groups showed improvement in outcomes, but analyses of covariance demonstrated significant differences in dental anxiety, fear, avoidance, and overall severity of dental phobia in favor of immediate treatment at the follow-up assessment. Of the patients who met diagnostic criteria for phobia at baseline, fewer patients in the immediate treatment group continued to meet criteria for dental phobia at follow-up as compared with the wait-list group. A new computer-based tool seems to be efficacious in reducing dental anxiety and fear/avoidance of dental procedures. Examination of its effectiveness when administered in dental offices under less controlled conditions is warranted (ClinicalTrials.gov NCT02081365). PMID:26202996

  4. Computerized decision support for concurrent utilization review using the HELP system.

    PubMed Central

    Nelson, B D; Gardner, R M; Hedrick, G; Gould, P

    1994-01-01

    OBJECTIVE: Development and evaluation of computerized concurrent utilization review (UR) support taking advantage of a clinically rich computerized patient database. DESIGN: The Automated Support System for Utilization Review (ASSURE) applies the Appropriateness Evaluation Protocol (AEP) Day of Care criteria to computerized patient data in the HELP hospital information system. This paper reports the development, verification, and validation of ASSURE. MEASUREMENTS: Implementation correctness was verified by measuring agreement with a nurse reviewer, using separate sample sets for all 20 criteria for a total of 560 current inpatients. Usefulness in detecting inappropriate days of care was validated by two nurse reviewers who were crossed with manual and computer-assisted review methods in a blocked design for 168 current inpatients. Agreement with reviewers, sensitivity, specificity, positive predictive value, and negative predictive value were measured. RESULTS: Agreement was very good for satisfaction of criteria, and good for appropriateness of day of care. A patient day identified by ASSURE as potentially inappropriate would be twice as likely to be judged inappropriate by a reviewer as a randomly selected patient day. Review of the 10% of patient days identified as potentially inappropriate by ASSURE would identify approximately 21% of the inappropriate days of care. CONCLUSION: ASSURE is a clinically useful tool for screening adult acute care patients for inappropriate days of care, and promises to make a major contribution to reducing health care costs. The prognosis for successful routine clinical use is good. PMID:7719820

  5. What can Natural Language Processing do for Clinical Decision Support?

    PubMed Central

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

    2009-01-01

    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

  6. Initial clinical experience with computerized tomography of the body.

    PubMed

    Stephens, D H; Sheedy, P F; Hattery, R R; Hartman, G W

    1976-04-01

    Computerized tomography of the body, now possible with an instrument that can complete a scan rapidly enough to permit patients to suspend respiration, adds an important new dimension to radiologic diagnosis. Cross-sectional antomy is uniquely reconstructed to provide accurate diagnostic information for various disorders throughout the body. PMID:772746

  7. Redesign of a computerized clinical reminder for colorectal cancer screening: a human-computer interaction evaluation

    PubMed Central

    2011-01-01

    Background Based on barriers to the use of computerized clinical decision support (CDS) learned in an earlier field study, we prototyped design enhancements to the Veterans Health Administration's (VHA's) colorectal cancer (CRC) screening clinical reminder to compare against the VHA's current CRC reminder. Methods In a controlled simulation experiment, 12 primary care providers (PCPs) used prototypes of the current and redesigned CRC screening reminder in a within-subject comparison. Quantitative measurements were based on a usability survey, workload assessment instrument, and workflow integration survey. We also collected qualitative data on both designs. Results Design enhancements to the VHA's existing CRC screening clinical reminder positively impacted aspects of usability and workflow integration but not workload. The qualitative analysis revealed broad support across participants for the design enhancements with specific suggestions for improving the reminder further. Conclusions This study demonstrates the value of a human-computer interaction evaluation in informing the redesign of information tools to foster uptake, integration into workflow, and use in clinical practice. PMID:22126324

  8. Use of web services for computerized medical decision support, including infection control and antibiotic management, in the intensive care unit.

    PubMed

    Steurbaut, Kristof; Van Hoecke, Sofie; Colpaert, Kirsten; Lamont, Kristof; Taveirne, Kristof; Depuydt, Pieter; Benoit, Dominique; Decruyenaere, Johan; De Turck, Filip

    2010-01-01

    The increasing complexity of procedures in the intensive care unit (ICU) requires complex software services, to reduce improper use of antibiotics and inappropriate therapies, and to offer earlier and more accurate detection of infections and antibiotic resistance. We investigated whether web-based software can facilitate the computerization of complex medical processes in the ICU. The COSARA application contains the following modules: Infection overview, Thorax, Microbiology, Antibiotic therapy overview, Admission cause with comorbidity and admission diagnosis, Infection linking and registration, and Feedback. After the implementation and test phase, the COSARA software was installed on a physician's office PC and then on the bedside PCs of the patients. Initial evaluation indicated that the services had been integrated easily into the daily clinical workflow of the medical staff. The use of a service oriented architecture with web service technology for the development of advanced decision support in the ICU offers several advantages over classical software design approaches. PMID:20086264

  9. Computerized documentation in middle ear surgery. Methods and clinical experiences.

    PubMed

    Harris, S

    1981-01-01

    A computerized system for recording results of ear surgery is presented. Specially designed forms are filled in at the time of operation as well as 2 months, 6 months and annually for 1-5 years after operation. The data are processed in a Univac 1100-80 by specific programmes written in FORTRAN. A Follow-up programme gives up-to-date information on hearing and healing after different types of operations. An Annual Production Control programme gives more detailed information about various correlations, such as results in draining ears, frequency of residual cholesteatoma etc. Four years experience with the system and obtainable data is discussed. PMID:6274131

  10. Computerized Neuropsychological Assessment in Aging: Testing Efficacy and Clinical Ecology of Different Interfaces

    PubMed Central

    Della Rosa, Pasquale Anthony; Catricalà, Eleonora; Castiglioni, Isabella

    2014-01-01

    Digital technologies have opened new opportunities for psychological testing, allowing new computerized testing tools to be developed and/or paper and pencil testing tools to be translated to new computerized devices. The question that rises is whether these implementations may introduce some technology-specific effects to be considered in neuropsychological evaluations. Two core aspects have been investigated in this work: the efficacy of tests and the clinical ecology of their administration (the ability to measure real-world test performance), specifically (1) the testing efficacy of a computerized test when response to stimuli is measured using a touch-screen compared to a conventional mouse-control response device; (2) the testing efficacy of a computerized test with respect to different input modalities (visual versus verbal); and (3) the ecology of two computerized assessment modalities (touch-screen and mouse-control), including preference measurements of participants. Our results suggest that (1) touch-screen devices are suitable for administering experimental tasks requiring precise timings for detection, (2) intrinsic nature of neuropsychological tests should always be respected in terms of stimuli presentation when translated to new digitalized environment, and (3) touch-screen devices result in ecological instruments being proposed for the computerized administration of neuropsychological tests with a high level of preference from elderly people. PMID:25147578

  11. Computerized neuropsychological assessment in aging: testing efficacy and clinical ecology of different interfaces.

    PubMed

    Canini, Matteo; Battista, Petronilla; Della Rosa, Pasquale Anthony; Catricalà, Eleonora; Salvatore, Christian; Gilardi, Maria Carla; Castiglioni, Isabella

    2014-01-01

    Digital technologies have opened new opportunities for psychological testing, allowing new computerized testing tools to be developed and/or paper and pencil testing tools to be translated to new computerized devices. The question that rises is whether these implementations may introduce some technology-specific effects to be considered in neuropsychological evaluations. Two core aspects have been investigated in this work: the efficacy of tests and the clinical ecology of their administration (the ability to measure real-world test performance), specifically (1) the testing efficacy of a computerized test when response to stimuli is measured using a touch-screen compared to a conventional mouse-control response device; (2) the testing efficacy of a computerized test with respect to different input modalities (visual versus verbal); and (3) the ecology of two computerized assessment modalities (touch-screen and mouse-control), including preference measurements of participants. Our results suggest that (1) touch-screen devices are suitable for administering experimental tasks requiring precise timings for detection, (2) intrinsic nature of neuropsychological tests should always be respected in terms of stimuli presentation when translated to new digitalized environment, and (3) touch-screen devices result in ecological instruments being proposed for the computerized administration of neuropsychological tests with a high level of preference from elderly people. PMID:25147578

  12. Differentiation of Calcium Oxalate Monohydrate and Calcium Oxalate Dihydrate Stones Using Quantitative Morphological Information from Micro-Computerized and Clinical Computerized Tomography

    PubMed Central

    Duan, Xinhui; Qu, Mingliang; Wang, Jia; Trevathan, James; Vrtiska, Terri; Williams, James C.; Krambeck, Amy; Lieske, John; McCollough, Cynthia

    2014-01-01

    Purpose We differentiated calcium oxalate monohydrate and calcium oxalate dihydrate kidney stones using micro and clinical computerized tomography images. Materials and Methods A total of 22 calcium oxalate monohydrate and 15 calcium oxalate dihydrate human kidney stones were scanned using a commercial micro-computerized tomography scanner with a pixel size of 7 to 23 μm. Under an institutional review board approved protocol, image data on 10 calcium oxalate monohydrate and 9 calcium oxalate dihydrate stones greater than 5 mm were retrieved from a total of 80 patients who underwent clinical dual energy computerized tomography for clinical indications and had stones available for infrared spectroscopic compositional analysis. Micro and clinical computerized tomography images were processed using in-house software, which quantified stone surface morphology with curvature based calculations. A shape index was generated as a quantitative shape metric to differentiate calcium oxalate monohydrate from calcium oxalate dihydrate stones. Statistical tests were used to test the performance of the shape index. Results On micro-computerized tomography images the shape index of calcium oxalate monohydrate and calcium oxalate dihydrate stones significantly differed (ROC curve AUC 0.92, p <0.0001). At the optimal cutoff sensitivity was 0.93 and specificity was 0.91. On clinical computerized tomography images a significant morphological difference was also detected (p = 0.007). AUC, sensitivity and specificity were 0.90, 1 and 0.73, respectively. Conclusions On micro and clinical computerized tomography images a morphological difference was detectable in calcium oxalate monohydrate and calcium oxalate dihydrate stones larger than 5 mm. The shape index is a highly promising method that can distinguish calcium oxalate monohydrate and calcium oxalate dihydrate stones with reasonable accuracy. PMID:23142201

  13. Design model of computerized personal decision aid for youth: An expert review

    NASA Astrophysics Data System (ADS)

    Sarif, Siti Mahfuzah; Ibrahim, Norfiza; Shiratuddin, Norshuhada

    2016-08-01

    This paper provides a structured review of a design model of a computerized personal decision aid that is intended for youth, named as YouthPDA Design Model. The proposed design model was examined by experts in related areas to ensure the appropriateness of the proposed components and elements, relevancy of the terminologies used, logic of the flow, usability, and practicality of the design model towards development of YouthPDA application. Seven experts from related areas were involved in the evaluation. Discussions on the findings obtained from the expert review are included in this paper. Finally, a revised design model of YouthPDA is proposed as main guidance to develop YouthPDA application.

  14. Computerized provider order entry in the clinical laboratory

    PubMed Central

    Baron, Jason M.; Dighe, Anand S.

    2011-01-01

    Clinicians have traditionally ordered laboratory tests using paper-based orders and requisitions. However, paper orders are becoming increasingly incompatible with the complexities, challenges, and resource constraints of our modern healthcare systems and are being replaced by electronic order entry systems. Electronic systems that allow direct provider input of diagnostic testing or medication orders into a computer system are known as Computerized Provider Order Entry (CPOE) systems. Adoption of laboratory CPOE systems may offer institutions many benefits, including reduced test turnaround time, improved test utilization, and better adherence to practice guidelines. In this review, we outline the functionality of various CPOE implementations, review the reported benefits, and discuss strategies for using CPOE to improve the test ordering process. Further, we discuss barriers to the implementation of CPOE systems that have prevented their more widespread adoption. PMID:21886891

  15. Methodology to Establish Associations between Data and Clinical Assessment for Computerized Nursing Process in Intensive Care Units.

    PubMed

    Couto Carvalho Barra, Daniela; Marcon Dal Sasso, Grace Teresinha; Paese, Fernanda

    2015-01-01

    Combining the Information and Communication Technologies (ICT) in the Nursing Process (NP) is a way to support their development in health contexts. The alliance between ICT and the NP integrates and organizes a logical structure of data and clinical information supporting nurses in decision-making. This manuscript describes the methodology used to articulate data and information cynical of Computerized Nursing Process (CNP), according to ICNP® 2.0, associating detailed clinical assessment of each human system to their diagnoses, interventions, and patient outcomes. This is a methodological study and technological production conducted in 2010, and is developed in three stages. It was possible to restructure the CNP from the associations between the data and clinical information of all human systems (cardiovascular, neurological, respiratory, renal, gastrointestinal, cutaneous, musculoskeletal, female/male and biopsychosocial) to their diagnoses, interventions, and results of Nursing. PMID:26262243

  16. Economic aspects of clinical decision making: applications of clinical decision analysis.

    PubMed

    Crane, V S

    1988-03-01

    Clinical decision analysis as a basic tool for decision making is described, and potential applications of decision analysis in six areas of clinical practice are identified. Clinical decision analysis is a systematic method of describing clinical problems in a quantitative fashion, identifying possible courses of action, assessing the probability and value of outcomes, and then making a calculation to select the ultimate course of action. Clinical decision analysis provides a structure for clinical decision problems, helps clarify medical controversies, and encourages decision makers to speak a common language. Applications of clinical decision analysis in the areas of diagnostic testing, patient management, product and program selection, research and education, patient preferences, and health-care-policy evaluation are described. Decision analysis offers health professionals a tool for making quantifiable, cost-effective clinical decisions, especially in terms of clinical outcomes. PMID:3285672

  17. Towards computerizing intensive care sedation guidelines: design of a rule-based architecture for automated execution of clinical guidelines

    PubMed Central

    2010-01-01

    Background Computerized ICUs rely on software services to convey the medical condition of their patients as well as assisting the staff in taking treatment decisions. Such services are useful for following clinical guidelines quickly and accurately. However, the development of services is often time-consuming and error-prone. Consequently, many care-related activities are still conducted based on manually constructed guidelines. These are often ambiguous, which leads to unnecessary variations in treatments and costs. The goal of this paper is to present a semi-automatic verification and translation framework capable of turning manually constructed diagrams into ready-to-use programs. This framework combines the strengths of the manual and service-oriented approaches while decreasing their disadvantages. The aim is to close the gap in communication between the IT and the medical domain. This leads to a less time-consuming and error-prone development phase and a shorter clinical evaluation phase. Methods A framework is proposed that semi-automatically translates a clinical guideline, expressed as an XML-based flow chart, into a Drools Rule Flow by employing semantic technologies such as ontologies and SWRL. An overview of the architecture is given and all the technology choices are thoroughly motivated. Finally, it is shown how this framework can be integrated into a service-oriented architecture (SOA). Results The applicability of the Drools Rule language to express clinical guidelines is evaluated by translating an example guideline, namely the sedation protocol used for the anaesthetization of patients, to a Drools Rule Flow and executing and deploying this Rule-based application as a part of a SOA. The results show that the performance of Drools is comparable to other technologies such as Web Services and increases with the number of decision nodes present in the Rule Flow. Most delays are introduced by loading the Rule Flows. Conclusions The framework is an

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

    PubMed Central

    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

    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

  19. Clinical and Management Requirements for Computerized Mental Health Information Systems

    PubMed Central

    Levinton, Paula H.; Dunning, Tessa F.E.

    1980-01-01

    Information requirements of mental health providers are sufficiently different from those of other health care managers to warrant a different approach to the development of management information systems (MIS). Advances in computer technology and increased demands for fiscal accountability have led to developing integrated mental health information systems (MHIS) that support clinical and management requirements. In a study made to define a set of generic information requirements of mental health providers that can be supported by an MHIS, it was found that basic data needs can be defined and classified in functional terms: clinical, management, and consultation/education requirements. A basic set of data to support these needs was defined: demographic, financial, clinical, programmatic, and service delivery data.

  20. Legal Considerations in Clinical Decision Making.

    ERIC Educational Resources Information Center

    Ursu, Samuel C.

    1992-01-01

    Discussion of legal issues in dental clinical decision making looks at the nature and elements of applicable law, especially malpractice, locus of responsibility, and standards of care. Greater use of formal decision analysis in clinical dentistry and better research on diagnosis and treatment are recommended, particularly in light of increasing…

  1. ClinicalAccess: a clinical decision support tool.

    PubMed

    Crowell, Karen; Vardell, Emily

    2015-01-01

    ClinicalAccess is a new clinical decision support tool that uses a question-and-answer format to mirror clinical decision-making strategies. The unique format of ClinicalAccess delivers concise, authoritative answers to more than 120,000 clinical questions. This column presents a review of the product, a sample search, and a comparison with other point-of-care search engines. PMID:25927513

  2. Computerized recording of visits to an outpatient sports clinic.

    PubMed

    Kannus, P; Aho, H; Järvinen, M; Niittymäki, S

    1987-01-01

    At the Tampere Research Station of Sports Medicine (TRSSM) a continuous coding system of patient visits was started on March 1, 1985. The registration form contained 25 variables including all essential information about the patient's identification, sports, time of and reason for the visit, physician, examinations, diagnosis, treatment, and possible further measures. To classify and number the diagnosis, a specific classification of sports injuries and diseases was drawn up. The data were stored and analyzed using a DEC-2060 computer at the University of Tampere. During 6 months a total of 814 visits were recorded. The three most common sports were soccer, long-distance running, and orienteering. Competitive athletes totalled 337 (62%); 43 of these were top-ranking athletes. The most common reasons for visits were problems of the knee (266 visits, 33%), ankle (80, 10%), and low back (71, 9%). Knee sprains accounted for 10% of all visits. Problems related to the musculoskeletal system were the reason for 751 (92%) of all visits. Operative treatment was needed by 49 patients (6%). The continuous coding system of patient visits at an outpatient sports clinic showed great advantages as a basic data bank for scientific research, annual statistics, and patient identification and filing. The system described has been adopted as part of the daily routine at the TRSSM. PMID:3812865

  3. Details of a Successful Clinical Decision Support System

    PubMed Central

    Friedlin, Jeff; Dexter, Paul R.; Overhage, J. Marc

    2007-01-01

    Computerized physician order entry (CPOE) with clinical decision support (CDS) is regarded as one of the most effective ways to improve the quality of health care and increase patient safety. As electronic medical records become more available, such systems will increasingly become the method of choice to achieve these goals. Creating a CPOE/CDS system is a complex task, and some fail despite time consuming and expensive development. The CPOE system at the Regenstrief Institute incorporates sophisticated CDS and is one of the oldest and most successful in the U.S. Many years in development, it is currently used by hundreds of providers. Our well established, successful system can serve as a template or model for the future development of similar systems. We recently completed a full analysis of our CPOE/CDS system and present details of its structure, functionality and contents. PMID:18693837

  4. Clinical Decision Support for Early Recognition of Sepsis

    PubMed Central

    Amland, Robert C.; Hahn-Cover, Kristin E.

    2014-01-01

    Sepsis is an inflammatory response triggered by infection, with a high in-hospital mortality rate. Early recognition and treatment can reverse the inflammatory response, with evidence of improved patient outcomes. One challenge clinicians face is identifying the inflammatory syndrome against the background of the patient’s infectious illness and comorbidities. An approach to this problem is implementation of computerized early warning tools for sepsis. This multicenter retrospective study sought to determine clinimetric performance of a cloud-based computerized sepsis clinical decision support system (CDS), understand the epidemiology of sepsis, and identify opportunities for quality improvement. Data encompassed 6200 adult hospitalizations from 2012 through 2013. Of 13% patients screened-in, 51% were already suspected to have an infection when the system activated. This study focused on a patient cohort screened-in before infection was suspected; median time from arrival to CDS activation was 3.5 hours, and system activation to diagnostic collect was another 8.6 hours. PMID:25385815

  5. Clinical Decision Making of Rural Novice Nurses

    ERIC Educational Resources Information Center

    Seright, Teresa J.

    2010-01-01

    The purpose of this study was to develop substantive theory regarding decision making by the novice nurse in a rural hospital setting. Interviews were guided by the following research questions: What cues were used by novice rural registered nurses in order to make clinical decisions? What were the sources of feedback which influenced subsequent…

  6. Computerized v. In-person Brief Intervention for Drug Misuse: A Randomized Clinical Trial

    PubMed Central

    Schwartz, Robert P.; Gryczynski, Jan; Mitchell, Shannon Gwin; Gonzales, Arturo; Moseley, Ana; Peterson, Thomas R.; Ondersma, Steven J.; O’Grady, Kevin E.

    2014-01-01

    Background and aims Several studies have found that brief interventions (BIs) for drug misuse have superior effectiveness to no-treatment controls. However, many health centers do not provide BIs for drug use consistently due to insufficient behavioral health staff capacity. Computerized BIs for drug use are a promising approach, but their effectiveness compared with in-person BIs has not been established. This study compared the effectiveness of a computerized brief intervention (CBI) to an in-person brief intervention (IBI) delivered by a behavioral health counselor. Methods Two-arm randomized clinical trial, conducted in two health centers in New Mexico, USA. Participants were 360 adult primary care patients with moderate-risk drug scores on the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) who were randomly assigned on a 1:1 basis to a computerized brief intervention (CBI) or to an in-person brief intervention (IBI) delivered by a behavioral health counselor. Assessments were conducted at baseline and 3-month follow-up, and included the ASSIST and drug testing on hair samples. Results The IBI and CBI conditions did not differ at 3 months on global ASSIST drug scores (b=−1.79; 95% CI=−4.37,0.80) or drug-positive hair tests (OR=.97; 95% CI= 0.47,2.02). There was a statistically significant advantage of CBI over IBI in substance-specific ASSIST scores for marijuana (b=−1.73; 95% CI= −2.91,−0.55; Cohen’s d=.26; p=.004) and cocaine (b= −4.48; 95% CI= −8.26,−0.71; Cohen’s d=.50; p=.021) at 3 months. Conclusions Computerized brief intervention can be an effective alternative to in-person brief intervention for addressing moderate drug use in primary care. PMID:24520906

  7. Development of the Computerized Model of Performance-Based Measurement System to Measure Nurses' Clinical Competence.

    PubMed

    Liou, Shwu-Ru; Liu, Hsiu-Chen; Tsai, Shu-Ling; Cheng, Ching-Yu; Yu, Wei-Chieh; Chu, Tsui-Ping

    2016-04-01

    Critical thinking skills and clinical competence are for providing quality patient care. The purpose of this study is to develop the Computerized Model of Performance-Based Measurement system based on the Clinical Reasoning Model. The system can evaluate and identify learning needs for clinical competency and be used as a learning tool to increase clinical competency by using computers. The system includes 10 high-risk, high-volume clinical case scenarios coupled with questions testing clinical reasoning, interpersonal, and technical skills. Questions were sequenced to reflect patients' changing condition and arranged by following the process of collecting and managing information, diagnosing and differentiating urgency of problems, and solving problems. The content validity and known-groups validity was established. The Kuder-Richardson Formula 20 was 0.90 and test-retest reliability was supported (r = 0.78). Nursing educators can use the system to understand students' needs for achieving clinical competence, and therefore, educational plans can be made to better prepare students and facilitate their smooth transition to a future clinical environment. Clinical nurses can use the system to evaluate their performance-based abilities and weakness in clinical reasoning. Appropriate training programs can be designed and implemented to practically promote nurses' clinical competence and quality of patient care. PMID:26829522

  8. Grand challenges in clinical decision support.

    PubMed

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

    2008-04-01

    There is a pressing need for high-quality, effective means of designing, developing, presenting, implementing, evaluating, and maintaining 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, funders, and policy-makers. The list of challenges in order of importance that they be solved if patients and organizations are to begin realizing the fullest benefits possible of these systems consists of: improve the human-computer interface; disseminate best practices in CDS design, development, and implementation; summarize patient-level information; prioritize and filter recommendations to the user; create an architecture for sharing executable CDS modules and services; combine recommendations for patients with co-morbidities; prioritize CDS content development and implementation; create internet-accessible clinical decision support repositories; use freetext information to drive clinical decision support; mine large clinical databases to create new CDS. Identification of solutions to these challenges is critical if clinical decision support is to achieve its potential and improve the quality, safety and efficiency of healthcare. PMID:18029232

  9. Randomized Trial of a Computerized Touch Screen Decision Aid to Increase Acceptance of Colonoscopy Screening in an African American Population with Limited Literacy.

    PubMed

    Ruzek, Sheryl B; Bass, Sarah Bauerle; Greener, Judith; Wolak, Caitlin; Gordon, Thomas F

    2016-10-01

    The goal of this study was to assess the effectiveness of a touch screen decision aid to increase acceptance of colonoscopy screening among African American patients with low literacy, developed and tailored using perceptual mapping methods grounded in Illness Self-Regulation and Information-Communication Theories. The pilot randomized controlled trial investigated the effects of a theory-based intervention on patients' acceptance of screening, including their perceptions of educational value, feelings about colonoscopy, likelihood to undergo screening, and decisional conflict about colonoscopy screening. Sixty-one African American patients with low literacy, aged 50-70 years, with no history of colonoscopy, were randomly assigned to receive a computerized touch screen decision aid (CDA; n = 33) or a literacy appropriate print tool (PT; n = 28) immediately before a primary care appointment in an urban, university-affiliated general internal medicine clinic. Patients rated the CDA significantly higher than the PT on all indicators of acceptance, including the helpfulness of the information for making a screening decision, and reported positive feelings about colonoscopy, greater likelihood to be screened, and lower decisional conflict. Results showed that a touch screen decision tool is acceptable to African American patients with low iteracy and, by increasing intent to screen, may increase rates of colonoscopy screening. PMID:26940369

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

    PubMed Central

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

    1980-01-01

    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.

  11. Predicting the learning and consultation time in a computerized primary healthcare clinic.

    PubMed

    Blignaut, P J; McDonald, T; Tolmie, C J

    2001-01-01

    Managers would like to know how long it takes healthcare service providers to achieve the same throughput of patients per day that they were used to with a pen-and-paper system. This study has been undertaken to derive a model for predicting the time it takes a service provider from a previously disadvantaged community to enter a patient's record in terms of his or her experience and the number of data units that have to be captured. A model was also derived to predict the average consultation time in terms of the number of data units that are captured by an experienced service provider. It can be inferred that healthcare service providers should be allowed at least 6 months of computerized system experience before any decisions about the success of the technology introduction can be made. PMID:11391885

  12. Computerized Management of Patient Care in a Complex, Controlled Clinical Trial in the Intensive Care Unit

    PubMed Central

    Sittig, Dean F.

    1987-01-01

    Acute Respiratory Distress Syndrome (ARDS) is often not responsive to conventional supportive therapy and the mortality rate may exceed 90%. A new form of supportive care, Extracorporeal Carbon Dioxide Removal (ECCO2R), has shown a dramatic increase in survival (48%). A controlled clinical trial of the new ECCO2R therapy versus conventional Continuous Positive Pressure Ventilation (CPPV) is being initiated. Detailed care protocols have been developed by “expert” critical care physicians for the management of patients. Using a blackboard control architecture, the protocols have been implemented on an existing hospital information system and will direct patient care and help manage the controlled clinical trial. Therapeutic instructions are automatically generated by the computer from data input by physicians, nurses, respiratory therapists, and the laboratory. Preliminary results show that the computerized protocol system can direct therapy for acutely ill patients.

  13. Helping novice nurses make effective clinical decisions: the situated clinical decision-making framework.

    PubMed

    Gillespie, Mary; Peterson, Barbara L

    2009-01-01

    The nature of novice nurses' clinical decision-making has been well documented as linear, based on limited knowledge and experience in the profession, and frequently focused on single tasks or problems. Theorists suggest that, with sufficient experience in the clinical setting, novice nurses will move from reliance on abstract principles to the application of concrete experience and to view a clinical situation within its context and as a whole. In the current health care environment, novice nurses frequently work with few clinical supports and mentors while facing complex patient situations that demand skilled decision-making. The Situated Clinical Decision-Making Framework is presented for use by educators and novice nurses to support development of clinical decision-making. It provides novice nurses with a tool that a) assists them in making decisions; b) can be used to guide retrospective reflection on decision-making processes and outcomes; c) socializes them to an understanding of the nature of decision-making in nursing; and d) fosters the development of their knowledge, skill, and confidence as nurses. This article provides an overview of the framework, including its theoretical foundations and a schematic representation of its components. A case exemplar illustrates one application of the framework in assisting novice nurses in developing their decision-making skills. Future directions regarding the use and study of this framework in nursing education are considered. PMID:19606659

  14. Entrustment Decision Making in Clinical Training.

    PubMed

    Ten Cate, Olle; Hart, Danielle; Ankel, Felix; Busari, Jamiu; Englander, Robert; Glasgow, Nicholas; Holmboe, Eric; Iobst, William; Lovell, Elise; Snell, Linda S; Touchie, Claire; Van Melle, Elaine; Wycliffe-Jones, Keith

    2016-02-01

    The decision to trust a medical trainee with the critical responsibility to care for a patient is fundamental to clinical training. When carefully and deliberately made, such decisions can serve as significant stimuli for learning and also shape the assessment of trainees. Holding back entrustment decisions too much may hamper the trainee's development toward unsupervised practice. When carelessly made, however, they jeopardize patient safety. Entrustment decision-making processes, therefore, deserve careful analysis.Members (including the authors) of the International Competency-Based Medical Education Collaborative conducted a content analysis of the entrustment decision-making process in health care training during a two-day summit in September 2013 and subsequently reviewed the pertinent literature to arrive at a description of the critical features of this process, which informs this article.The authors discuss theoretical backgrounds and terminology of trust and entrustment in the clinical workplace. The competency-based movement and the introduction of entrustable professional activities force educators to rethink the grounds for assessment in the workplace. Anticipating a decision to grant autonomy at a designated level of supervision appears to align better with health care practice than do most current assessment practices. The authors distinguish different modes of trust and entrustment decisions and elaborate five categories, each with related factors, that determine when decisions to trust trainees are made: the trainee, supervisor, situation, task, and the relationship between trainee and supervisor. The authors' aim in this article is to lay a theoretical foundation for a new approach to workplace training and assessment. PMID:26630606

  15. Modelling and Decision Support of Clinical Pathways

    NASA Astrophysics Data System (ADS)

    Gabriel, Roland; Lux, Thomas

    The German health care market is under a rapid rate of change, forcing especially hospitals to provide high-quality services at low costs. Appropriate measures for more effective and efficient service provision are process orientation and decision support by information technology of clinical pathway of a patient. The essential requirements are adequate modelling of clinical pathways as well as usage of adequate systems, which are capable of assisting the complete path of a patient within a hospital, and preferably also outside of it, in a digital way. To fulfil these specifications the authors present a suitable concept, which meets the challenges of well-structured clinical pathways as well as rather poorly structured diagnostic and therapeutic decisions, by interplay of process-oriented and knowledge-based hospital information systems.

  16. Clinical Decision Support Systems for Ambulatory Care

    PubMed Central

    Lloyd, Stephen C.

    1984-01-01

    This conference serves to further the state of the art in the application of computers to medical care via a forum for the intercommunication of ideas. Papers discuss the experiences of diverse research projects. It is the purpose of this article to review the major developments in ambulatory care decision support. From this vantage point, the major impediments to broad applicability of information systems are discussed. The DUCHESS Medical Information Management System is then described as a step towards overcoming these obstacles. Two distinct but often overlapping issues are the representation of the data and its subsequent manipulation: records vs. knowledge. The complexity of the medical record requires state-of-the-art computer science. Clinical decision support requires flexible means for representing medical knowledge and the ability to input “rules.” Artificial intelligence has provided tools for simulating the decision making processes. A sample of the major systems are contrasted and compared. In the realm of medical records COSTAR, TMR, SCAMP, HELP, and STOR are considered. In clinical decision support CADEUCUS, REGENSTRIEF, PKC, and DUCHESS are reviewed.

  17. Nurses' Clinical Decision Making on Adopting a Wound Clinical Decision Support System.

    PubMed

    Khong, Peck Chui Betty; Hoi, Shu Yin; Holroyd, Eleanor; Wang, Wenru

    2015-07-01

    Healthcare information technology systems are considered the ideal tool to inculcate evidence-based nursing practices. The wound clinical decision support system was built locally to support nurses to manage pressure ulcer wounds in their daily practice. However, its adoption rate is not optimal. The study's objective was to discover the concepts that informed the RNs' decisions to adopt the wound clinical decision support system as an evidence-based technology in their nursing practice. This was an exploratory, descriptive, and qualitative design using face-to-face interviews, individual interviews, and active participatory observation. A purposive, theoretical sample of 14 RNs was recruited from one of the largest public tertiary hospitals in Singapore after obtaining ethics approval. After consenting, the nurses were interviewed and observed separately. Recruitment stopped when data saturation was reached. All transcribed interview data underwent a concurrent thematic analysis, whereas observational data were content analyzed independently and subsequently triangulated with the interview data. Eight emerging themes were identified, namely, use of the wound clinical decision support system, beliefs in the wound clinical decision support system, influences of the workplace culture, extent of the benefits, professional control over nursing practices, use of knowledge, gut feelings, and emotions (fear, doubt, and frustration). These themes represented the nurses' mental outlook as they made decisions on adopting the wound clinical decision support system in light of the complexities of their roles and workloads. This research has provided insight on the nurses' thoughts regarding their decision to interact with the computer environment in a Singapore context. It captured the nurses' complex thoughts when deciding whether to adopt or reject information technology as they practice in a clinical setting. PMID:26066306

  18. Implementation Issues and Challenges for Computerized Clinical Protocols for Management of Mechanical Ventilation in ARDS Patients

    PubMed Central

    East, Thomas D.; Henderson, Susan; Morris, Alan H.; Gardner, Reed M.

    1989-01-01

    In the process of implementing complex computerized protocols for the management of ventilation in ARDS patients several unique problems were encountered in the areas of temporal dependency, testing, decision making architecture, data integrity, user interaction and order generation. The protocols are different from many of the applications previously developed in that they depend not only on the current status of the patient but the temporal sequence of events that led up to the present time. This necessitated timely charting which was not a small requirement in the demanding ICU environment. New testing tools had to be developed to simulate a temporal sequence of events so that all branches of the protocols could be thoroughly tested. The blackboard control architecture originally implemented had to be abandoned for the sake of data integrity. The inability to have interactive communication, during execution of the protocols required a thorough re-evaluation of the data which was routinely charted. The mechanism for triggering execution of the protocols had to be redesigned to provide shorter response time for the ICU environment. This new version of the protocols has been used in 16 patients for a total of 3553 therapy suggestions. It is now being generally accepted in the ICU and routinely used to treat a wide variety of respiratory failure patients.

  19. FDDI information management system for centralizing interactive, computerized multimedia clinical experiences in pediatric rheumatology/Immunology.

    PubMed

    Rouhani, R; Cronenberger, H; Stein, L; Hannum, W; Reed, A M; Wilhelm, C; Hsiao, H

    1995-01-01

    This paper describes the design, authoring, and development of interactive, computerized, multimedia clinical simulations in pediatric rheumatology/immunology and related musculoskeletal diseases, the development and implementation of a high speed information management system for their centralized storage and distribution, and analytical methods for evaluating the total system's educational impact on medical students and pediatric residents. An FDDI fiber optic network with client/server/host architecture is the core. The server houses digitized audio, still-image video clips and text files. A host station houses the DB2/2 database containing case-associated labels and information. Cases can be accessed from any workstation via a customized interface in AVA/2 written specifically for this application. OS/2 Presentation Manager controls, written in C, are incorporated into the interface. This interface allows SQL searches and retrievals of cases and case materials. In addition to providing user-directed clinical experiences, this centralized information management system provides designated faculty with the ability to add audio notes and visual pointers to image files. Users may browse through case materials, mark selected ones and download them for utilization in lectures or for editing and converting into 35mm slides. PMID:8591407

  20. Implementing computerized adaptive tests in routine clinical practice: experience implementing CATs.

    PubMed

    Hart, Dennis L; Deutscher, Daniel; Werneke, Mark W; Holder, Judy; Wang, Ying-Chih

    2010-01-01

    This paper traces the development, testing and use of CATs in outpatient rehabilitation from the perspective of one proprietary international medical rehabilitation database management company, Focus On Therapeutic Outcomes, Inc. (FOTO). Between the FOTO data in the United States and Maccabi Healthcare Services data in Israel, over 1.5 million CATs have been administered. Using findings from published studies and results of internal public relations surveys, we discuss (1) reasons for CAT development, (2) how the CATs were received by clinicians and patients in the United States and Israel, (3) results of psychometric property assessments of CAT estimated measures of functional status in routine clinical practice, (4) clinical interpretation of CAT functional status measures, and (5) future development directions. Results of scientific studies and business history provide confidence that CATs are pertinent and valuable to clinicians, patients and payers, and suggest CATs will be prominent in the development of future integrated computerized electronic medical record systems with electronic outcomes data collection. PMID:20847476

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

    PubMed Central

    Phillips, Christine; Hall, Sally; Travaglia, Joanne

    2013-01-01

    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

  2. [Clinical decisions in a philosophical perspective].

    PubMed

    Wulff, H R

    1993-09-20

    Medicine is both a scientific and a humanistic discipline. The foundation for clinical decisions has four components (two scientific and two humanistic). 1) The biological component (reasoning based on biological theory). Biological thinking is currently being revolutionised, partly through the development of systems theory. 2) The empirical component (reasoning based on experience from earlier patients), which comprises both uncontrolled and controlled experience. 3) The empathic-hermeneutic component (reasoning based on an understanding of the patient as a fellow human being). Empathy requires hermeneutic knowledge which can be acquired through personal experience and by qualitative research. 4) The ethical component which comprises both utilitarian and deontological considerations. PMID:8211903

  3. Computerizing the Budget Office: An On-Line Decision Support System.

    ERIC Educational Resources Information Center

    Rosenberg, Glenn R.; Peterson, William R.

    The implementation process and resource requirements of the University of Connecticut Budget Office's online decision support system are described. Successes and failures of shifting to a fully interactive budget review and development process are also reviewed. Special attention is given to the personnel problems and analytical challenges…

  4. Driving and dementia: a clinical decision pathway

    PubMed Central

    Carter, Kirsty; Monaghan, Sophie; O'Brien, John; Teodorczuk, Andrew; Mosimann, Urs; Taylor, John-Paul

    2015-01-01

    Objective This study aimed to develop a pathway to bring together current UK legislation, good clinical practice and appropriate management strategies that could be applied across a range of healthcare settings. Methods The pathway was constructed by a multidisciplinary clinical team based in a busy Memory Assessment Service. A process of successive iteration was used to develop the pathway, with input and refinement provided via survey and small group meetings with individuals from a wide range of regional clinical networks and diverse clinical backgrounds as well as discussion with mobility centres and Forum of Mobility Centres, UK. Results We present a succinct clinical pathway for patients with dementia, which provides a decision-making framework for how health professionals across a range of disciplines deal with patients with dementia who drive. Conclusions By integrating the latest guidance from diverse roles within older people's health services and key experts in the field, the resulting pathway reflects up-to-date policy and encompasses differing perspectives and good practice. It is potentially a generalisable pathway that can be easily adaptable for use internationally, by replacing UK legislation for local regulations. A limitation of this pathway is that it does not address the concern of mild cognitive impairment and how this condition relates to driving safety. © 2014 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons, Ltd. PMID:24865643

  5. A Computerized Decision Support System Improves the Accuracy of Temperature Capture from Nursing Personnel at the Bedside

    PubMed Central

    Kroth, Philip J.; Dexter, Paul R.; Overhage, J. Marc; Knipe, Cynthia; Hui, Siu L.; Belsito, Anne; McDonald, Clement J.

    2006-01-01

    Objective To assess the effect of a computerized decision support system (CDSS) on the accuracy of patient temperature recording at the bed side. Design This is a randomized, controlled trial comparing nurses assigned to an intervention group that received CDSS whenever they attempted to store a low temperature (≤ 96.4°F) or a control group that received no CDSS. Measurements The computer recorded temperatures that would trigger reminders equally in both control and intervention groups. It also logged the reactions of nurses who received reminders and whether they retook the patient’s temperature or chose to store the original low value. Results We analyzed the temperature data over a 10-month period tracking a total of 44339 temperatures taken by the control group and 45823 temperatures taken by the intervention group. We showed a 51% relative reduction in the number of erroneous low temperatures stored by the intervention versus the control group. Conclusion CDSS are effective with nursing personnel in improving the accuracy of temperature capture at the bedside. PMID:17238380

  6. Cost-effectiveness of a shared computerized decision support system for diabetes linked to electronic medical records

    PubMed Central

    Holbrook, Anne; Blackhouse, Gordon; Troyan, Sue; Goeree, Ron

    2011-01-01

    Background Computerized decision support systems (CDSSs) are believed to enhance patient care and reduce healthcare costs; however the current evidence is limited and the cost-effectiveness remains unknown. Objective To estimate the long-term cost-effectiveness of a CDSS linked to evidence-based treatment recommendations for type 2 diabetes. Methods Using the Ontario Diabetes Economic Model, changes in factors (eg, HbA1c) from a randomized controlled trial were used to estimate cost-effectiveness. The cost of implementation, development, and maintenance of the core dataset, and projected diabetes-related complications were included. The base case assumed a 1-year treatment effect, 5% discount rate, and 40-year time horizon. Univariate, one-way sensitivity analyses were carried out by altering different parameter values. The perspective was the Ontario Ministry of Health and costs were in 2010 Canadian dollars. Results The cost of implementing the intervention was $483 699. The one-year intervention reduced HbA1c by 0.2 and systolic blood pressure by 3.95 mm Hg, but increased body mass index by 0.02 kg/m2, resulting in a relative risk reduction of 14% in the occurrence of amputation. The model estimated that the intervention resulted in an additional 0.0117 quality-adjusted life year; the incremental cost-effectiveness ratio was $160 845 per quality-adjusted life-year. Conclusion The web-based prototype decision support system slightly improved short-term risk factors. The model predicted moderate improvements in long-term health outcomes. This disease management program will need to develop considerable efficiencies in terms of costs and processes or improved effectiveness to be considered a cost-effective intervention for treating patients with type 2 diabetes. PMID:22052900

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

    NASA Astrophysics Data System (ADS)

    Huo, Zhimin; Giger, Maryellen L.

    2000-06-01

    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.

  8. Computerized Neuropsychological Assessment Devices: Joint Position Paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology†

    PubMed Central

    Bauer, Russell M.; Iverson, Grant L.; Cernich, Alison N.; Binder, Laurence M.; Ruff, Ronald M.; Naugle, Richard I.

    2013-01-01

    This joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology sets forth our position on appropriate standards and conventions for computerized neuropsychological assessment devices (CNADs). In this paper, we first define CNADs and distinguish them from examiner-administered neuropsychological instruments. We then set forth position statements on eight key issues relevant to the development and use of CNADs in the healthcare setting. These statements address (a) device marketing and performance claims made by developers of CNADs; (b) issues involved in appropriate end-users for administration and interpretation of CNADs; (c) technical (hardware/software/firmware) issues; (d) privacy, data security, identity verification, and testing environment; (e) psychometric development issues, especially reliability and validity; (f) cultural, experiential, and disability factors affecting examinee interaction with CNADs; (g) use of computerized testing and reporting services; and (h) the need for checks on response validity and effort in the CNAD environment. This paper is intended to provide guidance for test developers and users of CNADs that will promote accurate and appropriate use of computerized tests in a way that maximizes clinical utility and minimizes risks of misuse. The positions taken in this paper are put forth with an eye toward balancing the need to make validated CNADs accessible to otherwise underserved patients with the need to ensure that such tests are developed and utilized competently, appropriately, and with due concern for patient welfare and quality of care. PMID:22394228

  9. Computerized Neuropsychological Assessment Devices: Joint Position Paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology†

    PubMed Central

    Bauer, Russell M.; Iverson, Grant L.; Cernich, Alison N.; Binder, Laurence M.; Ruff, Ronald M.; Naugle, Richard I.

    2012-01-01

    This joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology sets forth our position on appropriate standards and conventions for computerized neuropsychological assessment devices (CNADs). In this paper, we first define CNADs and distinguish them from examiner-administered neuropsychological instruments. We then set forth position statements on eight key issues relevant to the development and use of CNADs in the healthcare setting. These statements address (a) device marketing and performance claims made by developers of CNADs; (b) issues involved in appropriate end-users for administration and interpretation of CNADs; (c) technical (hardware/software/firmware) issues; (d) privacy, data security, identity verification, and testing environment; (e) psychometric development issues, especially reliability, and validity; (f) cultural, experiential, and disability factors affecting examinee interaction with CNADs; (g) use of computerized testing and reporting services; and (h) the need for checks on response validity and effort in the CNAD environment. This paper is intended to provide guidance for test developers and users of CNADs that will promote accurate and appropriate use of computerized tests in a way that maximizes clinical utility and minimizes risks of misuse. The positions taken in this paper are put forth with an eye toward balancing the need to make validated CNADs accessible to otherwise underserved patients with the need to ensure that such tests are developed and utilized competently, appropriately, and with due concern for patient welfare and quality of care. PMID:22382386

  10. Computerized neuropsychological assessment devices: joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology.

    PubMed

    Bauer, Russell M; Iverson, Grant L; Cernich, Alison N; Binder, Laurence M; Ruff, Ronald M; Naugle, Richard I

    2012-05-01

    This joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology sets forth our position on appropriate standards and conventions for computerized neuropsychological assessment devices (CNADs). In this paper, we first define CNADs and distinguish them from examiner-administered neuropsychological instruments. We then set forth position statements on eight key issues relevant to the development and use of CNADs in the healthcare setting. These statements address (a) device marketing and performance claims made by developers of CNADs; (b) issues involved in appropriate end-users for administration and interpretation of CNADs; (c) technical (hardware/software/firmware) issues; (d) privacy, data security, identity verification, and testing environment; (e) psychometric development issues, especially reliability, and validity; (f) cultural, experiential, and disability factors affecting examinee interaction with CNADs; (g) use of computerized testing and reporting services; and (h) the need for checks on response validity and effort in the CNAD environment. This paper is intended to provide guidance for test developers and users of CNADs that will promote accurate and appropriate use of computerized tests in a way that maximizes clinical utility and minimizes risks of misuse. The positions taken in this paper are put forth with an eye toward balancing the need to make validated CNADs accessible to otherwise underserved patients with the need to ensure that such tests are developed and utilized competently, appropriately, and with due concern for patient welfare and quality of care. PMID:22382386

  11. Computerized neuropsychological assessment devices: joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology.

    PubMed

    Bauer, Russell M; Iverson, Grant L; Cernich, Alison N; Binder, Laurence M; Ruff, Ronald M; Naugle, Richard I

    2012-01-01

    This joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology sets forth our position on appropriate standards and conventions for computerized neuropsychological assessment devices (CNADs). In this paper, we first define CNADs and distinguish them from examiner-administered neuropsychological instruments. We then set forth position statements on eight key issues relevant to the development and use of CNADs in the healthcare setting. These statements address (a) device marketing and performance claims made by developers of CNADs; (b) issues involved in appropriate end-users for administration and interpretation of CNADs; (c) technical (hardware/software/firmware) issues; (d) privacy, data security, identity verification, and testing environment; (e) psychometric development issues, especially reliability and validity; (f) cultural, experiential, and disability factors affecting examinee interaction with CNADs; (g) use of computerized testing and reporting services; and (h) the need for checks on response validity and effort in the CNAD environment. This paper is intended to provide guidance for test developers and users of CNADs that will promote accurate and appropriate use of computerized tests in a way that maximizes clinical utility and minimizes risks of misuse. The positions taken in this paper are put forth with an eye toward balancing the need to make validated CNADs accessible to otherwise underserved patients with the need to ensure that such tests are developed and utilized competently, appropriately, and with due concern for patient welfare and quality of care. PMID:22394228

  12. Electronic medication ordering with integrated drug database and clinical decision support system.

    PubMed

    Cufar, Andreja; Droljc, Anže; Orel, Andrej

    2012-01-01

    Medication errors have been identified as one of the most important causes of adverse drug events. Computerized physician order-entry (CPOE) systems, coupled with decision support (Medication allergy checking, drug interactions, and dose calculations), are considered to be appropriate solutions for reducing medication errors and standardizing care. It is quite useful if clinical information system (CIS) supports order sets, which help with standardizing care, preventing omission errors, and expediting the ordering process. Order sets are predefined groups of orders pertinent to one or more specific clinical conditions or diagnoses. The article describes how a clinical information system can be used to support medication process (prescribing, ordering, dispensing, administration and monitoring) and offer participating medical teams real time warnings and key information regarding medications and patient status, thus reducing medication errors. Integrated electronic prescribing support system benefits for total parenteral nutrition (TPN) are discussed at the end. PMID:22874280

  13. Evaluation of a Computerized Decision Support Intervention to Decrease Use of Anti-Pseudomonal Carbapenems in Penicillin Allergic Patients

    PubMed Central

    Caplinger, Christina; Smith, Garret; Remington, Richard; Madaras-Kelly, Karl

    2016-01-01

    Allergies to β-lactam antibiotics are commonly documented in hospitalized patients; however, true allergy is uncommon. Cross-reactivity rates for advanced generation cephalosporins and carbapenems are low; particularly for patients without a history of symptoms consistent with type 1 hypersensitivity. We observed that providers preferentially prescribed antipseudomonal carbapenems (APC) over advanced generation cephalosporins for patients with β-lactam allergy history, including those with low risk for antimicrobial-resistant infections. Information was inserted into the computerized decision support system (CDSS) to aid clinicians in assessing β-lactam cross-reactivity risk and selecting appropriate therapy. A retrospective evaluation was conducted in a small hospital to assess the impact of the CDSS changes in APC prescribing. Inpatients (n = 68) who received at least one APC dose during hospitalization over a 13 month pre-intervention period were compared to inpatients who received an APC during the 15 month post-intervention period (n = 59) for documented APC indications and β-lactam allergy history. APC initiations were measured and corrected per 1000 patient-days; interrupted time-series analysis was performed to assess changes in use before and after implementation. Aggregate monthly APC initiations decreased from 7.01 to 6.14 per 1000 patient-days after the implementation (p = 0.03). Post-intervention APC initiations for patients with low-risk β-lactam histories decreased from 92% to 83% (p = 0.17). No adverse events were observed in patients with low-risk β-lactam histories. The intervention was associated with a reduction in APC initiations. PMID:27025522

  14. Evaluation of a Computerized Decision Support Intervention to Decrease Use of Anti-Pseudomonal Carbapenems in Penicillin Allergic Patients.

    PubMed

    Caplinger, Christina; Smith, Garret; Remington, Richard; Madaras-Kelly, Karl

    2016-01-01

    Allergies to β-lactam antibiotics are commonly documented in hospitalized patients; however, true allergy is uncommon. Cross-reactivity rates for advanced generation cephalosporins and carbapenems are low; particularly for patients without a history of symptoms consistent with type 1 hypersensitivity. We observed that providers preferentially prescribed antipseudomonal carbapenems (APC) over advanced generation cephalosporins for patients with β-lactam allergy history, including those with low risk for antimicrobial-resistant infections. Information was inserted into the computerized decision support system (CDSS) to aid clinicians in assessing β-lactam cross-reactivity risk and selecting appropriate therapy. A retrospective evaluation was conducted in a small hospital to assess the impact of the CDSS changes in APC prescribing. Inpatients (n = 68) who received at least one APC dose during hospitalization over a 13 month pre-intervention period were compared to inpatients who received an APC during the 15 month post-intervention period (n = 59) for documented APC indications and β-lactam allergy history. APC initiations were measured and corrected per 1000 patient-days; interrupted time-series analysis was performed to assess changes in use before and after implementation. Aggregate monthly APC initiations decreased from 7.01 to 6.14 per 1000 patient-days after the implementation (p = 0.03). Post-intervention APC initiations for patients with low-risk β-lactam histories decreased from 92% to 83% (p = 0.17). No adverse events were observed in patients with low-risk β-lactam histories. The intervention was associated with a reduction in APC initiations. PMID:27025522

  15. Outpatient diabetes clinical decision support: current status and future directions.

    PubMed

    O'Connor, P J; Sperl-Hillen, J M; Fazio, C J; Averbeck, B M; Rank, B H; Margolis, K L

    2016-06-01

    Outpatient clinical decision support systems have had an inconsistent impact on key aspects of diabetes care. A principal barrier to success has been low use rates in many settings. Here, we identify key aspects of clinical decision support system design, content and implementation that are related to sustained high use rates and positive impacts on glucose, blood pressure and lipid management. Current diabetes clinical decision support systems may be improved by prioritizing care recommendations, improving communication of treatment-relevant information to patients, using such systems for care coordination and case management and integrating patient-reported information and data from remote devices into clinical decision algorithms and interfaces. PMID:27194173

  16. Supporting patients in shared decision making in clinical practice.

    PubMed

    Madsen, Claire; Fraser, Aileen

    2015-04-01

    This article defines shared decision making in patient care and describes the background to this philosophy. The shared decision making approach is part of a wider initiative to promote patient-centred care and increase patient involvement in clinical decisions. Shared decision making recognises patients' rights to make decisions about their care and is used to assist them to make informed and individualised decisions about care and treatment. As well as reviewing the principles of shared decision making, the article offers practical guidance on how nurses can implement this initiative, including information on sharing expertise, agenda setting, assessing risks and benefits, setting goals, and support and follow up. PMID:25828022

  17. A Multisite, Randomized Controlled Clinical Trial of Computerized Cognitive Remediation Therapy for Schizophrenia

    PubMed Central

    Gomar, Jesús J.; Valls, Elia; Radua, Joaquim; Mareca, Celia; Tristany, Josep; del Olmo, Francisco; Rebolleda-Gil, Carlos; Jañez-Álvarez, María; de Álvaro, Francisco J.; Ovejero, María R.; Llorente, Ana; Teixidó, Cristina; Donaire, Ana M.; García-Laredo, Eduardo; Lazcanoiturburu, Andrea; Granell, Luis; Mozo, Cristina de Pablo; Pérez-Hernández, Mónica; Moreno-Alcázar, Ana; Pomarol-Clotet, Edith; McKenna, Peter J.

    2015-01-01

    The effectiveness of cognitive remediation therapy (CRT) for the neuropsychological deficits seen in schizophrenia is supported by meta-analysis. However, a recent methodologically rigorous trial had negative findings. In this study, 130 chronic schizophrenic patients were randomly assigned to computerized CRT, an active computerized control condition (CC) or treatment as usual (TAU). Primary outcome measures were 2 ecologically valid batteries of executive function and memory, rated under blind conditions; other executive and memory tests and a measure of overall cognitive function were also employed. Carer ratings of executive and memory failures in daily life were obtained before and after treatment. Computerized CRT was found to produce improvement on the training tasks, but this did not transfer to gains on the primary outcome measures and most other neuropsychological tests in comparison to either CC or TAU conditions. Nor did the intervention result in benefits on carer ratings of daily life cognitive failures. According to this study, computerized CRT is not effective in schizophrenia. The use of both active and passive CCs suggests that nature of the control group is not an important factor influencing results. PMID:26006264

  18. Phenotyping, endotyping and clinical decision-making.

    PubMed

    Fokkens, W J

    2016-06-01

    We have exiting times in the treatment of chronic rhinosinusitis (CRS). The last year has brought us a number of new ideas and publications to help in decision-making in daily practice. In the first issue of this year, Claire Hopkins and co-authors identified the most important outcomes for patients, public and practitioners that should be evaluated in studies on health interventions for CRS. In this issue of the journal, a group of experts tried to define appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis. Appropriate indications for endoscopic sinus surgery (ESS) are currently poorly defined and the lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates. Using the Delphi method a total of 624 clinical scenarios (half CRSsNP and half CRSwNP) were ranked. The study clearly states that this group of experts indicates that ESS can only be indicated after medical treatment has failed with patients still having significant symptoms (SNOT-22 over 20) and at least some abnormalities at CT scan. PMID:27236249

  19. Identifying the Basis for Clinical Decisions - A Feasibility Study.

    PubMed

    Hurlen, Petter; Ofstad, Eirik; Gulbrandsen, Pål

    2016-01-01

    This study explored the possibility of defining a set of terms to describe and identify the basis for clinical decisions in a set of transcriptions from clinical encounters with previously identified decisions. The paper presents the considerations behind the exploratory study and considerations for further work. PMID:27577435

  20. Computerized Physician Order Entry

    PubMed Central

    Khanna, Raman; Yen, Tony

    2014-01-01

    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

  1. Heuristics in Managing Complex Clinical Decision Tasks in Experts’ Decision Making

    PubMed Central

    Islam, Roosan; Weir, Charlene; Del Fiol, Guilherme

    2016-01-01

    Background Clinical decision support is a tool to help experts make optimal and efficient decisions. However, little is known about the high level of abstractions in the thinking process for the experts. Objective The objective of the study is to understand how clinicians manage complexity while dealing with complex clinical decision tasks. Method After approval from the Institutional Review Board (IRB), three clinical experts were interviewed the transcripts from these interviews were analyzed. Results We found five broad categories of strategies by experts for managing complex clinical decision tasks: decision conflict, mental projection, decision trade-offs, managing uncertainty and generating rule of thumb. Conclusion Complexity is created by decision conflicts, mental projection, limited options and treatment uncertainty. Experts cope with complexity in a variety of ways, including using efficient and fast decision strategies to simplify complex decision tasks, mentally simulating outcomes and focusing on only the most relevant information. Application Understanding complex decision making processes can help design allocation based on the complexity of task for clinical decision support design.

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

    PubMed

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

    2012-12-01

    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

  3. Personalizing Drug Selection Using Advanced Clinical Decision Support

    PubMed Central

    Pestian, John; Spencer, Malik; Matykiewicz, Pawel; Zhang, Kejian; Vinks, Alexander A.; Glauser, Tracy

    2009-01-01

    This article describes the process of developing an advanced pharmacogenetics clinical decision support at one of the United States’ leading pediatric academic medical centers. This system, called CHRISTINE, combines clinical and genetic data to identify the optimal drug therapy when treating patients with epilepsy or Attention Deficit Hyperactivity Disorder. In the discussion a description of clinical decision support systems is provided, along with an overview of neurocognitive computing and how it is applied in this setting. PMID:19898682

  4. Standardized Glycemic Management with a Computerized Workflow and Decision Support System for Hospitalized Patients with Type 2 Diabetes on Different Wards

    PubMed Central

    Neubauer, Katharina M.; Höll, Bernhard; Aberer, Felix; Donsa, Klaus; Augustin, Thomas; Schaupp, Lukas; Spat, Stephan; Beck, Peter; Fruhwald, Friedrich M.; Schnedl, Christian; Rosenkranz, Alexander R.; Lumenta, David B.; Kamolz, Lars-Peter; Plank, Johannes; Pieber, Thomas R.

    2015-01-01

    Abstract Background: This study investigated the efficacy, safety, and usability of standardized glycemic management by a computerized decision support system for non-critically ill hospitalized patients with type 2 diabetes on four different wards. Materials and Methods: In this open, noncontrolled intervention study, glycemic management of 99 patients with type 2 diabetes (62% acute admissions; 41 females; age, 67±11 years; hemoglobin A1c, 65±21 mmol/mol; body mass index, 30.4±6.5 kg/m2) on clinical wards (Cardiology, Endocrinology, Nephrology, Plastic Surgery) of a tertiary-care hospital was guided by GlucoTab® (Joanneum Research GmbH [Graz, Austria] and Medical University of Graz [Graz, Austria]), a mobile decision support system providing automated workflow support and suggestions for insulin dosing to nurses and physicians. Results: Adherence to insulin dosing suggestions was high (96.5% bolus, 96.7% basal). The primary outcome measure, percentage of blood glucose (BG) measurements in the range of 70–140 mg/dL, occurred in 50.2±22.2% of all measurements. The overall mean BG level was 154±35 mg/dL. BG measurements in the ranges of 60–70 mg/dL, 40–60 mg/dL, and <40 mg/dL occurred in 1.4%, 0.5%, and 0.0% of all measurements, respectively. A regression analysis showed that acute admission to the Cardiology Ward (+30 mg/dL) and preexisting home insulin therapy (+26 mg/dL) had the strongest impact on mean BG. Acute admission to other wards had minor effects (+4 mg/dL). Ninety-one percent of the healthcare professionals felt confident with GlucoTab, and 89% believed in its practicality and 80% in its ability to prevent medication errors. Conclusions: An efficacious, safe, and user-accepted implementation of GlucoTab was demonstrated. However, for optimized personalized patient care, further algorithm modifications are required. PMID:26355756

  5. Computerized Vocational Information System (CVIS): Evaluation Manual. A Futuristic Concept of Vocational and Educational Decision-Making.

    ERIC Educational Resources Information Center

    Harris, JoAnn, Ed.

    Designed to assist Computerized Vocational Information System (CVIS) users in evaluating projects in local secondary school sites, the handbook provides users with a variety of variables or viewpoints from which to assess the CVIS system. Four different approaches are presented to CVIS evaluation: the analysis of use patterns; the reaction of…

  6. Programmable Calculators and Minicomputers in Agriculture. A Symposium Exploring Computerized Decision-Making Aids and Their Extension to the Farm Level. Proceedings of a Symposium (Hot Springs, Arkansas, February 6-7, 1980)

    ERIC Educational Resources Information Center

    Bentley, Ernest, Ed.

    Ten papers presented at a symposium discuss the array of computerized decision-making aids currently available to farmers and ways to speed up the rate of adoption of computers by agriculturalists. Topics presented include the development of software for agricultural decision-making; the role of programmable calculators and minicomputers in…

  7. Integrating Clinical Decision Support into EMR and PHR: a Case Study Using Anticoagulation.

    PubMed

    Chackery, Dave-Gregory; Keshavjee, Karim; Mirza, Kashif; Ghany, Ahmad; Holbrook, Anne M

    2015-01-01

    Clinical decision support (CDS) for atrial fibrillation is expected to ease the implementation of often-complex guidelines for atrial fibrillation and anticoagulation. Most clinical decision support systems (CDSS) for anticoagulation are stand-alone systems that do not integrate with electronic medical records (EMR). We have developed an architecture that consists of a computerized CDS that can integrate with multiple EMRs and multiple patient health records (PHRs). The design process revealed some significant issues that were resolved through systematic business/clinical analysis and creative clinical design in the diagnostic and treatment domains. Key issues identified and resolved include: 1) how to correctly allocate existing patients into various CDSS states (e.g., MAINTENANCE, HOLD, DISCONTINUE, etc), 2) identify when a patient becomes eligible for CDSS guidance over time, 3) how the CDSS maintains information about the patient's anticoagulation state and 4) how to transform vague human-readable concepts to explicit computable concepts. The management of anticoagulation for atrial fibrillation is no easy task and we believe our architecture will improve patient care at all levels and ultimately better balance the reduction of stroke risk while minimizing harms from major bleeding. In addition, the architecture presented is scalable to other treatment guidelines and is scalable to multiple EMRs and PHRs, making it suitable for use in a platform approach. PMID:25676955

  8. A computerized data acquisition system for infusion devices--a clinical support tool, or a risk management tool?

    PubMed

    Belal, S Y; Nevill, A J; Jeyaratnam, P

    2001-01-01

    A prototype computerized system for automatic data collection from multi-vendor infusion devices was constructed. The system was specifically designed around the needs of the critical care environment, and a survey of clinical staff was conducted to determine the functional requirements. Hardware, software and system configuration was based on the Medical Information Bus IEEE 1073 standard for medical device data communications. The infusion devices were configured into device communication controllers (DCC), which were polled at 0.25 Hz by a PC configured as a bedside communication controller (BCC). The system stores data samples after intervals of 1 ml of drug delivery and following any changes in the infusion rate. The system demonstrated significant opportunities for supporting clinical care and for the management of health care technology. PMID:11452634

  9. Clinical Decision Making among Dental Students and General Practitioners.

    ERIC Educational Resources Information Center

    Grembowski, David; And Others

    1989-01-01

    Senior dental students and family dental practitioners were surveyed concerning their choice of pairs of alternative treatments and the technical and patient factors influencing their decisions. Greater agreement in clinical decision-making was found among dentists than among students for all four pairs of alternative services. (MSE)

  10. Advancing clinical decision support using lessons from outside of healthcare: an interdisciplinary systematic review

    PubMed Central

    2012-01-01

    Background Greater use of computerized decision support (DS) systems could address continuing safety and quality problems in healthcare, but the healthcare field has struggled to implement DS technology. This study surveys DS experience across multiple non-healthcare disciplines for new insights that are generalizable to healthcare provider decisions. In particular, it sought design principles and lessons learned from the other disciplines that could inform efforts to accelerate the adoption of clinical decision support (CDS). Methods Our systematic review drew broadly from non-healthcare databases in the basic sciences, social sciences, humanities, engineering, business, and defense: PsychINFO, BusinessSource Premier, Social Sciences Abstracts, Web of Science, and Defense Technical Information Center. Because our interest was in DS that could apply to clinical decisions, we selected articles that (1) provided a review, overview, discussion of lessons learned, or an evaluation of design or implementation aspects of DS within a non-healthcare discipline and (2) involved an element of human judgment at the individual level, as opposed to decisions that can be fully automated or that are made at the organizational level. Results Clinical decisions share some similarities with decisions made by military commanders, business managers, and other leaders: they involve assessing new situations and choosing courses of action with major consequences, under time pressure, and with incomplete information. We identified seven high-level DS system design features from the non-healthcare literature that could be applied to CDS: providing broad, system-level perspectives; customizing interfaces to specific users and roles; making the DS reasoning transparent; presenting data effectively; generating multiple scenarios covering disparate outcomes (e.g., effective; effective with side effects; ineffective); allowing for contingent adaptations; and facilitating collaboration. The

  11. A Framework and Model for Evaluating Clinical Decision Support Architectures

    PubMed Central

    Wright, Adam; Sittig, Dean F.

    2008-01-01

    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

  12. Better clinical decision making and reducing diagnostic error.

    PubMed

    Croskerry, P; Nimmo, G R

    2011-06-01

    A major amount of our time working in clinical practice involves thinking and decision making. Perhaps it is because decision making is such a commonplace activity that it is assumed we can all make effective decisions. However, this is not the case and the example of diagnostic error supports this assertion. Until quite recently there has been a general nihilism about the ability to change the way that we think, but it is now becoming accepted that if we can think about, and understand, our thinking processes we can improve our decision making, including diagnosis. In this paper we review the dual process model of decision making and highlight ways in which decision making can be improved through the application of this model to our day-to-day practice and by the adoption of de-biasing strategies and critical thinking. PMID:21677922

  13. A Comparison of Content-Balancing Procedures for Estimating Multiple Clinical Domains in Computerized Adaptive Testing: Relative Precision, Validity, and Detection of Persons with Misfitting Responses

    ERIC Educational Resources Information Center

    Riley, Barth B.; Dennis, Michael L.; Conrad, Kendon J.

    2010-01-01

    This simulation study sought to compare four different computerized adaptive testing (CAT) content-balancing procedures designed for use in a multidimensional assessment with respect to measurement precision, symptom severity classification, validity of clinical diagnostic recommendations, and sensitivity to atypical responding. The four…

  14. Reducing Diagnostic Error with Computer-Based Clinical Decision Support

    ERIC Educational Resources Information Center

    Greenes, Robert A.

    2009-01-01

    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…

  15. Cognitive Elements in Clinical Decision-Making

    ERIC Educational Resources Information Center

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

    2010-01-01

    Physician cognition, metacognition and affect may have an impact upon the quality of clinical reasoning. The purpose of this study was to examine the relationship between measures of physician metacognition and affect and patient outcomes in obstetric practice. Reflective coping (RC), proactive coping, need for cognition (NFC), tolerance for…

  16. [Multislice computerized tomography coronary angiography: general principles, technique and clinical applications].

    PubMed

    Karabulut, Nevzat

    2008-07-01

    Electrocardiogram-gated coronary multislice computerized tomography (CT) angiography is a rapidly improving technology allowing noninvasive imaging of coronary arteries. After the initial promising results obtained with four-section CT scanners, progressively higher temporal and spatial resolutions have been achieved by increasing gantry rotation speed and the number of detector rows and by reducing individual detector size. This review presents an overview of the general principles, technique and emerging applications and artifacts of coronary multislice CT angiography. The diagnostic performance of this new technology allows it to be used to evaluate the presence of coronary plaques and stenosis, coronary bypass graft patency, and the origin and course of congenital coronary anomalies. As it visualizes coronary artery wall in addition to lumen and provides volumetric data of heart and great vessels, it readily demonstrates plaque remodeling, ostial lesions and other cardiac and extracardiac abnormalities. The high negative predictive value of coronary CT angiography makes it a valuable tool in the evaluation of patients with low or intermediate pretest probability for coronary artery disease. However, improvements in spatial and temporal resolution are still needed in the imaging of small coronary stents, in the detection and characterization of noncalcified plaques, and to overcome image degradation by arrhythmias, higher heart rates, and calcium-related artifacts. PMID:18611837

  17. Clinical Decision Support Tools: The Evolution of a Revolution.

    PubMed

    Mould, D R; D'Haens, G; Upton, R N

    2016-04-01

    Dashboard systems for clinical decision support integrate data from multiple sources. These systems, the newest in a long line of dose calculators and other decision support tools, utilize Bayesian approaches to fully individualize dosing using information gathered through therapeutic drug monitoring. In the treatment of inflammatory bowel disease patients with infliximab, dashboards may reduce therapeutic failures and treatment costs. The history and future development of modern Bayesian dashboard systems is described. PMID:26785109

  18. Consensus, clinical decision making, and unsettled cases.

    PubMed

    Adams, David M; Winslade, William J

    2011-01-01

    The model of clinical ethics consultation (CEC) defended in the ASBH Core Competencies report has gained significant traction among scholars and healthcare providers. On this model, the aim of CEC is to facilitate deliberative reflection and thereby resolve conflicts and clarify value uncertainty by invoking and pursuing a process of consensus building. It is central to the model that the facilitated consensus falls within a range of allowable options, defined by societal values: prevailing legal requirements, widely endorsed organizational policies, and professional standards of practice and codes of conduct. Moreover, the model stipulates that ethics consultants must refrain from giving substantive recommendations regarding how parties to a moral disagreement in the clinic should evaluate their options. We argue that this model of CEC is incomplete, because it wrongly assumes that what counts as the proper set of allowable options among which the parties are to deliberate will itself always be clearly discernible. We illustrate this problem with a recent case on which one of us consulted-a neonate born with trisomy 18 (T18). We try to show that law, policy, and standards of practice reveal no clear answer to the question posed by the case: namely, whether forgoing gastrostomy tube feedings for a baby with T18 is allowable. We suggest there may be other kinds of cases in which it may simply be unsettled whether a given choice falls within the set of allowable options within which consensus is to be facilitated. What should an ethicist do when confronting such unsettled cases? We agree with the facilitation model that an ethicist should remain neutral among the allowable options, when it is clear what the allowable options are. But, in unsettled cases, the role of a consultant should be expanded to include a process of moral inquiry into what the allowable options should be. We end by raising the issue of whether this means an ethicist should share his or her own

  19. The thinking doctor: clinical decision making in contemporary medicine.

    PubMed

    Trimble, Michael; Hamilton, Paul

    2016-08-01

    Diagnostic errors are responsible for a significant number of adverse events. Logical reasoning and good decision-making skills are key factors in reducing such errors, but little emphasis has traditionally been placed on how these thought processes occur, and how errors could be minimised. In this article, we explore key cognitive ideas that underpin clinical decision making and suggest that by employing some simple strategies, physicians might be better able to understand how they make decisions and how the process might be optimised. PMID:27481378

  20. DocBot: a novel clinical decision support algorithm.

    PubMed

    Ninh, Andrew Q

    2014-01-01

    DocBot is a web-based clinical decision support system (CDSS) that uses patient interaction and electronic health record analytics to assist medical practitioners with decision making. It consists of two distinct HTML interfaces: a preclinical form wherein a patient inputs symptomatic and demographic information, and an interface wherein a medical practitioner views patient information and analysis. DocBot comprises an improved software architecture that uses patient information, electronic health records, and etiologically relevant binary decision questions (stored in a knowledgebase) to provide medical practitioners with information including, but not limited to medical assessments, treatment plans, and specialist referrals. PMID:25571435

  1. Improving clinical decision support using data mining techniques

    NASA Astrophysics Data System (ADS)

    Burn-Thornton, Kath E.; Thorpe, Simon I.

    1999-02-01

    Physicians, in their ever-demanding jobs, are looking to decision support systems for aid in clinical diagnosis. However, clinical decision support systems need to be of sufficiently high accuracy that they help, rather than hinder, the physician in his/her diagnosis. Decision support systems with accuracies, of patient state determination, of greater than 80 percent, are generally perceived to be sufficiently accurate to fulfill the role of helping the physician. We have previously shown that data mining techniques have the potential to provide the underpinning technology for clinical decision support systems. In this paper, an extension of the work in reverence 2, we describe how changes in data mining methodologies, for the analysis of 12-lead ECG data, improve the accuracy by which data mining algorithms determine which patients are suffering from heart disease. We show that the accuracy of patient state prediction, for all the algorithms, which we investigated, can be increased by up to 6 percent, using the combination of appropriate test training ratios and 5-fold cross-validation. The use of cross-validation greater than 5-fold, appears to reduce the improvement in algorithm classification accuracy gained by the use of this validation method. The accuracy of 84 percent in patient state predictions, obtained using the algorithm OCI, suggests that this algorithm will be capable of providing the required accuracy for clinical decision support systems.

  2. Enablers, Barriers, and the Influence of Organizational Environmental Factors on Computerized Clinical Documentation Training Developed and Delivered by Nursing Informaticists

    ERIC Educational Resources Information Center

    Kulhanek, Brenda J.

    2010-01-01

    Within the past decade, the introduction of computerized medical records into the business and practice of health care has created a need for effective training. The implementation of computerized medical records into a health care organization has been often associated with increased costs and decreased productivity. Although existing human…

  3. The effect of Computerized Physician Order Entry and decision support system on medication errors in the neonatal ward: experiences from an Iranian teaching hospital.

    PubMed

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

    2011-02-01

    Medication dosing errors are frequent in neonatal wards. In an Iranian neonatal ward, a 7.5 months study was designed in three 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. Before intervention (Period 1), error rate was 53%, which did not significantly change after the implementation of CPOE without decision support (Period 2). However, errors were significantly reduced to 34% after that the decision support was added to the CPOE (Period 3; P < 0.001). Dose errors were more often intercepted than frequency errors. Over-dose was the most frequent type of medication errors and curtailed-interval was the least. Transcription errors did not reduce after the CPOE implementation. Physicians ignored alerts when they could not understand why they appeared. A suggestion is to add explanations about these reasons to increase physicians' compliance with the system's recommendations. PMID:20703588

  4. Semantic Interoperability in Clinical Decision Support Systems: A Systematic Review.

    PubMed

    Marco-Ruiz, Luis; Bellika, Johan Gustav

    2015-01-01

    The interoperability of Clinical Decision Support (CDS) systems with other health information systems has become one of the main limitations to their broad adoption. Semantic interoperability must be granted in order to share CDS modules across different health information systems. Currently, numerous standards for different purposes are available to enable the interoperability of CDS systems. We performed a literature review to identify and provide an overview of the available standards that enable CDS interoperability in the areas of clinical information, decision logic, terminology, and web service interfaces. PMID:26262260

  5. The role of emotions in clinical reasoning and decision making.

    PubMed

    Marcum, James A

    2013-10-01

    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

  6. Improving Congestive Heart Failure Care with a Clinical Decision Unit.

    PubMed

    Carpenter, Jo Ellen; Short, Nancy; Williams, Tracy E; Yandell, Ben; Bowers, Margaret T

    2015-01-01

    Evidence supporting the development of Clinical Decision Units (CDUs) to impact congestive heart failure readmission rates comes from several categories of the literature. In this study, a pre-post design with comparison group was used to evaluate the impact of the CDU. Early changes in clinical and financial outcome indicators are encouraging. Nurse leaders seek ways to improve clinical outcomes while managing the current financially challenging environment. Implementation of a CDU provides many opportunities for nurse leaders to positively impact clinical care and financial performance within their institutions. PMID:26625578

  7. Hip Arthroplasty Pseudotumors: Pathogenesis, Imaging, and Clinical Decision Making

    PubMed Central

    Davis, Derik L; Morrison, James J

    2016-01-01

    Pseudotumors are a complication of hip arthroplasty. The goal of this article is to review the clinical presentation, pathogenesis, histology, and the role of diagnostic imaging in clinical decision making for treatment, and surveillance of pseudotumors. We will discuss the multimodal imaging appearances, differential diagnosis, associated complications, treatment, and prognosis of pseudotumors, as an aid to the assessment of orthopedic prostheses at the hip. PMID:27195183

  8. The relationship between patient data and pooled clinical management decisions.

    PubMed

    Ludbrook, G I; O'Loughlin, E J; Corcoran, T B; Grant, C

    2013-01-01

    A strong relationship between patient data and preoperative clinical decisions could potentially be used to support clinical decisions in preoperative management. The aim of this exploratory study was to determine the relationship between key patient data and pooled clinical opinions on management. In a previous study, panels of anaesthetists compared the quality of computer-assisted patient health assessments with outpatient consultations and made decisions on the need for preoperative tests, no preoperative outpatient assessment, possible postoperative intensive care unit/high dependency unit requirements and aspiration prophylaxis. In the current study, the relationship between patient data and these decisions was examined using binomial logistic regression analysis. Backward stepwise regression was used to identify independent predictors of each decision (at P >0.15), which were then incorporated into a predictive model. The number of factors related to each decision varied: blood picture (four factors), biochemistry (six factors), coagulation studies (three factors), electrocardiography (eight factors), chest X-ray (seven factors), preoperative outpatient assessment (17 factors), intensive care unit requirement (eight factors) and aspiration prophylaxis (one factor). The factor types also varied, but included surgical complexity, age, gender, number of medications or comorbidities, body mass index, hypertension, central nervous system condition, heart disease, sleep apnoea, smoking, persistent pain and stroke. Models based on these relationships usually demonstrated good sensitivity and specificity, with receiver operating characteristics in the following areas under curve: blood picture (0.75), biochemistry (0.86), coagulation studies (0.71), electrocardiography (0.90), chest X-ray (0.85), outpatient assessment (0.85), postoperative intensive care unit requirement (0.88) and aspiration prophylaxis (0.85). These initial results suggest modelling of patient

  9. Thinking Processes Used by Nurses in Clinical Decision Making.

    ERIC Educational Resources Information Center

    Higuchi, Kathryn A. Smith; Donald, Janet G.

    2002-01-01

    Interviews with eight medical and surgical nurses and audits of patient charts investigated clinical decision-making processes. Predominant thinking processes were description of facts, selection of information, inference, syntheses, and verification, with differences between medical and surgical specialties. Exemplars of thinking processes…

  10. Using Clinical Decision Support Software in Health Insurance Company

    NASA Astrophysics Data System (ADS)

    Konovalov, R.; Kumlander, Deniss

    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.

  11. Adoption of Clinical Decision Support in Multimorbidity: A Systematic Review

    PubMed Central

    Arguello Casteleiro, Mercedes; Ainsworth, John; Buchan, Iain

    2015-01-01

    Background Patients with multiple conditions have complex needs and are increasing in number as populations age. This multimorbidity is one of the greatest challenges facing health care. Having more than 1 condition generates (1) interactions between pathologies, (2) duplication of tests, (3) difficulties in adhering to often conflicting clinical practice guidelines, (4) obstacles in the continuity of care, (5) confusing self-management information, and (6) medication errors. In this context, clinical decision support (CDS) systems need to be able to handle realistic complexity and minimize iatrogenic risks. Objective The aim of this review was to identify to what extent CDS is adopted in multimorbidity. Methods This review followed PRISMA guidance and adopted a multidisciplinary approach. Scopus and PubMed searches were performed by combining terms from 3 different thesauri containing synonyms for (1) multimorbidity and comorbidity, (2) polypharmacy, and (3) CDS. The relevant articles were identified by examining the titles and abstracts. The full text of selected/relevant articles was analyzed in-depth. For articles appropriate for this review, data were collected on clinical tasks, diseases, decision maker, methods, data input context, user interface considerations, and evaluation of effectiveness. Results A total of 50 articles were selected for the full in-depth analysis and 20 studies were included in the final review. Medication (n=10) and clinical guidance (n=8) were the predominant clinical tasks. Four studies focused on merging concurrent clinical practice guidelines. A total of 17 articles reported their CDS systems were knowledge-based. Most articles reviewed considered patients’ clinical records (n=19), clinical practice guidelines (n=12), and clinicians’ knowledge (n=10) as contextual input data. The most frequent diseases mentioned were cardiovascular (n=9) and diabetes mellitus (n=5). In all, 12 articles mentioned generalist doctor(s) as the

  12. The Relationship Between the Clinical Orientation of Substance Abuse Professionals and Their Clinical Decisions

    ERIC Educational Resources Information Center

    Toriello, Paul J.; Leierer, Stephen J.

    2005-01-01

    In this study, the authors examined the relationship between the clinical orientations of substance abuse professionals (SAPs) and their clinical decisions. Cluster analysis grouped a sample of 245 SAPs on two clinical orientations that differed in their relative endorsement of traditional versus contemporary substance abuse counseling processes…

  13. An Intelligent Computerized Stretch Reflex Measurement System For Clinical And Investigative Neurology

    NASA Astrophysics Data System (ADS)

    Flanagan, P. M.; Chutkow, J. G.; Riggs, M. T.; Cristiano, V. D.

    1987-05-01

    We describe the design of a reliable, user-friendly preprototype system for quantifying the tendon stretch reflexes in humans and large mammals. A hand-held, instrumented reflex gun, the impactor of which contains a single force sensor, interfaces with a computer. The resulting test system can deliver sequences of reproducible stimuli at graded intensities and adjustable durations to a muscle's tendon ("tendon taps"), measure the impacting force of each tap, and record the subsequent reflex muscle contraction from the same tendon -- all automatically. The parameters of the reflex muscle contraction include latency; mechanical threshold; and peak time, peak magnitude, and settling time. The results of clinical tests presented in this paper illustrate the system's potential usefulness in detecting neurologic dysfunction affecting the tendon stretch reflexes, in documenting the course of neurologic illnesses and their response to therapy, and in clinical and laboratory neurologic research.

  14. Dynamic clinical data mining: search engine-based decision support.

    PubMed

    Celi, Leo Anthony; Zimolzak, Andrew J; Stone, David J

    2014-01-01

    The research world is undergoing a transformation into one in which data, on massive levels, is freely shared. In the clinical world, the capture of data on a consistent basis has only recently begun. We propose an operational vision for a digitally based care system that incorporates data-based clinical decision making. The system would aggregate individual patient electronic medical data in the course of care; query a universal, de-identified clinical database using modified search engine technology in real time; identify prior cases of sufficient similarity as to be instructive to the case at hand; and populate the individual patient's electronic medical record with pertinent decision support material such as suggested interventions and prognosis, based on prior outcomes. Every individual's course, including subsequent outcomes, would then further populate the population database to create a feedback loop to benefit the care of future patients. PMID:25600664

  15. Dynamic Clinical Data Mining: Search Engine-Based Decision Support

    PubMed Central

    Zimolzak, Andrew J; Stone, David J

    2014-01-01

    The research world is undergoing a transformation into one in which data, on massive levels, is freely shared. In the clinical world, the capture of data on a consistent basis has only recently begun. We propose an operational vision for a digitally based care system that incorporates data-based clinical decision making. The system would aggregate individual patient electronic medical data in the course of care; query a universal, de-identified clinical database using modified search engine technology in real time; identify prior cases of sufficient similarity as to be instructive to the case at hand; and populate the individual patient's electronic medical record with pertinent decision support material such as suggested interventions and prognosis, based on prior outcomes. Every individual's course, including subsequent outcomes, would then further populate the population database to create a feedback loop to benefit the care of future patients. PMID:25600664

  16. Computerized Drug Information Services

    ERIC Educational Resources Information Center

    And Others; Smith, Daniel R.

    1972-01-01

    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…

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

    PubMed Central

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

    2014-01-01

    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

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

    PubMed

    Jibaja-Weiss, Maria L; Volk, Robert J

    2007-01-01

    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

  19. Computerized tomographic simulation compared with clinical mark-up in palliative radiotherapy: A prospective study

    SciTech Connect

    Haddad, Peiman; Cheung, Fred; Pond, Gregory; Easton, Debbie; Cops, Frederick; Bezjak, Andrea; McLean, Michael; Levin, Wilfred; Billingsley, Susan; Williams, Diane; Wong, Rebecca . E-mail: Rebecca.Wong@rmp.uhn.on.ca

    2006-07-01

    Purpose To evaluate the impact of computed tomographic (CT) planning in comparison to clinical mark-up (CM) for palliative radiation of chest wall metastases. Methods and Materials In patients treated with CM for chest wall bone metastases (without conventional simulation/fluoroscopy), two consecutive planning CT scans were acquired with and without an external marker to delineate the CM treatment field. The two sets of scans were fused for evaluation of clinical tumor volume (CTV) coverage by the CM technique. Under-coverage was defined as the proportion of CTV not covered by the CM 80% isodose. Results Twenty-one treatments (ribs 17, sternum 2, and scapula 2) formed the basis of our study. Due to technical reasons, comparable data between CM and CT plans were available for 19 treatments only. CM resulted in a mean CTV under-coverage of 36%. Eleven sites (58%) had an under-coverage of >20%. Mean volume of normal tissues receiving {>=}80% of the dose was 5.4% in CM and 9.3% in CT plans (p = 0.017). Based on dose-volume histogram comparisons, CT planning resulted in a change of treatment technique from direct apposition to a tangential pair in 7 of 19 cases. Conclusions CT planning demonstrated a 36% under-coverage of CTV with CM of ribs and chest wall metastases.

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

    PubMed Central

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

    2013-01-01

    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

  1. Ethical decision-making challenges in clinical practice.

    PubMed

    Horowitz, Beverly P

    2003-01-01

    Today's health care environment requires professionals to pay increasing attention to efficiencies and functional outcomes. Today's patients are hospitalized for short stays, and those needing rehabilitation often have multiple diagnoses and goals. Cost effective strategies support fast paced occupational therapy programs and professionals who are adept multi-task specialists and problem solvers. Practitioners have multiple resources and strategies for clinical reasoning and decision-making; however, ethical decision-making requires use of additional resources and strategies. This paper provides strategies to examine everyday ethical problems and dilemmas, including application of The American Occupational Therapy's Code of Ethics, to support ethical decision-making in practice settings (American Occupational Therapy Association, 2000a). PMID:23930704

  2. The effects of clinical decision making on nurse practitioners' clinical productivity.

    PubMed

    Chumbler, N R; Geller, J M; Weier, A W

    2000-09-01

    The degree of clinical decision making and clinical productivity among nurse practitioners (NPs) is of great interest to policy makers and planners involved in providing appropriate outpatient primary care services. The authors performed a statewide mailed survey of all NPs practicing either full-time or part-time in Wisconsin (response rate of 72.1%) to address the following research questions: Do the demographic characteristics, practice attributes, and primary practice settings of NPs impact their level of clinical decision making (e.g., the autonomy to order laboratory and radiological tests or to refer a patient to a physician specialist other than their collaborating physician)? Do NPs' levels of clinical decision making correlate with their outpatient clinical productivity, adjusting for demographic characteristics, practice attributes, and primary practice settings? The multiple linear regression results indicated that having more years in practice as an NP, practicing in the family specialty area (vs. a combined other category, which included pediatrics, acute care, geriatrics, neonatal, and school), treating patients according to clinical guidelines, practicing in settings with a fewer number of physicians, and practicing in a multispecialty group practice versus a single-specialty group practice were associated with greater levels of clinical decision making. However, NPs who primarily practiced in a hospital/facility-based practice, as compared with a single-specialty group practice, had lower levels of clinical decision making. After adjusting for demographic characteristics, practice attributes, and primary practice settings, NPs with greater clinical decision-making authority had greater outpatient clinical productivity. The conclusions discuss the policy implications of the findings. PMID:11067192

  3. Creating Shareable Clinical Decision Support Rules for a Pharmacogenomics Clinical Guideline Using Structured Knowledge Representation.

    PubMed

    Linan, Margaret K; Sottara, Davide; Freimuth, Robert R

    2015-01-01

    Pharmacogenomics (PGx) guidelines contain drug-gene relationships, therapeutic and clinical recommendations from which clinical decision support (CDS) rules can be extracted, rendered and then delivered through clinical decision support systems (CDSS) to provide clinicians with just-in-time information at the point of care. Several tools exist that can be used to generate CDS rules that are based on computer interpretable guidelines (CIG), but none have been previously applied to the PGx domain. We utilized the Unified Modeling Language (UML), the Health Level 7 virtual medical record (HL7 vMR) model, and standard terminologies to represent the semantics and decision logic derived from a PGx guideline, which were then mapped to the Health eDecisions (HeD) schema. The modeling and extraction processes developed here demonstrate how structured knowledge representations can be used to support the creation of shareable CDS rules from PGx guidelines. PMID:26958298

  4. Creating Shareable Clinical Decision Support Rules for a Pharmacogenomics Clinical Guideline Using Structured Knowledge Representation

    PubMed Central

    Linan, Margaret K.; Sottara, Davide; Freimuth, Robert R.

    2015-01-01

    Pharmacogenomics (PGx) guidelines contain drug-gene relationships, therapeutic and clinical recommendations from which clinical decision support (CDS) rules can be extracted, rendered and then delivered through clinical decision support systems (CDSS) to provide clinicians with just-in-time information at the point of care. Several tools exist that can be used to generate CDS rules that are based on computer interpretable guidelines (CIG), but none have been previously applied to the PGx domain. We utilized the Unified Modeling Language (UML), the Health Level 7 virtual medical record (HL7 vMR) model, and standard terminologies to represent the semantics and decision logic derived from a PGx guideline, which were then mapped to the Health eDecisions (HeD) schema. The modeling and extraction processes developed here demonstrate how structured knowledge representations can be used to support the creation of shareable CDS rules from PGx guidelines. PMID:26958298

  5. Integrating a Computerized Clinical Laboratory Information System into a Global Hospital Information System

    PubMed Central

    Rappoport, Arthur E.

    1981-01-01

    We have developed Laboratory (LIS) and Hospital (HIS) Information Systems in a distributed, shared satellite-host configuration. The LIS processes data on-line from 25 electronic analytical instruments from two geographically separated hospital units connected on-line to a laboratory computer (LDM). Manual test results are entered by CRTs or punch cards. Free Text is entered by CRT or CMC/ST. Machine readable specimen identification is accomplished by OCR or mini-punch card readers attached to the test instruments. The LDM transmits all test data to the HIS for storage in patients' files. The HIS is an IBM 4341 and serves both hospital units through 8100's. It performs all administrative tasks. The LIS is the Technicon 7000R system. A communication system, DIVOTS (Data Voice Output Telephone System) is based on an IBM S/7 processor coupled to the 4341 and uses Touch-Tone, Audio-Response technology. It provides test order entry and result inquiry functions between nursing stations, clinics and physicians' offices to and from the laboratory and other departments. HIS prints all interim and daily updated, reformatted, cumulative patient summary reports which are sent to the wards.

  6. Clinical decision support systems: data quality management and governance.

    PubMed

    Liaw, Siaw-Teng

    2013-01-01

    This chapter examines data quality management (DQM) and information governance (IG) of electronic decision support (EDS) systems so that they are safe and fit for use by clinicians and patients and their carers. This is consistent with the ISO definition of data quality as being fit for purpose. The scope of DQM & IG should range from data creation and collection in clinical settings, through cleaning and, where obtained from multiple sources, linkage, storage, use by the EDS logic engine and algorithms, knowledge base and guidance provided, to curation and presentation. It must also include protocols and mechanisms to monitor the safety of EDS, which will feedback into DQM & IG activities. Ultimately, DQM & IG must be integrated across the data cycle to ensure that the EDS systems provide guidance that leads to safe and effective clinical decisions and care. PMID:24018528

  7. IBM’s Health Analytics and Clinical Decision Support

    PubMed Central

    Sun, J.; Knoop, S.; Shabo, A.; Carmeli, B.; Sow, D.; Syed-Mahmood, T.; Rapp, W.

    2014-01-01

    Summary Objectives This survey explores the role of big data and health analytics developed by IBM in supporting the transformation of healthcare by augmenting evidence-based decision-making. Methods Some problems in healthcare and strategies for change are described. It is argued that change requires better decisions, which, in turn, require better use of the many kinds of healthcare information. Analytic resources that address each of the information challenges are described. Examples of the role of each of the resources are given. Results There are powerful analytic tools that utilize the various kinds of big data in healthcare to help clinicians make more personalized, evidenced-based decisions. Such resources can extract relevant information and provide insights that clinicians can use to make evidence-supported decisions. There are early suggestions that these resources have clinical value. As with all analytic tools, they are limited by the amount and quality of data. Conclusion Big data is an inevitable part of the future of healthcare. There is a compelling need to manage and use big data to make better decisions to support the transformation of healthcare to the personalized, evidence-supported model of the future. Cognitive computing resources are necessary to manage the challenges in employing big data in healthcare. Such tools have been and are being developed. The analytic resources, themselves, do not drive, but support healthcare transformation. PMID:25123736

  8. Clinical Decision Support for Vascular Disease in Community Family Practice

    PubMed Central

    Keshavjee, K; Holbrook, AM; Lau, E; Esporlas-Jewer, I; Troyan, S

    2006-01-01

    The COMPETE III Vascular Disease Tracker (C3VT) is a personalized, Web-based, clinical decision support tool that provides patients and physicians access to a patient’s 16 individual vascular risk markers, specific advice for each marker and links to best practices in vascular disease management. It utilizes the chronic care model1 so that physicians can better manage patients with chronic diseases. Over 1100 patients have been enrolled into the COMPETE III study to date.

  9. Knowledge-analytics synergy in Clinical Decision Support.

    PubMed

    Slonim, Noam; Carmeli, Boaz; Goldsteen, Abigail; Keller, Oliver; Kent, Carmel; Rinott, Ruty

    2012-01-01

    Clinical Decision Support (CDS) systems hold tremendous potential for improving patient care. Most existing systems are knowledge-based tools that rely on relatively simple rules. More recent approaches rely on analytics techniques to automatically mine EHR data to reveal meaningful insights. Here, we propose the Knowledge-Analytics Synergy paradigm for CDS, in which we synergistically combine existing relevant knowledge with analytics applied to EHR data. We propose a framework for implementing such a paradigm and demonstrate its principles over real-world clinical and genomic data of hypertensive patients. PMID:22874282

  10. Mechanistic biomarkers for clinical decision making in rheumatic diseases

    PubMed Central

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

    2013-01-01

    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

  11. Neural networks and psychiatry: candidate applications in clinical decision making.

    PubMed

    Florio, T; Einfeld, S; Levy, F

    1994-12-01

    Neural networks comprise a fundamentally new type of computer system inspired by the functioning of neurons in the brain. Such networks are good at solving problems that involve pattern recognition and categorisation. An important difference between a neural network and a traditional computer system is that in developing an application, a neural network is not programmed; instead, it is trained to solve a particular type of problem. This ability to learn to solve a problem makes neural networks adaptable to solving a wide variety of problems, some of which have proved intractable using a traditional computing approach. Neural networks are particularly suited to tasks involving the categorisation of patterns of information, such as is required in diagnosis and clinical decision making. In the last three years reports of applications involving neural networks have begun to appear in the medical literature, and these are described in this paper. However, a comprehensive search of the literature has shown that there have not as yet been reports of any applications in psychiatry. This paper discusses the nature of clinical decision making, outlines the sorts of problems in psychiatry which neural networks applications might be developed to address, and gives examples of candidate applications in clinical decision making. PMID:7794209

  12. Priority oral health research identification for clinical decision-making.

    PubMed

    Worthington, Helen; Clarkson, Jan; Weldon, Jo

    2015-09-01

    The Cochrane Library is a core resource for clinical decision-making globally, by clinicians, guideline developers, healthcare providers and patients.The publication of Cochrane Library systematic reviews concerning oral health conditions has grown exponentially to over 215 individual titles (as of 20 June 2015) during the past 20 years.Consequently, maintaining updates of the most clinically important reviews to provide up-to-date and accurate sources of evidence for decision-making has become a pressing concern for the editorial group behind their production, Cochrane Oral Health Group.To identify priority research required by oral health decision-makers, the Cochrane OHG embarked on a consultation process across eight defined areas of dentistry (periodontology, operative (including endodontics) and prosthodontics, paediatric dentistry, dental public health, oral and maxillofacial surgery, oral medicine, orthodontics, cleft lip and/or palate) with existing authors (by email), with members of the public (by online survey), and established internationally clinically expert panels for each area of defined area of dentistry to discuss and ratify (by teleconference) a core portfolio of priority evidence to be produced and maintained on the Cochrane Library.The resulting portfolio of priority research encompasses 81 existing titles to be maintained, and an additional 15 new systematic reviews to be developed by the Cochrane OHG in due course.The Cochrane OHG has actively responded to the outcomes of this prioritisation process by allocating resources to primarily supporting the maintenance of identified priority evidence for the Cochrane Library. PMID:26492797

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

    PubMed Central

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

    2013-01-01

    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

  14. Reducing diagnostic error with computer-based clinical decision support.

    PubMed

    Greenes, Robert A

    2009-09-01

    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 making (Schiff). In addition, several other considerations relating to this topic are interesting to ponder. We are moving toward increased understanding of gene regulation and gene expression, identification of biomarkers, and the ability to predict patient response to disease and to tailor treatments to these individual variations-referred to as "personalized" or, more recently, "predictive" medicine. Consequently, diagnostic decision making is more and more linked to management decision making, and generic diagnostic labels like "diabetes" or "colon cancer" will no longer be sufficient, because they don't tell us what to do. Ultimately, if we have more complete data including more structured capture of phenomic data as well as the characterization of the patient's genome, direct prediction from responses of highly refined subsets of similar patients in a database can be used to select appropriate management, the effectiveness of which was demonstrated in projects in selected limited domains as early as the 1970s. In general, there are six classes of methodologies, including the above, which can be applied to delivering CDS. In addition, patients are becoming more knowledgeable and should be regarded as active participants, not only in helping to obtain data but also in their own status assessment and as recipients of decision support. With the above advances, this is a very promising time to be engaged in pursuit of methods of CDS. PMID:19669915

  15. Cancer diagnostics: decision criteria for marker utilization in the clinic.

    PubMed

    Taube, Sheila E; Jacobson, James W; Lively, Tracy G

    2005-01-01

    A new diagnostic tool must pass three major tests before it is adopted for routine clinical use. First, the tool must be robust and reproducible; second, the clinical value of the tool must be proven, i.e. the tool should reliably trigger a clinical decision that results in patient benefit; and, third, the clinical community has to be convinced of the need for this tool and the benefits it affords. Another factor that can influence the adoption of new tools relates to the cost and the vagaries of insurance reimbursement. The Cancer Diagnosis Program (CDP) of the US National Cancer Institute (NCI) launched the Program for the Assessment of Clinical Cancer Tests (PACCT) in 2000 to develop a process for moving the results of new technologies and new understanding of cancer biology more efficiently and effectively into clinical practice. PACCT has developed an algorithm that incorporates the iterative nature of assay development into an evaluation process that includes developers and end users. The effective introduction of new tests into clinical practice has been hampered by a series of common problems that are best described using examples of successes and failures. The successful application of the PACCT algorithm is described in the discussion of the recent development of the OncotypeDX assay and plan for a prospective trial of this assay by the NCI-supported Clinical Trials Cooperative Groups. The assay uses reverse transcription (RT)-PCR evaluation of a set of 16 genes that were shown to strongly associate with the risk of recurrence of breast cancer in women who presented with early stage disease (hormone responsive, and no involvement of the auxiliary lymph nodes). The test is highly reproducible. It provides information to aid the physician and patient in making important clinical decisions, including the aggressiveness of the therapy that should be recommended. A trial is planned to test whether OncotypeDX can be used as a standalone trigger for specific

  16. Web-based health services and clinical decision support.

    PubMed

    Jegelevicius, Darius; Marozas, Vaidotas; Lukosevicius, Arunas; Patasius, Martynas

    2004-01-01

    The purpose of this study was the development of a Web-based e-health service for comprehensive assistance and clinical decision support. The service structure consists of a Web server, a PHP-based Web interface linked to a clinical SQL database, Java applets for interactive manipulation and visualization of signals and a Matlab server linked with signal and data processing algorithms implemented by Matlab programs. The service ensures diagnostic signal- and image analysis-sbased clinical decision support. By using the discussed methodology, a pilot service for pathology specialists for automatic calculation of the proliferation index has been developed. Physicians use a simple Web interface for uploading the pictures under investigation to the server; subsequently a Java applet interface is used for outlining the region of interest and, after processing on the server, the requested proliferation index value is calculated. There is also an "expert corner", where experts can submit their index estimates and comments on particular images, which is especially important for system developers. These expert evaluations are used for optimization and verification of automatic analysis algorithms. Decision support trials have been conducted for ECG and ophthalmology ultrasonic investigations of intraocular tumor differentiation. Data mining algorithms have been applied and decision support trees constructed. These services are under implementation by a Web-based system too. The study has shown that the Web-based structure ensures more effective, flexible and accessible services compared with standalone programs and is very convenient for biomedical engineers and physicians, especially in the development phase. PMID:15718591

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

    PubMed

    Tomaszewski, Wiesław

    2012-01-01

    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

  18. An integrated computerized triage system in the emergency department.

    PubMed

    Aronsky, Dominik; Jones, Ian; Raines, Bill; Hemphill, Robin; Mayberry, Scott R; Luther, Melissa A; Slusser, Ted

    2008-01-01

    Emergency department (ED) triage is a fast-paced process that prioritizes the allocation of limited health care resources to patients in greatest need. This paper describes the experiences with an integrated, computerized triage application. The system exchanges information with other information systems, including the ED patient tracking board, the longitudinal electronic medical record, the computerized provider order entry, and the medi-cation reconciliation application. The application includes decision support capabilities such as assessing the patients acuity level, age-dependent alerts for vital signs, and clinical reminders. The browser-based system utilizes the institutions controlled vocabulary, improves data completeness and quality, such as compliance with capturing required data elements and screening questions, initiates clinical processes, such as pneumococcal vaccination ordering, and reminders to start clinical pathways, issues alerts for clinical trial eligibility, and facilitates various reporting needs. The system has supported the triage documentation of >140,000 pediatric and adult patients. PMID:18999190

  19. DYNAMICALLY EVOLVING CLINICAL PRACTICES AND IMPLICATIONS FOR PREDICTING MEDICAL DECISIONS.

    PubMed

    Chen, Jonathan H; Goldstein, Mary K; Asch, Steven M; Altman, Russ B

    2016-01-01

    Automatically data-mining clinical practice patterns from electronic health records (EHR) can enable prediction of future practices as a form of clinical decision support (CDS). Our objective is to determine the stability of learned clinical practice patterns over time and what implication this has when using varying longitudinal historical data sources towards predicting future decisions. We trained an association rule engine for clinical orders (e.g., labs, imaging, medications) using structured inpatient data from a tertiary academic hospital. Comparing top order associations per admission diagnosis from training data in 2009 vs. 2012, we find practice variability from unstable diagnoses with rank biased overlap (RBO)<0.35 (e.g., pneumonia) to stable admissions for planned procedures (e.g., chemotherapy, surgery) with comparatively high RBO>0.6. Predicting admission orders for future (2013) patients with associations trained on recent (2012) vs. older (2009) data improved accuracy evaluated by area under the receiver operating characteristic curve (ROC-AUC) 0.89 to 0.92, precision at ten (positive predictive value of the top ten predictions against actual orders) 30% to 37%, and weighted recall (sensitivity) at ten 2.4% to 13%, (P<10(-10)). Training with more longitudinal data (2009-2012) was no better than only using recent (2012) data. Secular trends in practice patterns likely explain why smaller but more recent training data is more accurate at predicting future practices. PMID:26776186

  20. DYNAMICALLY EVOLVING CLINICAL PRACTICES AND IMPLICATIONS FOR PREDICTING MEDICAL DECISIONS

    PubMed Central

    CHEN, JONATHAN H; GOLDSTEIN, MARY K; ASCH, STEVEN M; ALTMAN, RUSS B

    2015-01-01

    Automatically data-mining clinical practice patterns from electronic health records (EHR) can enable prediction of future practices as a form of clinical decision support (CDS). Our objective is to determine the stability of learned clinical practice patterns over time and what implication this has when using varying longitudinal historical data sources towards predicting future decisions. We trained an association rule engine for clinical orders (e.g., labs, imaging, medications) using structured inpatient data from a tertiary academic hospital. Comparing top order associations per admission diagnosis from training data in 2009 vs. 2012, we find practice variability from unstable diagnoses with rank biased overlap (RBO)<0.35 (e.g., pneumonia) to stable admissions for planned procedures (e.g., chemotherapy, surgery) with comparatively high RBO>0.6. Predicting admission orders for future (2013) patients with associations trained on recent (2012) vs. older (2009) data improved accuracy evaluated by area under the receiver operating characteristic curve (ROC-AUC) 0.89 to 0.92, precision at ten (positive predictive value of the top ten predictions against actual orders) 30% to 37%, and weighted recall (sensitivity) at ten 2.4% to 13%, (P<10−10). Training with more longitudinal data (2009-2012) was no better than only using recent (2012) data. Secular trends in practice patterns likely explain why smaller but more recent training data is more accurate at predicting future practices. PMID:26776186

  1. Clinical decision making-a functional medicine perspective.

    PubMed

    Pizzorno, Joseph E

    2012-09-01

    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

  2. Clinical decision support for physician order-entry: design challenges.

    PubMed

    Broverman, C A; Clyman, J I; Schlesinger, J M; Want, E

    1996-01-01

    We report on a joint development effort between ALLTEL Information Services Health Care Division and IBM Worldwide Healthcare Industry to demonstrate concurrent clinical decision support using Arden Syntax at order-entry time. The goal of the partnership is to build a high performance CDS toolkit that may be easily customized for multiple health care enterprises. Our work uses and promotes open technologies and health care standards while building a generalizable interface to a legacy patient-care system and clinical database. This paper identifies four areas of design challenges and solutions unique to a concurrent order-entry environment: the clinical information model, the currency of the patient virtual chart, the granularity of event triggers and rule evaluation context, and performance. PMID:8947731

  3. A Clinical Decision Support System for Breast Cancer Patients

    NASA Astrophysics Data System (ADS)

    Fernandes, Ana S.; Alves, Pedro; Jarman, Ian H.; Etchells, Terence A.; Fonseca, José M.; Lisboa, Paulo J. G.

    This paper proposes a Web clinical decision support system for clinical oncologists and for breast cancer patients making prognostic assessments, using the particular characteristics of the individual patient. This system comprises three different prognostic modelling methodologies: the clinically widely used Nottingham prognostic index (NPI); the Cox regression modelling and a partial logistic artificial neural network with automatic relevance determination (PLANN-ARD). All three models yield a different prognostic index that can be analysed together in order to obtain a more accurate prognostic assessment of the patient. Missing data is incorporated in the mentioned models, a common issue in medical data that was overcome using multiple imputation techniques. Risk group assignments are also provided through a methodology based on regression trees, where Boolean rules can be obtained expressed with patient characteristics.

  4. A highly scalable, interoperable clinical decision support service

    PubMed Central

    Goldberg, Howard S; Paterno, Marilyn D; Rocha, Beatriz H; Schaeffer, Molly; Wright, Adam; Erickson, Jessica L; Middleton, Blackford

    2014-01-01

    Objective To create a clinical decision support (CDS) system that is shareable across healthcare delivery systems and settings over large geographic regions. Materials and methods The enterprise clinical rules service (ECRS) realizes nine design principles through a series of enterprise java beans and leverages off-the-shelf rules management systems in order to provide consistent, maintainable, and scalable decision support in a variety of settings. Results The ECRS is deployed at Partners HealthCare System (PHS) and is in use for a series of trials by members of the CDS consortium, including internally developed systems at PHS, the Regenstrief Institute, and vendor-based systems deployed at locations in Oregon and New Jersey. Performance measures indicate that the ECRS provides sub-second response time when measured apart from services required to retrieve data and assemble the continuity of care document used as input. Discussion We consider related work, design decisions, comparisons with emerging national standards, and discuss uses and limitations of the ECRS. Conclusions ECRS design, implementation, and use in CDS consortium trials indicate that it provides the flexibility and modularity needed for broad use and performs adequately. Future work will investigate additional CDS patterns, alternative methods of data passing, and further optimizations in ECRS performance. PMID:23828174

  5. Eliminating Healthcare Disparities Via Mandatory Clinical Decision Support: The Venous Thromboembolism (VTE) Example

    PubMed Central

    Lau, Brandyn D.; Haider, Adil H.; Streiff, Michael B.; Lehmann, Christoph U.; Kraus, Peggy S.; Hobson, Deborah B.; Kraenzlin, Franca S.; Zeidan, Amer M.; Pronovost, Peter J.; Haut, Elliott R.

    2014-01-01

    Background All hospitalized patients should be assessed for VTE risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacologic prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen. Objectives To examine the effect of a quality improvement intervention on race- and gender-based healthcare disparities across two distinct clinical services. Research Design Retrospective cohort study of a quality improvement intervention Subjects 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients Measures Proportion of patients prescribed risk-appropriate, best-practice VTE prophylaxis Results Racial disparities existed in prescription of best-practice VTE prophylaxis in the pre-implementation period between black and white patients on both the trauma (70.1% vs. 56.6%, p=0.025) and medicine (69.5% vs. 61.7%, p=0.015) services. After implementation of the CCDS tool, compliance improved for all patients and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, p=0.99) and medicine (91.8% vs. 88.0%, p=0.082). Similar findings were noted for gender disparities in the trauma cohort. Conclusions Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and gender, practice varied widely prior to our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across two distinct clinical services. Health information technology approaches to care standardization are effective to eliminate healthcare disparities. PMID:25373403

  6. A health examination system integrated with clinical decision support system.

    PubMed

    Kuo, Kuan-Liang; Fuh, Chiou-Shann

    2010-10-01

    Health examinations play a key role in preventive medicine. We propose a health examination system named Health Examination Automatic Logic System (HEALS) to assist clinical workers in improving the total quality of health examinations. Quality of automated inference is confirmed by the zero inference error where during 6 months and 14,773 cases. Automated inference time is less than one second per case in contrast to 2 to 5 min for physicians. The most significant result of efficiency evaluation is that 3,494 of 4,356 (80.2%) cases take less than 3 min per case for producing a report summary. In the evaluation of effectiveness, novice physicians got 18% improvement in making decisions with the assistance of our system. We conclude that a health examination system with a clinical decision system can greatly reduce the mundane burden on clinical workers and markedly improve the quality and efficiency of health examination tasks. PMID:20703626

  7. Is it the time to rethink clinical decision-making strategies? From a single clinical outcome evaluation to a Clinical Multi-criteria Decision Assessment (CMDA).

    PubMed

    Migliore, Alberto; Integlia, Davide; Bizzi, Emanuele; Piaggio, Tomaso

    2015-10-01

    There are plenty of different clinical, organizational and economic parameters to consider in order having a complete assessment of the total impact of a pharmaceutical treatment. In the attempt to follow, a holistic approach aimed to provide an evaluation embracing all clinical parameters in order to choose the best treatments, it is necessary to compare and weight multiple criteria. Therefore, a change is required: we need to move from a decision-making context based on the assessment of one single criteria towards a transparent and systematic framework enabling decision makers to assess all relevant parameters simultaneously in order to choose the best treatment to use. In order to apply the MCDA methodology to clinical decision making the best pharmaceutical treatment (or medical devices) to use to treat a specific pathology, we suggest a specific application of the Multiple Criteria Decision Analysis for the purpose, like a Clinical Multi-criteria Decision Assessment CMDA. In CMDA, results from both meta-analysis and observational studies are used by a clinical consensus after attributing weights to specific domains and related parameters. The decision will result from a related comparison of all consequences (i.e., efficacy, safety, adherence, administration route) existing behind the choice to use a specific pharmacological treatment. The match will yield a score (in absolute value) that link each parameter with a specific intervention, and then a final score for each treatment. The higher is the final score; the most appropriate is the intervention to treat disease considering all criteria (domain an parameters). The results will allow the physician to evaluate the best clinical treatment for his patients considering at the same time all relevant criteria such as clinical effectiveness for all parameters and administration route. The use of CMDA model will yield a clear and complete indication of the best pharmaceutical treatment to use for patients

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

    PubMed

    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

    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

  9. Multiple Perspectives on the Meaning of Clinical Decision Support

    PubMed Central

    Richardson, Joshua E.; Ash, Joan S.; Sittig, Dean F.; Bunce, Arwen; Carpenter, James; Dykstra, Richard H.; Guappone, Ken; McCormack, James; McMullen, Carmit K.; Shapiro, Michael; Wright, Adam; Middleton, Blackford

    2010-01-01

    Clinical Decision Support (CDS) is viewed as a means to improve safety and efficiency in health care. Yet the lack of consensus about what is meant by CDS represents a barrier to effective design, implementation, and utilization of CDS tools. We conducted a multi-site qualitative inquiry to understand how different people define and describe CDS. Using subjects’ multiple perspectives we were able to gain new insights as to what stakeholders want CDS to achieve and how to achieve it even when those perspectives are competing and conflicting. PMID:21347119

  10. Multiple Perspectives on the Meaning of Clinical Decision Support

    PubMed Central

    Richardson, Joshua E.; Ash, Joan S.; Sittig, Dean F.; Bunce, Arwen; Carpenter, James; Dykstra, Richard H.; Guappone, Ken; McMullen, Carmit K.; Shapiro, Michael; Wright, Adam

    2010-01-01

    Clinical Decision Support (CDS) is viewed as a means to improve safety and efficiency in health care. Yet the lack of a consensus around what is meant by CDS represents a barrier to effective design, use, and utilization of CDS tools. We conducted a multi-site qualitative inquiry to understand how different people define and describe CDS. Using subjects’ multiple perspectives we were able to gain new insights as to what stakeholders want CDS to achieve and how to achieve it; even at times when those perspectives are competing and conflicting. PMID:21347063

  11. Evaluation of RxNorm for Medication Clinical Decision Support

    PubMed Central

    Freimuth, Robert R.; Wix, Kelly; Zhu, Qian; Siska, Mark; Chute, Christopher G.

    2014-01-01

    We evaluated the potential use of RxNorm to provide standardized representations of generic drug name and route of administration to facilitate management of drug lists for clinical decision support (CDS) rules. We found a clear representation of generic drug name but not route of administration. We identified several issues related to data quality, including erroneous or missing defined relationships, and the use of different concept hierarchies to represent the same drug. More importantly, we found extensive semantic precoordination of orthogonal concepts related to route and dose form, which would complicate the use of RxNorm for drug-based CDS. This study demonstrated that while RxNorm is a valuable resource for the standardization of medications used in clinical practice, additional work is required to enhance the terminology so that it can support expanded use cases, such as managing drug lists for CDS. PMID:25954360

  12. Clinical Decision Support Knowledge Management: Strategies for Success.

    PubMed

    Khalifa, Mohamed; Alswailem, Osama

    2015-01-01

    Clinical Decision Support Systems have been shown to increase quality of care, patient safety, improve adherence to guidelines for prevention and treatment, and avoid medication errors. Such systems depend mainly on two types of content; the clinical information related to patients and the medical knowledge related to the specialty that informs the system rules and alerts. At King Faisal Specialist Hospital and Research Center, Saudi Arabia, the Health Information Technology Affairs worked on identifying best strategies and recommendations for successful CDSS knowledge management. A review of literature was conducted to identify main areas of challenges and factors of success. A qualitative survey was used over six months' duration to collect opinions, experiences and suggestions from both IT and healthcare professionals. Recommendations were categorized into ten main topics that should be addressed during the development and implementation of CDSS knowledge management tools in the hospital. PMID:26152955

  13. Evaluation of RxNorm for Medication Clinical Decision Support.

    PubMed

    Freimuth, Robert R; Wix, Kelly; Zhu, Qian; Siska, Mark; Chute, Christopher G

    2014-01-01

    We evaluated the potential use of RxNorm to provide standardized representations of generic drug name and route of administration to facilitate management of drug lists for clinical decision support (CDS) rules. We found a clear representation of generic drug name but not route of administration. We identified several issues related to data quality, including erroneous or missing defined relationships, and the use of different concept hierarchies to represent the same drug. More importantly, we found extensive semantic precoordination of orthogonal concepts related to route and dose form, which would complicate the use of RxNorm for drug-based CDS. This study demonstrated that while RxNorm is a valuable resource for the standardization of medications used in clinical practice, additional work is required to enhance the terminology so that it can support expanded use cases, such as managing drug lists for CDS. PMID:25954360

  14. Reducing diagnostic errors in primary care. A systematic meta-review of computerized diagnostic decision support systems by the LINNEAUS collaboration on patient safety in primary care

    PubMed Central

    Nurek, Martine; Kostopoulou, Olga; Delaney, Brendan C; Esmail, Aneez

    2015-01-01

    ABSTRACT Background: Computerized diagnostic decision support systems (CDDSS) have the potential to support the cognitive task of diagnosis, which is one of the areas where general practitioners have greatest difficulty and which accounts for a significant proportion of adverse events recorded in the primary care setting. Objective: To determine the extent to which CDDSS may meet the requirements of supporting the cognitive task of diagnosis, and the currently perceived barriers that prevent the integration of CDDSS with electronic health record (EHR) systems. Methods: We conducted a meta-review of existing systematic reviews published in English, searching MEDLINE, Embase, PsycINFO and Web of Knowledge for articles on the features and effectiveness of CDDSS for medical diagnosis published since 2004. Eligibility criteria included systematic reviews where individual clinicians were primary end users. Outcomes we were interested in were the effectiveness and identification of specific features of CDDSS on diagnostic performance. Results: We identified 1970 studies and excluded 1938 because they did not fit our inclusion criteria. A total of 45 articles were identified and 12 were found suitable for meta-review. Extraction of high-level requirements identified that a more standardized computable approach is needed to knowledge representation, one that can be readily updated as new knowledge is gained. In addition, a deep integration with the EHR is needed in order to trigger at appropriate points in cognitive workflow. Conclusion: Developing a CDDSS that is able to utilize dynamic vocabulary tools to quickly capture and code relevant diagnostic findings, and coupling these with individualized diagnostic suggestions based on the best-available evidence has the potential to improve diagnostic accuracy, but requires evaluation. PMID:26339829

  15. Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy.

    PubMed

    Tunis, Sean R; Stryer, Daniel B; Clancy, Carolyn M

    2003-09-24

    Decision makers in health care are increasingly interested in using high-quality scientific evidence to support clinical and health policy choices; however, the quality of available scientific evidence is often found to be inadequate. Reliable evidence is essential to improve health care quality and to support efficient use of limited resources. The widespread gaps in evidence-based knowledge suggest that systematic flaws exist in the production of scientific evidence, in part because there is no consistent effort to conduct clinical trials designed to meet the needs of decision makers. Clinical trials for which the hypothesis and study design are developed specifically to answer the questions faced by decision makers are called pragmatic or practical clinical trials (PCTs). The characteristic features of PCTs are that they (1) select clinically relevant alternative interventions to compare, (2) include a diverse population of study participants, (3) recruit participants from heterogeneous practice settings, and (4) collect data on a broad range of health outcomes. The supply of PCTs is limited primarily because the major funders of clinical research, the National Institutes of Health and the medical products industry, do not focus on supporting such trials. Increasing the supply of PCTs will depend on the development of a mechanism to establish priorities for these studies, significant expansion of an infrastructure to conduct clinical research within the health care delivery system, more reliance on high-quality evidence by health care decision makers, and a substantial increase in public and private funding for these studies. For these changes to occur, clinical and health policy decision makers will need to become more involved in all aspects of clinical research, including priority setting, infrastructure development, and funding. PMID:14506122

  16. Are patient decision aids the best way to improve clinical decision making? Report of the IPDAS Symposium.

    PubMed

    Holmes-Rovner, Margaret; Nelson, Wendy L; Pignone, Michael; Elwyn, Glyn; Rovner, David R; O'Connor, Annette M; Coulter, Angela; Correa-de-Araujo, Rosaly

    2007-01-01

    This article reports on the International Patient Decision Aid Standards Symposium held in 2006 at the annual meeting of the Society for Medical Decision Making in Cambridge, Massachusetts. The symposium featured a debate regarding the proposition that "decision aids are the best way to improve clinical decision making.'' The formal debate addressed the theoretical problem of the appropriate gold standard for an improved decision, efficacy of decision aids, and prospects for implementation. Audience comments and questions focused on both theory and practice: the often unacknowledged roots of decision aids in expected utility theory and the practical problems of limited patient decision aid implementation in health care. The participants' vote on the proposition was approximately half for and half against. PMID:17873257

  17. Endodontic retreatment. Aspects of decision making and clinical outcome.

    PubMed

    Kvist, T

    2001-01-01

    regardless of assessment method. Compared with Standard gamble Visual Analogue Scale systematically produced lower ratings. U-values were found to change considerably in both the short and long-term. Any significant correlation between endodontists' U-values and retreatment prescriptions could not be demonstrated. Surgical and nonsurgical retreatment were randomly assigned to 95 "failed" root filled teeth in 92 patients. Cases were followed clinically and radiographically for four years postoperatively. At the 12-month recall a statistically significant higher healing rate was observed for teeth retreated surgically. At the final 48-month recall no systematic difference was detected. Patients were found to be more subject to postoperative discomfort when teeth were retreated surgically compared with nonsurgically. Consequently, surgical retreatment tended to be associated with higher indirect costs than a nonsurgically approach. In the final part of the thesis it is argued that retreatment decision making in everyday clinical practice normally should be based on simple principles. It is suggested that in order to achieve the best overall consequence a periapical lesion in a root filled tooth that is not expected to heal should be retreated. Arguments to withhold retreatment should be based on (i) respect for patient autonomy, (ii) retreatment risks or (iii) retreatment costs. PMID:11288682

  18. A systematic review of clinical decision rules for epilepsy.

    PubMed

    Josephson, Colin B; Sandy, Sherry; Jette, Nathalie; Sajobi, Tolulope T; Marshall, Deborah; Wiebe, Samuel

    2016-04-01

    Clinical decision rules (CDRs) have been empirically demonstrated to improve patient satisfaction and enhance cost-effective care. The use of CDRs has not yet been robustly explored for epilepsy. We performed a systematic review of MEDLINE (from 1946) and Embase (from 1947) using Medical Subject Headings and keywords related to CDRs and epilepsy. We included original research of any language deriving, validating, or implementing a CDR using standardized definitions. Study quality was determined using a modified version of previously published criteria. A bivariate model was used to meta-analyze studies undergoing sequential derivation and validation studies. Of 2445 unique articles, 5 were determined to be relevant to this review. Three were derivation studies (three diagnostic and one therapeutic), one validation study, and one combined derivation and validation study. No implementation studies were identified. Study quality varied but was primarily of a moderate level. Two CDRs were validated and, thus, able to be meta-analyzed. Although initial measures of accuracy were high (sensitivity ~80% or above), they tended to diminish significantly in the validation studies. The pooled estimates of sensitivity and specificity both exhibited wide 95% confidence and prediction intervals that may limit their utility in routine practice. Despite the advances in therapeutic and diagnostic interventions for epilepsy, few CDRs have been developed to guide their use. Future CDRs should address common clinical scenarios such as efficient use of diagnostic tools and optimal clinical treatment decisions. Given their potential for advancing efficient, evidence-based, patient-centered healthcare, CDR development should be a priority in epilepsy. PMID:26922491

  19. Biostatistics in clinical decision making for cardiothoracic radiologists.

    PubMed

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

    2013-11-01

    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

  20. Assessment of Readiness for Clinical Decision Support to Aid Laboratory Monitoring of Immunosuppressive Care at U.S. Liver Transplant Centers

    PubMed Central

    Weir, C.; Evans, R. S.; Staes, C.

    2014-01-01

    Summary Background Following liver transplantation, patients require lifelong immunosuppressive care and monitoring. Computerized clinical decision support (CDS) has been shown to improve post-transplant immunosuppressive care processes and outcomes. The readiness of transplant information systems to implement computerized CDS to support post-transplant care is unknown. Objectives a) Describe the current clinical information system functionality and manual and automated processes for laboratory monitoring of immunosuppressive care, b) describe the use of guidelines that may be used to produce computable logic and the use of computerized alerts to support guideline adherence, and c) explore barriers to implementation of CDS in U.S. liver transplant centers. Methods We developed a web-based survey using cognitive interviewing techniques. We surveyed 119 U.S. transplant programs that performed at least five liver transplantations per year during 2010–2012. Responses were summarized using descriptive analyses; barriers were identified using qualitative methods. Results Respondents from 80 programs (67% response rate) completed the survey. While 98% of programs reported having an electronic health record (EHR), all programs used paper-based manual processes to receive or track immunosuppressive laboratory results. Most programs (85%) reported that 30% or more of their patients used external laboratories for routine testing. Few programs (19%) received most external laboratory results as discrete data via electronic interfaces while most (80%) manually entered laboratory results into the EHR; less than half (42%) could integrate internal and external laboratory results. Nearly all programs had guidelines regarding pre-specified target ranges (92%) or testing schedules (97%) for managing immunosuppressive care. Few programs used computerized alerting to notify transplant coordinators of out-of-range (27%) or overdue laboratory results (20%). Conclusions Use of EHRs is

  1. Methodologic standards for interpreting clinical decision rules in emergency medicine: 2014 update.

    PubMed

    Green, Steven M; Schriger, David L; Yealy, Donald M

    2014-09-01

    Clinical decision rules are increasingly prominent in medicine, particularly in emergency care. The quality, use, and impact of current published decision rules widely vary, requiring clinicians to be critical consumers. We present an approach to assist in the appraisal of clinical decision rules and in judging when to use such rules. PMID:24530108

  2. Clinical decision support for perioperative information management systems.

    PubMed

    Wanderer, Jonathan P; Ehrenfeld, Jesse M

    2013-12-01

    Clinical decision support (CDS) systems are being used to optimize the increasingly complex care that our health care system delivers. These systems have become increasingly important in the delivery of perioperative care for patients undergoing cardiac, thoracic, and vascular procedures. The adoption of perioperative information management systems (PIMS) has allowed these technologies to enter the operating room and support the clinical work flow of anesthesiologists and operational processes. Constructing effective CDS systems necessitates an understanding of operative work flow and technical considerations as well as achieving integration with existing information systems. In this review, we describe published examples of CDS for PIMS, including support for cardiopulmonary bypass separation physiological alarms, β-blocker guideline adherence, enhanced revenue capture for arterial line placement, and detection of hemodynamic monitoring gaps. Although these and other areas are amenable to CDS systems, the challenges of latency and data reliability represent fundamental limitations on the potential application of these tools to specific types of clinical issues. Ultimately, we expect that CDS will remain an important tool in our efforts to optimize the quality of care delivered. PMID:23690340

  3. Optimizing perioperative decision making: improved information for clinical workflow planning.

    PubMed

    Doebbeling, Bradley N; Burton, Matthew M; Wiebke, Eric A; Miller, Spencer; Baxter, Laurence; Miller, Donald; Alvarez, Jorge; Pekny, Joseph

    2012-01-01

    Perioperative care is complex and involves multiple interconnected subsystems. Delayed starts, prolonged cases and overtime are common. Surgical procedures account for 40-70% of hospital revenues and 30-40% of total costs. Most planning and scheduling in healthcare is done without modern planning tools, which have potential for improving access by assisting in operations planning support. We identified key planning scenarios of interest to perioperative leaders, in order to examine the feasibility of applying combinatorial optimization software solving some of those planning issues in the operative setting. Perioperative leaders desire a broad range of tools for planning and assessing alternate solutions. Our modeled solutions generated feasible solutions that varied as expected, based on resource and policy assumptions and found better utilization of scarce resources. Combinatorial optimization modeling can effectively evaluate alternatives to support key decisions for planning clinical workflow and improving care efficiency and satisfaction. PMID:23304284

  4. Optimizing Perioperative Decision Making: Improved Information for Clinical Workflow Planning

    PubMed Central

    Doebbeling, Bradley N.; Burton, Matthew M.; Wiebke, Eric A.; Miller, Spencer; Baxter, Laurence; Miller, Donald; Alvarez, Jorge; Pekny, Joseph

    2012-01-01

    Perioperative care is complex and involves multiple interconnected subsystems. Delayed starts, prolonged cases and overtime are common. Surgical procedures account for 40–70% of hospital revenues and 30–40% of total costs. Most planning and scheduling in healthcare is done without modern planning tools, which have potential for improving access by assisting in operations planning support. We identified key planning scenarios of interest to perioperative leaders, in order to examine the feasibility of applying combinatorial optimization software solving some of those planning issues in the operative setting. Perioperative leaders desire a broad range of tools for planning and assessing alternate solutions. Our modeled solutions generated feasible solutions that varied as expected, based on resource and policy assumptions and found better utilization of scarce resources. Combinatorial optimization modeling can effectively evaluate alternatives to support key decisions for planning clinical workflow and improving care efficiency and satisfaction. PMID:23304284

  5. Comparison of two kinds of interface, based on guided navigation or usability principles, for improving the adoption of computerized decision support systems: application to the prescription of antibiotics

    PubMed Central

    Tsopra, Rosy; Jais, Jean-Philippe; Venot, Alain; Duclos, Catherine

    2014-01-01

    Context It is important to consider the way in which information is presented by the interfaces of clinical decision support systems, to favor the adoption of these systems by physicians. Interface design can focus on decision processes (guided navigation) or usability principles. Objective The aim of this study was to compare these two approaches in terms of perceived usability, accuracy rate, and confidence in the system. Materials and methods We displayed clinical practice guidelines for antibiotic treatment via two types of interface, which we compared in a crossover design. General practitioners were asked to provide responses for 10 clinical cases and the System Usability Scale (SUS) for each interface. We assessed SUS scores, the number of correct responses, and the confidence level for each interface. Results SUS score and percentage confidence were significantly higher for the interface designed according to usability principles (81 vs 51, p=0.00004, and 88.8% vs 80.7%, p=0.004). The percentage of correct responses was similar for the two interfaces. Discussion/conclusion The interface designed according to usability principles was perceived to be more usable and inspired greater confidence among physicians than the guided navigation interface. Consideration of usability principles in the construction of an interface—in particular ‘effective information presentation’, ‘consistency’, ‘efficient interactions’, ‘effective use of language’, and ‘minimizing cognitive load’—seemed to improve perceived usability and confidence in the system. PMID:24008427

  6. Clinical implementation of RNA signatures for pharmacogenomic decision-making

    PubMed Central

    Tang, Weihua; Hu, Zhiyuan; Muallem, Hind; Gulley, Margaret L

    2011-01-01

    RNA profiling is increasingly used to predict drug response, dose, or toxicity based on analysis of drug pharmacokinetic or pharmacodynamic pathways. Before implementing multiplexed RNA arrays in clinical practice, validation studies are carried out to demonstrate sufficient evidence of analytic and clinical performance, and to establish an assay protocol with quality assurance measures. Pathologists assure quality by selecting input tissue and by interpreting results in the context of the input tissue as well as the technologies that were used and the clinical setting in which the test was ordered. A strength of RNA profiling is the array-based measurement of tens to thousands of RNAs at once, including redundant tests for critical analytes or pathways to promote confidence in test results. Instrument and reagent manufacturers are crucial for supplying reliable components of the test system. Strategies for quality assurance include careful attention to RNA preservation and quality checks at pertinent steps in the assay protocol, beginning with specimen collection and proceeding through the various phases of transport, processing, storage, analysis, interpretation, and reporting. Specimen quality is checked by probing housekeeping transcripts, while spiked and exogenous controls serve as a check on analytic performance of the test system. Software is required to manipulate abundant array data and present it for interpretation by a laboratory physician who reports results in a manner facilitating therapeutic decision-making. Maintenance of the assay requires periodic documentation of personnel competency and laboratory proficiency. These strategies are shepherding genomic arrays into clinical settings to provide added value to patients and to the larger health care system. PMID:23226056

  7. A Scalable Architecture for Rule Engine Based Clinical Decision Support Systems.

    PubMed

    Chattopadhyay, Soumi; Banerjee, Ansuman; Banerjee, Nilanjan

    2015-01-01

    Clinical Decision Support systems (CDSS) have reached a fair level of sophistication and have emerged as the popular system of choice for their aid in clinical decision making. These decision support systems are based on rule engines navigate through a repertoire of clinical rules and multitudes of facts to assist a clinical expert to decide on the set of actuations in response to a medical situation. In this paper, we present the design of a scalable architecture for a rule engine based clinical decision system. PMID:26262249

  8. Computerized provider order entry systems.

    PubMed

    2001-01-01

    Computerized provider order entry (CPOE) systems are designed to replace a hospital's paper-based ordering system. They allow users to electronically write the full range of orders, maintain an online medication administration record, and review changes made to an order by successive personnel. They also offer safety alerts that are triggered when an unsafe order (such as for a duplicate drug therapy) is entered, as well as clinical decision support to guide caregivers to less expensive alternatives or to choices that better fit established hospital protocols. CPOE systems can, when correctly configured, markedly increase efficiency and improve patient safety and patient care. However, facilities need to recognize that currently available CPOE systems require a tremendous amount of time and effort to be spent in customization before their safety and clinical support features can be effectively implemented. What's more, even after they've been customized, the systems may still allow certain unsafe orders to be entered. Thus, CPOE systems are not currently a quick or easy remedy for medical errors. ECRI's Evaluation of CPOE systems--conducted in collaboration with the Institute for Safe Medication Practices (ISMP)--discusses these and other related issues. It also examines and compares CPOE systems from three suppliers: Eclipsys Corp., IDX Systems Corp., and Siemens Medical Solutions Health Services Corp. Our testing focuses primarily on the systems' interfacing capabilities, patient safeguards, and ease of use. PMID:11696968

  9. Evaluating clinical decision support rules as an intervention in clinician workflows with technology.

    PubMed

    Brokel, Jane M; Schwichtenberg, Tamara J; Wakefield, Douglas S; Ward, Marcia M; Shaw, Michael G; Kramer, J Michael

    2011-01-01

    The implementation of electronic health records in rural settings generated new challenges beyond those seen in urban hospitals. The preparation, implementation, and sustaining of clinical decision support rules require extensive attention to standards, content design, support resources, expert knowledge, and more. A formative evaluation was used to present progress and evolution of clinical decision support rule implementation and use within clinician workflows for application in an electronic health record. The rural hospital was able to use clinical decision support rules from five urban hospitals within its system to promote safety, prevent errors, establish evidence-based practices, and support communication. This article describes tools to validate initial 54 clinical decision support rules used in a rural referral hospital and 17 used in clinics. Since 2005, the study hospital has added specific system clinical decision support rules for catheter-acquired urinary tract infection, deep venous thrombosis, heart failure, and more. The findings validate the use of clinical decision support rules across sites and ability to use existing indicators to measure outcomes. Rural hospitals can rapidly overcome the barriers to prepare and implement as well as sustain use of clinical decision support rules with a systemized approach and support structures. A model for design and validation of clinical decision support rules into workflow processes is presented. The replication and reuse of clinical decision support rule templates with data specifications that follow data models can support reapplication of the rule intervention in subsequent rural and critical access hospitals through system support resources. PMID:21099543

  10. A rule-based clinical decision model to support interpretation of multiple data in health examinations.

    PubMed

    Kuo, Kuan-Liang; Fuh, Chiou-Shann

    2011-12-01

    Health examinations can obtain relatively complete health information and thus are important for the personal and public health management. For clinicians, one of the most important works in the health examinations is to interpret the health examination results. Continuously interpreting numerous health examination results of healthcare receivers is tedious and error-prone. This paper proposes a clinical decision support system to assist solving above problems. In order to customize the clinical decision support system intuitively and flexibly, this paper also proposes the rule syntax to implement computer-interpretable logic for health examinations. It is our purpose in this paper to describe the methodology of the proposed clinical decision support system. The evaluation was performed by the implementation and execution of decision rules on health examination results and a survey on clinical decision support system users. It reveals the efficiency and user satisfaction of proposed clinical decision support system. Positive impact of clinical data interpretation is also noted. PMID:20703517

  11. Are more endodontic consultations needed in dental school clinic settings? A study of treatment decisions at one school.

    PubMed

    Aminoshariae, Anita; Tulunoglu, Ibrahim; Demko, Catherine; Galsterer, Mark; Montagnese, Thomas A; Mickel, Andre

    2015-04-01

    With no previous studies of the occurrence of interdisciplinary consultations for tooth extraction in a dental school clinic setting, the aim of this cross-sectional descriptive investigation was to measure and compare the consultation process that occurred among departments at one U.S. dental school for making treatment decisions on tooth extraction. A comprehensive computerized retrieval (Crystal Reports) was used to identify and gather data from patient records from July 1, 2007, to July 1, 2011. Treatment plans and progress notes were analyzed to determine why each tooth had been extracted and which department had recommended the extraction. Results showed that the clinical departments involved in treatment planning decisions were the DMD dental student clinic, Department of Periodontics, and Department of Endodontics. The narrative records of 227 patients who had 516 teeth extracted were examined. About three-fourths (73.26%) of the extracted teeth were extracted based on the recommendation of only one department. Of these extracted teeth, 22.0% (n=114) were previously endodontically treated, and only four were recommended for endodontic consultation prior to extraction. The study found that most extractions were performed without specialty consultations and that the Department of Endodontics was consulted the least of all departments. To foster interdisciplinary collaboration in dental school clinics and help students develop expertise in such collaborations, more specialty consultations are needed for teeth that are treatment planned for extraction in order to preclude needless extraction of potentially salvageable teeth. Doing so will provide benefits for both patient care and students' education. PMID:25838010

  12. An Analysis of a Computerized System for Managing Curriculum Decisions and Tracking Student Progress in a Home-Based Pre-School Education Project.

    ERIC Educational Resources Information Center

    Lutz, John E.; And Others

    The degree of success of the computerized Child-Based Information System (CBIS) was analyzed in two areas--presenting, delivering, and managing a developmental curriculum; and recording, filing, and monitoring child tracking data, including requirements for Individualized Education Plans (IEP's). Preschool handicapped and high-risk children and…

  13. Attitude of Iranian physicians and nurses toward a clinical decision support system for pulmonary embolism and deep vein thrombosis.

    PubMed

    Agharezaei, Zhila; Bahaadinbeigy, Kambiz; Tofighi, Shahram; Agharezaei, Laleh; Nemati, Ali

    2014-07-01

    This research project sought to design and implement a computerized clinical decision support system (CDSS) that was able to identify patients who were at risk of pulmonary embolism (PE) and deep vein thrombosis (DVT), as well as produce reminders for prophylactic action for these diseases. The main purpose of the CDSS was to attempt to reduce the morbidity and mortality caused by embolism and thrombosis in patients admitted to hospitals. After implementation of this system in one of the large educational hospitals of Iran, a standard questionnaire was used, and interviews were conducted with physicians and nurses to evaluate the performance of the designed system for reducing the incidence of pulmonary embolism and thrombosis. From physicians and nurses' point of view, a system which assists the medical staff in making better decisions regarding patient care, and also reminds pulmonary embolism and thrombosis preventive procedures with timely warnings, can influence patient care quality improvement and lead to the improved performance of the medical staff in preventing the incidence of pulmonary embolism and thrombosis. PMID:24768080

  14. Improving Clinical Decisions on T2DM Patients Integrating Clinical, Administrative and Environmental Data.

    PubMed

    Segagni, Daniele; Sacchi, Lucia; Dagliati, Arianna; Tibollo, Valentina; Leporati, Paola; De Cata, Pasqale; Chiovato, Luca; Bellazzi, Riccardo

    2015-01-01

    This work describes an integrated informatics system developed to collect and display clinically relevant data that can inform physicians and researchers about Type 2 Diabetes Mellitus (T2DM) patient clinical pathways and therapy adherence. The software we developed takes data coming from the electronic medical record (EMR) of the IRCCS Fondazione Maugeri (FSM) hospital of Pavia, Italy, and combines the data with administrative, pharmacy drugs (purchased from the local healthcare agency (ASL) of the Pavia area), and open environmental data of the same region. By using different use cases, we explain the importance of gathering and displaying the data types through a single informatics tool: the use of the tool as a calculator of risk factors and indicators to improve current detection of T2DM, a generator of clinical pathways and patients' behaviors from the point of view of the hospital care management, and a decision support tool for follow-up visits. The results of the performed data analysis report how the use of the dashboard displays meaningful clinical decisions in treating complex chronic diseases and might improve health outcomes. PMID:26262138

  15. Development of a clinical event monitor for use with the Veterans Affairs Computerized Patient Record System and other data sources.

    PubMed Central

    Payne, T. H.; Savarino, J.

    1998-01-01

    We are developing an event monitor to operate with the Veterans Affairs Computerized Patient Record System (CPRS). The event monitor is designed to receive messages when important patient events such as posting of new results, patient movement, and orders occur. Our design separates the event monitor from CPRS itself, using communication via a network connection to receive HL7 messages, to access other data needed to run rules, and to communicate with providers by message display, electronic mail and other mechanisms. Results from operation of the event monitor using patient data in our test account show that a wide variety of data can be accessed by the event monitor with acceptable response times. Images Figure 1 PMID:9929199

  16. Decision analysis in the clinical neurosciences: a systematic review of the literature.

    PubMed

    Dippel, D W; Habbema, J D

    1995-12-01

    Clinical decision analysis can be a useful scientific tool for individual patient management, for planning of clinical research and for reaching consensus about clinical problems. We systematically reviewed the decision analytic studies in the clinical neurosciences that were published between 1975 and July 1994. All studies were assessed on aspects of clinical applicability: presence of case and context description, completeness of the analysed strategies from a clinical point of view, extendibility of the analyses to different patient profiles, and up-to-date-ness. Fifty-nine decision analyses of twenty-eight different clinical problems were identified. Twenty-eight analyses were based on the theory of subjective expected utility, twelve on cost-effectiveness analysis. Four studies used ROC analysis, and fifteen were risk-, or risk-benefit analyses. At least six studies could have been improved by more elaborately disclosing the context of the clinical problem that was addressed. In eleven studies, the effect of different, yet plausible assumptions was not explored, and in eighteen studies the reader was not informed how to extend the results of the analysis to patients with (slightly) different clinical characterisitics. All studies had, by nature, the potential to promote insight into the clinical problem and focus the discussion on clinically important aspects, and gave clinically useful advice. We conclude that clinical decision analysis, as an explicit, quantitative approach to uncertainty in decision making in the clinical neurosciences will fulfill a growing need in the near future. PMID:24283779

  17. Clinical decision making in restorative dentistry, endodontics, and antibiotic prescription.

    PubMed

    Zadik, Yehuda; Levin, Liran

    2008-01-01

    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 whether they would routinely prescribe antibiotics following regular endodontic treatment, retreatment, and impacted third molar surgical extraction in healthy patients. There was a 94 percent (n=92) response rate, of which eighty-five responses were used in the data analysis. Surgical treatment of asymptomatic enamel caries lesions was not recommended by most of the subjects, and surgery was recommended for DEJ caries lesions in low or moderate caries risk patients, both without significant differences between geographic regions of dental school graduation. Israelis had a lower frequency of retreatment in asymptomatic teeth that demonstrated periapical radiolucency with post restoration (without crown) compared to Latin Americans and East Europeans. Most of the participants would not retreat asymptomatic teeth that demonstrated periapical radiolucency with post and crown. After third molar surgery, 46 percent of participants routinely prescribed antibiotics. Significantly more Latin American graduates prescribed antibiotics following endodontic treatment, retreatment, and third molar extractions (p<0.05). Overmedication (antibiotics) and overtreatment (caries) among young practitioners reflect failure of undergraduate education in proper use of antibiotics and management of the carious lesions according to the patient's clinical presentation and caries risk assessment rather than routinely undertaking surgical caries treatment. PMID:18172239

  18. SANDS: a service-oriented architecture for clinical decision support in a National Health Information Network.

    PubMed

    Wright, Adam; Sittig, Dean F

    2008-12-01

    In this paper, we describe and evaluate a new distributed architecture for clinical decision support called SANDS (Service-oriented Architecture for NHIN Decision Support), which leverages current health information exchange efforts and is based on the principles of a service-oriented architecture. The architecture allows disparate clinical information systems and clinical decision support systems to be seamlessly integrated over a network according to a set of interfaces and protocols described in this paper. The architecture described is fully defined and developed, and six use cases have been developed and tested using a prototype electronic health record which links to one of the existing prototype National Health Information Networks (NHIN): drug interaction checking, syndromic surveillance, diagnostic decision support, inappropriate prescribing in older adults, information at the point of care and a simple personal health record. Some of these use cases utilize existing decision support systems, which are either commercially or freely available at present, and developed outside of the SANDS project, while other use cases are based on decision support systems developed specifically for the project. Open source code for many of these components is available, and an open source reference parser is also available for comparison and testing of other clinical information systems and clinical decision support systems that wish to implement the SANDS architecture. The SANDS architecture for decision support has several significant advantages over other architectures for clinical decision support. The most salient of these are: PMID:18434256

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

    PubMed Central

    2013-01-01

    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

  20. System-agnostic clinical decision support services: benefits and challenges for scalable decision support.

    PubMed

    Kawamoto, Kensaku; Del Fiol, Guilherme; Orton, Charles; Lobach, David F

    2010-01-01

    System-agnostic clinical decision support (CDS) services provide patient evaluation capabilities that are independent of specific CDS systems and system implementation contexts. While such system-agnostic CDS services hold great potential for facilitating the widespread implementation of CDS systems, little has been described regarding the benefits and challenges of their use. In this manuscript, the authors address this need by describing potential benefits and challenges of using a system-agnostic CDS service. This analysis is based on the authors' formal assessments of, and practical experiences with, various approaches to developing, implementing, and maintaining CDS capabilities. In particular, the analysis draws on the authors' experience developing and leveraging a system-agnostic CDS Web service known as SEBASTIAN. A primary potential benefit of using a system-agnostic CDS service is the relative ease and flexibility with which the service can be leveraged to implement CDS capabilities across applications and care settings. Other important potential benefits include facilitation of centralized knowledge management and knowledge sharing; the potential to support multiple underlying knowledge representations and knowledge resources through a common service interface; improved simplicity and componentization; easier testing and validation; and the enabling of distributed CDS system development. Conversely, important potential challenges include the increased effort required to develop knowledge resources capable of being used in many contexts and the critical need to standardize the service interface. Despite these challenges, our experiences to date indicate that the benefits of using a system-agnostic CDS service generally outweigh the challenges of using this approach to implementing and maintaining CDS systems. PMID:21603281

  1. Representation of Clinical Practice Guidelines in Conventional and Augmented Decision Tables

    PubMed Central

    Shiffman, Richard N.

    1997-01-01

    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

  2. Usability of clinical decision support system as a facilitator for learning the assistive technology adaptation process.

    PubMed

    Danial-Saad, Alexandra; Kuflik, Tsvi; Weiss, Patrice L Tamar; Schreuer, Naomi

    2016-01-01

    The aim of this study was to evaluate the usability of Ontology Supported Computerized Assistive Technology Recommender (OSCAR), a Clinical Decision Support System (CDSS) for the assistive technology adaptation process, its impact on learning the matching process, and to determine the relationship between its usability and learnability. Two groups of expert and novice clinicians (total, n = 26) took part in this study. Each group filled out system usability scale (SUS) to evaluate OSCAR's usability. The novice group completed a learning questionnaire to assess OSCAR's effect on their ability to learn the matching process. Both groups rated OSCAR's usability as "very good", (M [SUS] = 80.7, SD = 11.6, median = 83.7) by the novices, and (M [SUS] = 81.2, SD = 6.8, median = 81.2) by the experts. The Mann-Whitney results indicated that no significant differences were found between the expert and novice groups in terms of OSCAR's usability. A significant positive correlation existed between the usability of OSCAR and the ability to learn the adaptation process (rs = 0.46, p = 0.04). Usability is an important factor in the acceptance of a system. The successful application of user-centered design principles during the development of OSCAR may serve as a case study that models the significant elements to be considered, theoretically and practically in developing other systems. Implications for Rehabilitation Creating a CDSS with a focus on its usability is an important factor for its acceptance by its users. Successful usability outcomes can impact the learning process of the subject matter in general, and the AT prescription process in particular. The successful application of User-Centered Design principles during the development of OSCAR may serve as a case study that models the significant elements to be considered, theoretically and practically. The study emphasizes the importance of close collaboration between the developers and

  3. A Representation for Gaining Insight into Clinical Decision Models

    PubMed Central

    Jimison, Holly B.

    1988-01-01

    For many medical domains uncertainty and patient preferences are important components of decision making. Decision theory is useful as a representation for such medical models in computer decision aids, but the methodology has typically had poor performance in the areas of explanation and user interface. The additional representation of probabilities and utilities as random variables serves to provide a framework for graphical and text insight into complicated decision models. The approach allows for efficient customization of a generic model that describes the general patient population of interest to a patient- specific model. Monte Carlo simulation is used to calculate the expected value of information and sensitivity for each model variable, thus providing a metric for deciding what to emphasize in the graphics and text summary. The computer-generated explanation includes variables that are sensitive with respect to the decision or that deviate significantly from what is typically observed. These techniques serve to keep the assessment and explanation of the patient's decision model concise, allowing the user to focus on the most important aspects for that patient.

  4. Hodgkin lymphoma patients in first remission: routine positron emission tomography/computerized tomography imaging is not superior to clinical follow-up for patients with no residual mass.

    PubMed

    Dann, Eldad J; Berkahn, Leanne; Mashiach, Tatiana; Frumer, Michael; Agur, Ariel; McDiarmid, Bridgett; Bar-Shalom, Rachel; Paltiel, Ora; Goldschmidt, Neta

    2014-03-01

    There is no consensus regarding optimal follow-up mode for Hodgkin lymphoma (HL) patients that achieve complete remission following chemotherapy or combined chemo- and radiation therapy. Several studies demonstrated high sensitivity of positron emission tomography/computerized tomography (PET/CT) in detecting disease progression; however, these techniques are currently not recommended for routine follow-up. This retrospective study conducted in two Israeli (N = 291) and one New Zealand academic centres (N = 77), compared a group of HL patients, followed-up with routine imaging every 6 months during the first 2 years after achieving remission, once in the third year, with additional dedicated studies performed due to symptoms or physical findings (Group I) to a group of patients without residual masses who underwent clinically-based surveillance with dedicated imaging upon relapse suspicion (Group II). Five-year overall survival (OS) was 94% and median time to relapse was 8·6 months for both modes. Relapse rates in Groups I and II were 13% and 9%, respectively. During the first 3 years of follow-up, 47·5 and 4·7 studies were performed per detected relapse in Groups I and II, respectively. The current study demonstrated no benefit in either progression-free survival (PFS) or OS in HL patients followed by routine imaging versus clinical follow-up. The cost was 10 times higher for routine imaging. PMID:24313286

  5. Transient ischaemic attack clinic: an evaluation of diagnoses and clinical decision making.

    PubMed

    Lee, Will; Frayne, Judith

    2015-04-01

    The diagnosis of transient ischaemic attack (TIA) is based largely on the patient's symptom recall and clinical judgement. This decision-making process is highly subjective and the inter-observer reliability of TIA diagnosis is at best moderate, even among neurologists. The aim of this study is to examine the presenting features and final diagnoses of referrals to a TIA clinic and to evaluate characteristics that favoured the diagnosis of TIA over other TIA "mimics". Consecutive new referrals to a tertiary metropolitan hospital TIA clinic over a 9month period were examined. Characteristics between TIA and non-TIA diagnoses were compared and analysed. Eighty-two patients were recruited. Eighteen (22%) were given a final diagnosis of TIA or stroke. Major alternative diagnoses included migraine (n=17, 21%), presyncope/syncope (n=13, 16%) and anxiety (n=7, 9%). Four (5%) patients had unclassifiable symptoms with no clear final diagnosis. Mean age was 67±a standard deviation of 17years and patients diagnosed with TIA/stroke were on average older than those with non-TIA diagnoses (77±10 versus 64±17years, p=0.003). A diagnosis of TIA/stroke was favoured in the presence of moderate to severe weakness (p=0.032), dysphasia (p=0.037) or dysarthria (p=0.005). Unclassifiable symptoms (for example, palpitations, confusion, headache) were reported in 27 patients (33%) and their presence favoured non-TIA diagnoses (p=0.0003). TIA constituted a minority of the referrals to our clinic. Accurate clinical diagnosis of TIA facilitates early stroke prevention and avoids unnecessary investigations and prescriptions. Attempts to improve diagnostic accuracy of TIA should target improving the education and awareness of frontline medical practitioners. PMID:25669115

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

    PubMed Central

    2011-01-01

    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

  7. Clinical capital equipment acquisition: decision-making at the executive level.

    PubMed

    Greisler, D S; Stupak, R J

    1999-01-01

    Capital investment in the United States health care industry is one of the components of the system that has historically fueled cost increases and complicated the quality/cost/access conundrum. This article is concerned with capital development focused on clinical equipment acquisition in acute care hospitals. The research findings suggest that decision-makers are abandoning two approaches to decision-making known as Quantitative Decision-Making and Mixed Scanning in favor of two models known as Rational Decision-Making and Political Decision-Making. While this is the case, a method of decision-making known as Idea Sets (developed and labeled by James March as Garbage Can Decision-Making) is the most widely used approach. Equipment acquisition criteria used by the decision-makers are shifting away from concerns of enhancing existing clinical programs and/or adding new clinical programs. Acquisition criteria are shifting toward procuring equipment which will decrease institutional expense, improve organizational efficiency, and galvanize operational effectiveness. In addition to the technical findings of the research, further insights about ourselves and our colleagues are gleaned. Accordingly, we understand more completely the human dynamics surrounding decisions and thus are able to dialogue more richly about issues. Meaningful dialogue such as this will have the dual benefit of advancing teamwork and facilitating decision-making. PMID:10848195

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

    ERIC Educational Resources Information Center

    Jeffrey, Aaron

    2012-01-01

    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…

  9. Clinical Verification of A Clinical Decision Support System for Ventilator Weaning

    PubMed Central

    2013-01-01

    Background Weaning is typically regarded as a process of discontinuing mechanical ventilation in the daily practice of an intensive care unit (ICU). Among the ICU patients, 39%-40% need mechanical ventilator for sustaining their lives. The predictive rate of successful weaning achieved only 35-60% for decisions made by physicians. Clinical decision support systems (CDSSs) are promising in enhancing diagnostic performance and improve healthcare quality in clinical setting. To our knowledge, a prospective study has never been conducted to verify the effectiveness of the CDSS in ventilator weaning before. In this study, the CDSS capable of predicting weaning outcome and reducing duration of ventilator support for patients has been verified. Methods A total of 380 patients admitted to the respiratory care center of the hospital were randomly assigned to either control or study group. In the control group, patients were weaned with traditional weaning method, while in the study group, patients were weaned with CDSS monitored by physicians. After excluding the patients who transferred to other hospitals, refused further treatments, or expired the admission period, data of 168 and 144 patients in the study and control groups, respectively, were used for analysis. Results The results show that a sensitivity of 87.7% has been achieved, which is significantly higher (p<0.01) than the weaning determined by physicians (sensitivity: 61.4%). Furthermore, the days using mechanical ventilator for the study group (38.41 ± 3.35) is significantly (p<0.001) shorter than the control group (43.69 ± 14.89), with a decrease of 5.2 days in average, resulting in a saving of healthcare cost of NT$45,000 (US$1,500) per patient in the current Taiwanese National Health Insurance setting. Conclusions The CDSS is demonstrated to be effective in identifying the earliest time of ventilator weaning for patients to resume and sustain spontaneous breathing, thereby avoiding unnecessary prolonged

  10. Mental Workload as a Key Factor in Clinical Decision Making

    ERIC Educational Resources Information Center

    Byrne, Aidan

    2013-01-01

    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…

  11. [Locator or ball attachment: a guide for clinical decision making].

    PubMed

    Büttel, Adrian E; Bühler, Nico M; Marinello, Carlo P

    2009-01-01

    Various attachments are available to retain overdentures on natural roots or implants. Technical aspects, the clinical handling, the capability to adapt or repair and the costs are parameters to be considered when choosing the appropriate attachment. Ball attachments and bars are clinically established and well documented. Ball attachments as prefabricated, unsplinted units are easily replaceable and show hygienic advantages, while bars show favorable stability. The Locator is a newer, popular clinical alternative to these established attachments. The ball attachment and the Locator are compared from a technical and clinical point of view. PMID:19852208

  12. 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

    2013-01-01

    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

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

    ERIC Educational Resources Information Center

    Wolfenden, Andrew

    2012-01-01

    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…

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

    ERIC Educational Resources Information Center

    Krumwiede, Kelly A.

    2010-01-01

    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.…

  15. Disciplined Decision Making in an Interdisciplinary Environment: Some Implications for Clinical Applications of Statistical Process Control.

    ERIC Educational Resources Information Center

    Hantula, Donald A.

    1995-01-01

    Clinical applications of statistical process control (SPC) in human service organizations are considered. SPC is seen as providing a standard set of criteria that serves as a common interface for data-based decision making, which may bring decision making under the control of established contingencies rather than the immediate contingencies of…

  16. [An expert system of aiding decision making in breast pathology connected to a clinical data base].

    PubMed

    Brunet, M; Durrleman, S; Ferber, J; Ganascia, J G; Hacene, K; Hirt, F; Jouniaux, F; Meeus, L

    1987-01-01

    The René Huguenin Cancer Center holds a medical file for each patient which is intended to store and process medical data. Since 1970, we introduced computerization: a development plan was elaborated and simultaneously a statistical software (Clotilde--GSI/CFRO) was selected. Thus, we now have access to a large database, structured according to medical rationale, and utilizable with methods of artificial intelligence towards three objectives: improved data acquisition, decision making and exploitation. The first application was to breast pathology, which represents one of the Center's primary activities. The structure of the data concerning patients is by all criteria part of the medical knowledge. This information needs to be presented as well as processed with a suitable language. To this end, we chose a language-oriented object, Mering II, usable with Apple and IBM 4 micro-computers. This project has already allowed to work out an operational model. PMID:3620732

  17. SANDS: A Service-Oriented Architecture for Clinical Decision Support in a National Health Information Network

    PubMed Central

    Wright, Adam; Sittig, Dean F.

    2008-01-01

    In this paper we describe and evaluate a new distributed architecture for clinical decision support called SANDS (Service-oriented Architecture for NHIN Decision Support), which leverages current health information exchange efforts and is based on the principles of a service-oriented architecture. The architecture allows disparate clinical information systems and clinical decision support systems to be seamlessly integrated over a network according to a set of interfaces and protocols described in this paper. The architecture described is fully defined and developed, and six use cases have been developed and tested using a prototype electronic health record which links to one of the existing prototype National Health Information Networks (NHIN): drug interaction checking, syndromic surveillance, diagnostic decision support, inappropriate prescribing in older adults, information at the point of care and a simple personal health record. Some of these use cases utilize existing decision support systems, which are either commercially or freely available at present, and developed outside of the SANDS project, while other use cases are based on decision support systems developed specifically for the project. Open source code for many of these components is available, and an open source reference parser is also available for comparison and testing of other clinical information systems and clinical decision support systems that wish to implement the SANDS architecture. PMID:18434256

  18. Clinical Decision Analysis and Markov Modeling for Surgeons: An Introductory Overview.

    PubMed

    Hogendoorn, Wouter; Moll, Frans L; Sumpio, Bauer E; Hunink, M G Myriam

    2016-08-01

    This study addresses the use of decision analysis and Markov models to make contemplated decisions for surgical problems. Decision analysis and decision modeling in surgical research are increasing, but many surgeons are unfamiliar with the techniques and are skeptical of the results. The goal of this review is to familiarize surgeons with techniques and terminology used in decision analytic papers, to provide the reader a practical guide to read these papers, and to ensure that surgeons can critically appraise the quality of published clinical decision models and draw well founded conclusions from such reports.First, a brief explanation of decision analysis and Markov models is presented in simple steps, followed by an overview of the components of a decision and Markov model. Subsequently, commonly used terms and definitions are described and explained, including quality-adjusted life-years, disability-adjusted life-years, discounting, half-cycle correction, cycle length, probabilistic sensitivity analysis, incremental cost-effectiveness ratio, and the willingness-to-pay threshold.Finally, the advantages and limitations of research with Markov models are described, and new modeling techniques and future perspectives are discussed. It is important that surgeons are able to understand conclusions from decision analytic studies and are familiar with the specific definitions of the terminology used in the field to keep up with surgical research. Decision analysis can guide treatment strategies when complex clinical questions need to be answered and is a necessary and useful addition to the surgical research armamentarium. PMID:26756750

  19. The factors facilitating and inhibiting effective clinical decision-making in nursing: a qualitative study

    PubMed Central

    Hagbaghery, Mohsen Adib; Salsali, Mahvash; Ahmadi, Fazlolah

    2004-01-01

    Background Nurses' practice takes place in a context of ongoing advances in research and technology. The dynamic and uncertain nature of health care environment requires nurses to be competent decision-makers in order to respond to clients' needs. Recently, the public and the government have criticized Iranian nurses because of poor quality of patient care. However nurses' views and experiences on factors that affect their clinical function and clinical decision-making have rarely been studied. Methods Grounded theory methodology was used to analyze the participants' lived experiences and their viewpoints regarding the factors affecting their clinical function and clinical decision-making. Semi-structured interviews and participant observation methods were used to gather the data. Thirty-eight participants were interviewed and twelve sessions of observation were carried out. Constant comparative analysis method was used to analyze the data. Results Five main themes emerged from the data. From the participants' points of view, "feeling competent", "being self-confident", "organizational structure", "nursing education", and "being supported" were considered as important factors in effective clinical decision-making. Conclusion As participants in this research implied, being competent and self-confident are the most important personal factors influencing nurses clinical decision-making. Also external factors such as organizational structure, access to supportive resources and nursing education have strengthening or inhibiting effects on the nurses' decisions. Individual nurses, professional associations, schools of nursing, nurse educators, organizations that employ nurses and government all have responsibility for developing and finding strategies that facilitate nurses' effective clinical decision-making. They are responsible for identifying barriers and enhancing factors within the organizational structure that facilitate nurses' clinical decision-making. PMID

  20. Use of Simulation to Study Nurses' Acceptance and Nonacceptance of Clinical Decision Support Suggestions.

    PubMed

    Sousa, Vanessa E C; Lopez, Karen Dunn; Febretti, Alessandro; Stifter, Janet; Yao, Yingwei; Johnson, Andrew; Wilkie, Diana J; Keenan, Gail M

    2015-10-01

    Our long-term goal was to ensure nurse clinical decision support works as intended before full deployment in clinical practice. As part of a broader effort, this pilot project explored factors influencing acceptance/nonacceptance of eight clinical decision support suggestions displayed in an electronic health record-based nursing plan of care software prototype. A diverse sample of 21 nurses participated in this high-fidelity clinical simulation experience and completed a questionnaire to assess reasons for accepting/not accepting the clinical decision support suggestions. Of 168 total suggestions displayed during the experiment (eight for each of the 21 nurses), 123 (73.2%) were accepted, and 45 (26.8%) were not accepted. The mode number of acceptances by nurses was seven of eight, with only two of 21 nurses accepting all. The main reason for clinical decision support acceptance was the nurse's belief that the suggestions were good for the patient (100%), with other features providing secondary reinforcement. Reasons for nonacceptance were less clear, with fewer than half of the subjects indicating low confidence in the evidence. This study provides preliminary evidence that high-quality simulation and targeted questionnaires about specific clinical decision support selections offer a cost-effective means for testing before full deployment in clinical practice. PMID:26361268

  1. Hip fractures and dementia: clinical decisions for the future

    PubMed Central

    Waran, Eswaran; William, Leeroy

    2016-01-01

    Severe dementia is a life-limiting condition; hip fractures are more common in patients who have dementia. This study outlines the case of a 92-year-old female with severe dementia who sustained a hip fracture. Despite having a terminal diagnosis (severe dementia and hip fracture) and poor premorbid quality of life, she had a life-prolonging surgery. The report outlines issues around treatment options in such circumstances, informed consent and substitute decision-making. The authors propose a ‘goals of care’ approach to manage patients in whom the best treatment is unclear, during their attendance to the emergency department. It is suggested that utilization of such a model may help with substitute decision-making and true informed consent. PMID:26949537

  2. A decision-analysis methodology for consideration of morbidity factors in clinical decision-making.

    PubMed

    Corder, M P; Ellwein, L B

    1984-02-01

    An explicit and systematic means of incorporation of good medical practice plus individual patient preferences (utilities) for pretreatment and treatment options for a serious but curable neoplastic disease has been investigated. The methodology allows important quality-of-life information to be transmitted to patients, with the goal of providing an improved basis for informed consent. The example of Hodgkin's lymphoma staging and treatment selection is used. Individual patient utilities can be expressed and incorporated into a formal decision analysis for those who face the option of selecting MOPP chemotherapy or of pursuing the staging process in order to obtain a chance of being treated appropriately with irradiation. Equal survival probabilities for the two options are assumed, thus the short- and long-term toxicities (quality of Life) are the determinants of the decision. Patient-derived utilities can be developed for the 15 categories of anticipated toxicity. This, together with probabilistic inputs regarding toxicity severity and duration, will yield expected utilities for each of the decision options. Three physicians were studied and evaluated in the role of a patient. The physicians' toxicity preferences were different and because of this the management option of choice was different for each. This methodology allows explicit patient preferences to be incorporated into medical decisions without the requirement for detailed patient understanding of testing and/or treatment morbidity frequency and severity. PMID:6546469

  3. Nursing Research Using Computerized Data Bases

    PubMed Central

    McCormick, Kathleen A.

    1981-01-01

    Because of the implementation of large computerized information systems, the analyses of patient care data important to clinical nursing research is possible. Simultaneously, the heralding of computer technology in clinical practice areas has necessitated new research ideas to be pursued. This paper will describe a taxonomy of research data available on hospital information systems that may be used for clinical nursing research.

  4. 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

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

    2000-01-01

    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

  5. Development and Testing of a Computerized Decision Support System to Facilitate Brief Tobacco Cessation Treatment in the Pediatric Emergency Department: Proposal and Protocol

    PubMed Central

    Dexheimer, Judith W; Khoury, Jane C; Miller, Julie A; Gordon, Judith S

    2016-01-01

    Background Tobacco smoke exposure (TSE) is unequivocally harmful to children's health, yet up to 48% of children who visit the pediatric emergency department (PED) and urgent care setting are exposed to tobacco smoke. The incorporation of clinical decision support systems (CDSS) into the electronic health records (EHR) of PED patients may improve the rates of screening and brief TSE intervention of caregivers and result in decreased TSE in children. Objective We propose a study that will be the first to develop and evaluate the integration of a CDSS for Registered Nurses (RNs) into the EHR of pediatric patients to facilitate the identification of caregivers who smoke and the delivery of TSE interventions to caregivers in the urgent care setting. Methods We will conduct a two-phase project to develop, refine, and integrate an evidence-based CDSS into the pediatric urgent care setting. RNs will provide input on program content, function, and design. In Phase I, we will develop a CDSS with prompts to: (1) ASK about child TSE and caregiver smoking, (2) use a software program, Research Electronic Data Capture (REDCap), to ADVISE caregivers to reduce their child's TSE via total smoking home and car bans and quitting smoking, and (3) ASSESS their interest in quitting and ASSIST caregivers to quit by directly connecting them to their choice of free cessation resources (eg, Quitline, SmokefreeTXT, or SmokefreeGOV) during the urgent care visit. We will create reports to provide feedback to RNs on their TSE counseling behaviors. In Phase II, we will conduct a 3-month feasibility trial to test the results of implementing our CDSS on changes in RNs’ TSE-related behaviors, and child and caregiver outcomes. Results This trial is currently underway with funding support from the National Institutes of Health/National Cancer Institute. We have completed Phase I. The CDSS has been developed with input from our advisory panel and RNs, and pilot tested. We are nearing completion of

  6. Visual cluster analysis in support of clinical decision intelligence.

    PubMed

    Gotz, David; Sun, Jimeng; Cao, Nan; Ebadollahi, Shahram

    2011-01-01

    Electronic health records (EHRs) contain a wealth of information about patients. In addition to providing efficient and accurate records for individual patients, large databases of EHRs contain valuable information about overall patient populations. While statistical insights describing an overall population are beneficial, they are often not specific enough to use as the basis for individualized patient-centric decisions. To address this challenge, we describe an approach based on patient similarity which analyzes an EHR database to extract a cohort of patient records most similar to a specific target patient. Clusters of similar patients are then visualized to allow interactive visual refinement by human experts. Statistics are then extracted from the refined patient clusters and displayed to users. The statistical insights taken from these refined clusters provide personalized guidance for complex decisions. This paper focuses on the cluster refinement stage where an expert user must interactively (a) judge the quality and contents of automatically generated similar patient clusters, and (b) refine the clusters based on his/her expertise. We describe the DICON visualization tool which allows users to interactively view and refine multidimensional similar patient clusters. We also present results from a preliminary evaluation where two medical doctors provided feedback on our approach. PMID:22195102

  7. Visual Cluster Analysis in Support of Clinical Decision Intelligence

    PubMed Central

    Gotz, David; Sun, Jimeng; Cao, Nan; Ebadollahi, Shahram

    2011-01-01

    Electronic health records (EHRs) contain a wealth of information about patients. In addition to providing efficient and accurate records for individual patients, large databases of EHRs contain valuable information about overall patient populations. While statistical insights describing an overall population are beneficial, they are often not specific enough to use as the basis for individualized patient-centric decisions. To address this challenge, we describe an approach based on patient similarity which analyzes an EHR database to extract a cohort of patient records most similar to a specific target patient. Clusters of similar patients are then visualized to allow interactive visual refinement by human experts. Statistics are then extracted from the refined patient clusters and displayed to users. The statistical insights taken from these refined clusters provide personalized guidance for complex decisions. This paper focuses on the cluster refinement stage where an expert user must interactively (a) judge the quality and contents of automatically generated similar patient clusters, and (b) refine the clusters based on his/her expertise. We describe the DICON visualization tool which allows users to interactively view and refine multidimensional similar patient clusters. We also present results from a preliminary evaluation where two medical doctors provided feedback on our approach. PMID:22195102

  8. Empirically and Clinically Useful Decision Making in Psychotherapy: Differential Predictions with Treatment Response Models

    ERIC Educational Resources Information Center

    Lutz, Wolfgang; Saunders, Stephen M.; Leon, Scott C.; Martinovich, Zoran; Kosfelder, Joachim; Schulte, Dietmar; Grawe, Klaus; Tholen, Sven

    2006-01-01

    In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patient's response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research…

  9. Computer Decision Support to Improve Autism Screening and Care in Community Pediatric Clinics

    ERIC Educational Resources Information Center

    Bauer, Nerissa S.; Sturm, Lynne A.; Carroll, Aaron E.; Downs, Stephen M.

    2013-01-01

    An autism module was added to an existing computer decision support system (CDSS) to facilitate adherence to recommended guidelines for screening for autism spectrum disorders in primary care pediatric clinics. User satisfaction was assessed by survey and informal feedback at monthly meetings between clinical staff and the software team. To assess…

  10. Clinical decision-making and therapeutic approaches in osteopathy - a qualitative grounded theory study.

    PubMed

    Thomson, Oliver P; Petty, Nicola J; Moore, Ann P

    2014-02-01

    There is limited understanding of how osteopaths make decisions in relation to clinical practice. The aim of this research was to construct an explanatory theory of the clinical decision-making and therapeutic approaches of experienced osteopaths in the UK. Twelve UK registered osteopaths participated in this constructivist grounded theory qualitative study. Purposive and theoretical sampling was used to select participants. Data was collected using semi-structured interviews which were audio-recorded and transcribed. As the study approached theoretical sufficiency, participants were observed and video-recorded during a patient appointment, which was followed by a video-prompted interview. Constant comparative analysis was used to analyse and code data. Data analysis resulted in the construction of three qualitatively different therapeutic approaches which characterised participants and their clinical practice, termed; Treater, Communicator and Educator. Participants' therapeutic approach influenced their approach to clinical decision-making, the level of patient involvement, their interaction with patients, and therapeutic goals. Participants' overall conception of practice lay on a continuum ranging from technical rationality to professional artistry, and contributed to their therapeutic approach. A range of factors were identified which influenced participants' conception of practice. The findings indicate that there is variation in osteopaths' therapeutic approaches to practice and clinical decision-making, which are influenced by their overall conception of practice. This study provides the first explanatory theory of the clinical decision-making and therapeutic approaches of osteopaths. PMID:23932101

  11. Detecting fast, online reasoning processes in clinical decision making.

    PubMed

    Flores, Amanda; Cobos, Pedro L; López, Francisco J; Godoy, Antonio

    2014-06-01

    In an experiment that used the inconsistency paradigm, experienced clinical psychologists and psychology students performed a reading task using clinical reports and a diagnostic judgment task. The clinical reports provided information about the symptoms of hypothetical clients who had been previously diagnosed with a specific mental disorder. Reading times of inconsistent target sentences were slower than those of control sentences, demonstrating an inconsistency effect. The results also showed that experienced clinicians gave different weights to different symptoms according to their relevance when fluently reading the clinical reports provided, despite the fact that all the symptoms were of equal diagnostic value according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000). The diagnostic judgment task yielded a similar pattern of results. In contrast to previous findings, the results of the reading task may be taken as direct evidence of the intervention of reasoning processes that occur very early, rapidly, and online. We suggest that these processes are based on the representation of mental disorders and that these representations are particularly suited to fast retrieval from memory and to making inferences. They may also be related to the clinicians' causal reasoning. The implications of these results for clinician training are also discussed. PMID:24274045

  12. A Three-Question Framework to Facilitate Clinical Decision Making

    ERIC Educational Resources Information Center

    Sibold, Jeremy

    2012-01-01

    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…

  13. Image processing for the rest of us: the potential utility of inexpensive computerized image analysis in clinical pathology and radiology.

    PubMed

    McEachron, D L; Hess, S; Knecht, L B; True, L D

    1989-01-01

    Recent progress in computer technology in both hardware and software, combined with marked cost reductions, have placed quantitatively accurate video densitometry systems within the reach of the individual clinician, biomedical researcher, and community hospital. While much of the attention generated by advances in image processing has focussed on larger scale procedures, such as CAT, chemical shift, and positron emission tomography, important applications can be found for considerably more modest systems. In this article, we discuss three such applications of DUMAS, a personal computer-based imaging system developed by the Image Processing Center at Drexel University. A potential technique for quantifying numbers of estrogen receptors in tumorous breast tissue samples as a predictor of patient responsiveness to hormonal therapy is described first, along with possible sources of error. The second application, also related to clinical pathology and cancer, outlines methods for relating changes in nuclear and cell morphology to the diagnosis of Sezary Cell Syndrome. The utility of binary image filtering methods in the classification of cell types is discussed. The third application involves the development of a semi-automatic procedure for the determination of vessel diameter in arteriograms. A detailed description of the optimization and curve-fitting algorithms is provided along with preliminary test results comparing various approaches. The need for user demand to fuel research and development in small-scale imaging systems is also discussed. PMID:2647281

  14. Dental patient preferences and choice in clinical decision-making.

    PubMed

    Fukai, Kakuhiro; Yoshino, Koichi; Ohyama, Atsushi; Takaesu, Yoshinori

    2012-01-01

    In economics, the concept of utility refers to the strength of customer preference. In health care assessment, the visual analogue scale (VAS), the standard gamble, and the time trade-off are used to measure health state utilities. These utility measurements play a key role in promoting shared decision-making in dental care. Individual preference, however, is complex and dynamic. The purpose of this study was to investigate the relationship between patient preference and educational intervention in the field of dental health. The data were collected by distributing questionnaires to employees of two companies in Japan. Participants were aged 18-65 years and consisted of 111 males and 93 females (204 in total). One company (Group A) had a dental program of annual check-ups and health education in the workplace, while the other company (Group B) had no such program. Statistical analyses were performed with the t-test and Chi-square test. The questionnaire items were designed to determine: (1) oral health-related quality of life, (2) dental health state utilities (using VAS), and (3) time trade-off for regular dental check-ups. The percentage of respondents in both groups who were satisfied with chewing function, appearance of teeth, and social function ranged from 23.1 to 42.4%. There were no significant differences between groups A and B in the VAS of decayed, filled, and missing teeth. The VAS of gum bleeding was 42.8 in Group A and 51.3 in Group B (p<0.05). The percentage of persons having a regular dental check-up every three months was 34.1 and 31.3% in Groups A and B respectively. These results suggest that low preference results from lack of opportunity or utilization of dental care in the worksite. Ascertaining the factors involved in patient preference may have significant potential benefits in shared decision-making. PMID:22790334

  15. Managing risk: clinical decision-making in mental health services.

    PubMed

    Muir-Cochrane, Eimear; Gerace, Adam; Mosel, Krista; O'Kane, Debra; Barkway, Patricia; Curren, David; Oster, Candice

    2011-01-01

    Risk assessment and management is a major component of contemporary mental health practice. Risk assessment in health care exists within contemporary perspectives of management and risk aversive practices in health care. This has led to much discussion about the best approach to assessing possible risks posed by people with mental health problems. In addition, researchers and commentators have expressed concern that clinical practice is being dominated by managerial models of risk management at the expense of meeting the patient's health and social care needs. The purpose of the present study is to investigate the risk assessment practices of a multidisciplinary mental health service. Findings indicate that mental health professionals draw on both managerial and therapeutic approaches to risk management, integrating these approaches into their clinical practice. Rather than being dominated by managerial concerns regarding risk, the participants demonstrate professional autonomy and concern for the needs of their clients. PMID:22077745

  16. Computerized Mastery Testing with Nonequivalent Testlets.

    ERIC Educational Resources Information Center

    Sheehan, Kathleen; Lewis, Charles

    1992-01-01

    A procedure is introduced for determining the effect of testlet nonequivalence on operating characteristics of a testlet-based computerized mastery test (CMT). The procedure, which involves estimating the CMT decision rule twice with testlet likelihoods treated as equivalent or nonequivalent, is demonstrated with testlet pools from the Architect…

  17. Innovations in Computerized Assessment.

    ERIC Educational Resources Information Center

    Drasgow, Fritz, Ed.; Olson-Buchanan, Julie B., Ed.

    Chapters in this book present the challenges and dilemmas faced by researchers as they created new computerized assessments, focusing on issues addressed in developing, scoring, and administering the assessments. Chapters are: (1) "Beyond Bells and Whistles; An Introduction to Computerized Assessment" (Julie B. Olson-Buchanan and Fritz Drasgow);…

  18. Computerized Data Management.

    ERIC Educational Resources Information Center

    Grzywinski, Carol M.

    1983-01-01

    Argues that a computerized data management system can help the developmental educator maintain professional accountability. Reports on a project conducted at the State University of New York Agricultural and Technical College at Canton during which paperwork was reduced and report writing expedited through a computerized management information…

  19. Clinical decision making in seizures and status epilepticus.

    PubMed

    Teran, Felipe; Harper-Kirksey, Katrina; Jagoda, Andy

    2015-01-01

    Seizures and status epilepticus are frequent neurologic emergencies in the emergency department, accounting for 1% of all emergency department visits. The management of this time-sensitive and potentially life-threatening condition is challenging for both prehospital providers and emergency clinicians. The approach to seizing patients begins with differentiating seizure activity from mimics and follows with identifying potential secondary etiologies, such as alcohol-related seizures. The approach to the patient in status epilepticus and the patient with nonconvulsive status epilepticus constitutes a special clinical challenge. This review summarizes the best available evidence and recommendations regarding diagnosis and resuscitation of the seizing patient in the emergency setting. PMID:25902572

  20. Framework for securing personal health data in clinical decision support systems.

    PubMed

    Sandell, Protik

    2007-01-01

    If appropriate security mechanisms aren't in place, individuals and groups can get unauthorized access to personal health data residing in clinical decision support systems (CDSS). These concerns are well founded; there has been a dramatic increase in reports of security incidents. The paper provides a framework for securing personal health data in CDSS. The framework breaks down CDSS into data gathering, data management and data delivery functions. It then provides the vulnerabilities that can occur in clinical decision support activities and the measures that need to be taken to protect the data. The framework is applied to protect the confidentiality, integrity and availability of personal health data in a decision support system. Using the framework, project managers and architects can assess the potential risk of unauthorized data access in their decision support system. Moreover they can design systems and procedures to effectively secure personal health data. PMID:17583166

  1. A study of the use of past experiences in clinical decision making in emergency situations.

    PubMed

    Cioffi, J

    2001-10-01

    Making decisions to call emergency assistance to patients is an important dimension of nursing practice. Most usually these decision making situations are uncertain and it is expected nurses rely on past clinical experiences. This study, approved by the ethics committees of both a university and an area health service, aimed to describe nurses' reliance on past experiences and identify associated judgement strategies (heuristics). Thirty-two registered nurses with five or more years experience were interviewed. Main findings were: nurses did use their past experiences and these experiences were used in the form of the three "classic" heuristics, representativeness, availability and anchoring and adjustment. It can be concluded past experiences are intrinsic to decision making and this has implications for both the clinical components of nursing educational programs and staffing allocations made by administrators. Some nurses, however, did not include referral to past experiences in their decision-making accounts which may be a limitation of the study design. PMID:11524105

  2. Integrated risk assessment and feedback reporting for clinical decision making in a Medicare Risk plan.

    PubMed

    Schraeder, C; Britt, T; Shelton, P

    2000-10-01

    The challenge of tapping into the rich resource of population-based, aggregated data to inform and guide clinical processes remains one of the largely unrealized potentials of managed care. This article describes a multifaceted approach of using health-related data to support providers in clinical decision making as an adjunct to case management and primary care delivery. The goal is to provide data that can be used for clinical decision making that is population based, yet individualized for specific patient care situations. Information reporting holds great potential in the clinical care of patients because it can be used to identify persons who could benefit from early detection, intervention, or treatment. It has been suggested that one of the keys to success in managed Medicare is the timely use of information that is detailed, comprehensive, and real-time describing key parameters of clinical encounters. PMID:11067092

  3. Boosting standard order sets utilization through clinical decision support.

    PubMed

    Li, Haomin; Zhang, Yinsheng; Cheng, Haixia; Lu, Xudong; Duan, Huilong

    2013-01-01

    Well-designed standard order sets have the potential to integrate and coordinate care by communicating best practices through multiple disciplines, levels of care, and services. However, there are several challenges which certainly affected the benefits expected from standard order sets. To boost standard order sets utilization, a problem-oriented knowledge delivery solution was proposed in this study to facilitate access of standard order sets and evaluation of its treatment effect. In this solution, standard order sets were created along with diagnostic rule sets which can trigger a CDS-based reminder to help clinician quickly discovery hidden clinical problems and corresponding standard order sets during ordering. Those rule set also provide indicators for targeted evaluation of standard order sets during treatment. A prototype system was developed based on this solution and will be presented at Medinfo 2013. PMID:23920727

  4. Quantitative ultrasound texture analysis for clinical decision making support

    NASA Astrophysics Data System (ADS)

    Wu, Jie Ying; Beland, Michael; Konrad, Joseph; Tuomi, Adam; Glidden, David; Grand, David; Merck, Derek

    2015-03-01

    We propose a general ultrasound (US) texture-analysis and machine-learning framework for detecting the presence of disease that is suitable for clinical application across clinicians, disease types, devices, and operators. Its stages are image selection, image filtering, ROI selection, feature parameterization, and classification. Each stage is modular and can be replaced with alternate methods. Thus, this framework is adaptable to a wide range of tasks. Our two preliminary clinical targets are hepatic steatosis and adenomyosis diagnosis. For steatosis, we collected US images from 288 patients and their pathology-determined values of steatosis (%) from biopsies. Two radiologists independently reviewed all images and identified the region of interest (ROI) most representative of the hepatic echotexture for each patient. To parameterize the images into comparable quantities, we filter the US images at multiple scales for various texture responses. For each response, we collect a histogram of pixel features within the ROI, and parameterize it as a Gaussian function using its mean, standard deviation, kurtosis, and skew to create a 36-feature vector. Our algorithm uses a support vector machine (SVM) for classification. Using a threshold of 10%, we achieved 72.81% overall accuracy, 76.18% sensitivity, and 65.96% specificity in identifying steatosis with leave-ten-out cross-validation (p<0.0001). Extending this framework to adenomyosis, we identified 38 patients with MR-confirmed findings of adenomyosis and previous US studies and 50 controls. A single rater picked the best US-image and ROI for each case. Using the same processing pipeline, we obtained 76.14% accuracy, 86.00% sensitivity, and 63.16% specificity with leave-one-out cross-validation (p<0.0001).

  5. Identifying ultrasound and clinical features of breast cancer molecular subtypes by ensemble decision.

    PubMed

    Zhang, Lei; Li, Jing; Xiao, Yun; Cui, Hao; Du, Guoqing; Wang, Ying; Li, Ziyao; Wu, Tong; Li, Xia; Tian, Jiawei

    2015-01-01

    Breast cancer is molecularly heterogeneous and categorized into four molecular subtypes: Luminal-A, Luminal-B, HER2-amplified and Triple-negative. In this study, we aimed to apply an ensemble decision approach to identify the ultrasound and clinical features related to the molecular subtypes. We collected ultrasound and clinical features from 1,000 breast cancer patients and performed immunohistochemistry on these samples. We used the ensemble decision approach to select unique features and to construct decision models. The decision model for Luminal-A subtype was constructed based on the presence of an echogenic halo and post-acoustic shadowing or indifference. The decision model for Luminal-B subtype was constructed based on the absence of an echogenic halo and vascularity. The decision model for HER2-amplified subtype was constructed based on the presence of post-acoustic enhancement, calcification, vascularity and advanced age. The model for Triple-negative subtype followed two rules. One was based on irregular shape, lobulate margin contour, the absence of calcification and hypovascularity, whereas the other was based on oval shape, hypovascularity and micro-lobulate margin contour. The accuracies of the models were 83.8%, 77.4%, 87.9% and 92.7%, respectively. We identified specific features of each molecular subtype and expanded the scope of ultrasound for making diagnoses using these decision models. PMID:26046791

  6. Risk-Taking Behavior in a Computerized Driving Task: Brain Activation Correlates of Decision-Making, Outcome, and Peer Influence in Male Adolescents

    PubMed Central

    Vorobyev, Victor; Kwon, Myoung Soo; Moe, Dagfinn; Parkkola, Riitta; Hämäläinen, Heikki

    2015-01-01

    Increased propensity for risky behavior in adolescents, particularly in peer groups, is thought to reflect maturational imbalance between reward processing and cognitive control systems that affect decision-making. We used functional magnetic resonance imaging (fMRI) to investigate brain functional correlates of risk-taking behavior and effects of peer influence in 18–19-year-old male adolescents. The subjects were divided into low and high risk-taking groups using either personality tests or risk-taking rates in a simulated driving task. The fMRI data were analyzed for decision-making (whether to take a risk at intersections) and outcome (pass or crash) phases, and for the influence of peer competition. Personality test-based groups showed no difference in the amount of risk-taking (similarly increased during peer competition) and brain activation. When groups were defined by actual task performance, risk-taking activated two areas in the left medial prefrontal cortex (PFC) significantly more in low than in high risk-takers. In the entire sample, risky decision-specific activation was found in the anterior and dorsal cingulate, superior parietal cortex, basal ganglia (including the nucleus accumbens), midbrain, thalamus, and hypothalamus. Peer competition increased outcome-related activation in the right caudate head and cerebellar vermis in the entire sample. Our results suggest that the activation of the medial (rather than lateral) PFC and striatum is most specific to risk-taking behavior of male adolescents in a simulated driving situation, and reflect a stronger conflict and thus increased cognitive effort to take risks in low risk-takers, and reward anticipation for risky decisions, respectively. The activation of the caudate nucleus, particularly for the positive outcome (pass) during peer competition, further suggests enhanced reward processing of risk-taking under peer influence. PMID:26052943

  7. Risk-Taking Behavior in a Computerized Driving Task: Brain Activation Correlates of Decision-Making, Outcome, and Peer Influence in Male Adolescents.

    PubMed

    Vorobyev, Victor; Kwon, Myoung Soo; Moe, Dagfinn; Parkkola, Riitta; Hämäläinen, Heikki

    2015-01-01

    Increased propensity for risky behavior in adolescents, particularly in peer groups, is thought to reflect maturational imbalance between reward processing and cognitive control systems that affect decision-making. We used functional magnetic resonance imaging (fMRI) to investigate brain functional correlates of risk-taking behavior and effects of peer influence in 18-19-year-old male adolescents. The subjects were divided into low and high risk-taking groups using either personality tests or risk-taking rates in a simulated driving task. The fMRI data were analyzed for decision-making (whether to take a risk at intersections) and outcome (pass or crash) phases, and for the influence of peer competition. Personality test-based groups showed no difference in the amount of risk-taking (similarly increased during peer competition) and brain activation. When groups were defined by actual task performance, risk-taking activated two areas in the left medial prefrontal cortex (PFC) significantly more in low than in high risk-takers. In the entire sample, risky decision-specific activation was found in the anterior and dorsal cingulate, superior parietal cortex, basal ganglia (including the nucleus accumbens), midbrain, thalamus, and hypothalamus. Peer competition increased outcome-related activation in the right caudate head and cerebellar vermis in the entire sample. Our results suggest that the activation of the medial (rather than lateral) PFC and striatum is most specific to risk-taking behavior of male adolescents in a simulated driving situation, and reflect a stronger conflict and thus increased cognitive effort to take risks in low risk-takers, and reward anticipation for risky decisions, respectively. The activation of the caudate nucleus, particularly for the positive outcome (pass) during peer competition, further suggests enhanced reward processing of risk-taking under peer influence. PMID:26052943

  8. A service oriented approach for guidelines-based clinical decision support using BPMN.

    PubMed

    Rodriguez-Loya, Salvador; Aziz, Ayesha; Chatwin, Chris

    2014-01-01

    Evidence-based medical practice requires that clinical guidelines need to be documented in such a way that they represent a clinical workflow in its most accessible form. In order to optimize clinical processes to improve clinical outcomes, we propose a Service Oriented Architecture (SOA) based approach for implementing clinical guidelines that can be accessed from an Electronic Health Record (EHR) application with a Web Services enabled communication mechanism with the Enterprise Service Bus. We have used Business Process Modelling Notation (BPMN) for modelling and presenting the clinical pathway in the form of a workflow. The aim of this study is to produce spontaneous alerts in the healthcare workflow in the diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The use of BPMN as a tool to automate clinical guidelines has not been previously employed for providing Clinical Decision Support (CDS). PMID:25160142

  9. Development and evaluation of learning module on clinical decision-making in Prosthodontics

    PubMed Central

    Deshpande, Saee; Lambade, Dipti; Chahande, Jayashree

    2015-01-01

    Purpose: Best practice strategies for helping students learn the reasoning skills of problem solving and critical thinking (CT) remain a source of conjecture, particularly with regard to CT. The dental education literature is fundamentally devoid of research on the cognitive components of clinical decision-making. Aim: This study was aimed to develop and evaluate the impact of blended learning module on clinical decision-making skills of dental graduates for planning prosthodontics rehabilitation. Methodology: An interactive teaching module consisting of didactic lectures on clinical decision-making and a computer-assisted case-based treatment planning software was developed Its impact on cognitive knowledge gain in clinical decision-making was evaluated using an assessment involving problem-based multiple choice questions and paper-based case scenarios. Results: Mean test scores were: Pretest (17 ± 1), posttest 1 (21 ± 2) and posttest 2 (43 ± 3). Comparison of mean scores was done with one-way ANOVA test. There was overall significant difference in between mean scores at all the three points (P < 0.001). A pair-wise comparison of mean scores was done with Bonferroni test. The mean difference is significant at the 0.05 level. The pair-wise comparison shows that posttest 2 score is significantly higher than posttest 1 and posttest 1 is significantly higher than pretest that is, pretest 2 > posttest 1 > pretest. Conclusion: Blended teaching methods employing didactic lectures on the clinical decision-making as well as computer assisted case-based learning can be used to improve quality of clinical decision-making in prosthodontic rehabilitation for dental graduates. PMID:26929504

  10. Integrating decision support, based on the Arden Syntax, in a clinical laboratory environment.

    PubMed Central

    Johansson, B.; Bergqvist, Y.

    1993-01-01

    A clinical decision support system prototype have been developed in the clinical laboratory environment. The knowledge base consists of Medical Logic Modules, written in the Arden Syntax, and the work describes how these modules can be written, evoked and executed in a system, that is integrated with a laboratory information system, and facilitate real time validation of laboratory data. Tools and methods for building a decision support system are described and design aspects, such as database access, system validation and platform independence, are discussed. PMID:8130502

  11. Clinical decision rules for acute bacterial meningitis: current insights

    PubMed Central

    Viallon, Alain; Botelho-Nevers, Elisabeth; Zeni, Fabrice

    2016-01-01

    Acute community-acquired bacterial meningitis (BM) requires rapid diagnosis so that suitable treatment can be instituted within 60 minutes of admitting the patient. The cornerstone of diagnostic examination is lumbar puncture, which enables microbiological analysis and determination of the cerebrospinal fluid (CSF) cytochemical characteristics. However, microbiological testing is not sufficiently sensitive to rule out this diagnosis. With regard to the analysis of standard CSF cytochemical characteristics (polymorphonuclear count, CSF glucose and protein concentration, and CSF:serum glucose), this is often misleading. Indeed, the relatively imprecise nature of the cutoff values for these BM diagnosis markers can make their interpretation difficult. However, there are two markers that appear to be more efficient than the standard ones: CSF lactate and serum procalcitonin levels. Scores and predictive models are also available; however, they only define a clinical probability, and in addition, their use calls for prior validation on the population in which they are used. In this article, we review current methods of BM diagnosis. PMID:27307768

  12. Telemonitoring in heart failure patients with clinical decision support to optimize medication doses based on guidelines.

    PubMed

    Kropf, Martin; Modre-Osprian, Robert; Hayn, Dieter; Fruhwald, Friedrich; Schreier, Günter

    2014-01-01

    The European Society of Cardiology guidelines for heart failure management are based on strong evidence that adherence to optimal medication is beneficial for heart failure patients. Telemonitoring with integrated clinical decision support enables physicians to adapt medication dose based on up to date vital parameters and reduces the number of hospital visits needed solely for up-titration of heart failure medication. Although keeping track of weight and blood pressure changes is recommended during unstable phases, e.g. post-discharge and during up-titration of medication, guidelines are rather vague regarding telehealth aspects. In this paper, we focus on the evaluation of a clinical decision support system for adaption of heart failure medication and for detecting early deteriorations through monitoring of blood pressure, heart rate and weight changes. This clinical decision support system is currently used in INTENSE-HF, a large scale telemonitoring trial with heart failure patients. The aim of this paper was to apply the decision support algorithm to an existing telemonitoring dataset, to assess the ability of the decision support concept to adhere to the guidelines and to discuss its limitations and potential improvements. PMID:25570663

  13. The interaction of patient race, provider bias, and clinical ambiguity on pain management decisions

    PubMed Central

    Hirsh, Adam T.; Hollingshead, Nicole A.; Ashburn-Nardo, Leslie; Kroenke, Kurt

    2015-01-01

    Although racial disparities in pain care are widely reported, much remains to be known about the role of provider and contextual factors. We used computer-simulated patients to examine the influence of patient race, provider racial bias, and clinical ambiguity on pain decisions. One hundred twenty nine medical residents/fellows made assessment (pain intensity) and treatment (opioid and non-opioid analgesics) decisions for 12 virtual patients with acute pain. Race (Black/White) and clinical ambiguity (high/low) were manipulated across vignettes. Participants completed the Implicit Association Test and feeling thermometers, which assess implicit and explicit racial biases, respectively. Individual- and group-level analyses indicated that race and ambiguity had an interactive effect on providers’ decisions, such that decisions varied as a function of ambiguity for White but not Black patients. Individual differences across providers were observed for the effect of race and ambiguity on decisions; however providers’ implicit and explicit biases did not account for this variability. These data highlight the complexity of racial disparities and suggest that differences in care between White and Black patients are, in part, attributable to the nature (i.e., ambiguity) of the clinical scenario. The current study suggests that interventions to reduce disparities should differentially target patient, provider, and contextual factors. PMID:25828370

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

    PubMed

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

    2014-01-01

    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

  15. Evaluating a Clinical Decision Support Interface for End-of-Life Nurse Care

    PubMed Central

    Febretti, Alessandro; Stifter, Janet; Keenan, Gail M; Lopez, Karen D; Johnson, Andrew; Wilkie, Diana J

    2016-01-01

    Clinical Decision Support Systems (CDSS) are tools that assist healthcare personnel in the decision-making process for patient care. Although CDSSs have been successfully deployed in the clinical setting to assist physicians, few CDSS have been targeted at professional nurses, the largest group of health providers. We present our experience in designing and testing a CDSS interface embedded within a nurse care planning and documentation tool. We developed four prototypes based on different CDSS feature designs, and tested them in simulated end-of-life patient handoff sessions with a group of 40 nurse clinicians. We show how our prototypes directed nurses towards an optimal care decision that was rarely performed in unassisted practice. We also discuss the effect of CDSS layout and interface navigation in a nurse’s acceptance of suggested actions. These findings provide insights into effective nursing CDSS design that are generalizable to care scenarios different than end-of-life.

  16. Computerized Fleet Maintenance.

    ERIC Educational Resources Information Center

    Cataldo, John J.

    1985-01-01

    The Computerized Fleet Maintenance (CFM) program of a New York school district has major component areas of garage operation, vehicle replacement, and fuel consumption. CFM detects high expenditures and provides the rationale for bus replacement. (MLF)

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

    PubMed

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

    2014-09-01

    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

  18. 78 FR 35937 - Food and Drug Administration Decisions for Investigational Device Exemption Clinical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-14

    ... for Investigational Device Exemption (IDE) Clinical Investigations.'' This guidance document was... investigations to evaluate medical devices under FDA's IDE regulations. The guidance was also intended to provide... IDE and to provide a general explanation of the reasons for those decisions. This guidance has...

  19. Students' Stereotypes of Patients as Barriers to Clinical Decision-Making.

    ERIC Educational Resources Information Center

    Johnson, Shirley M.; And Others

    1986-01-01

    At the Michigan State University College of Osteopathic Medicine, a study was designed that graphically illustrated to beginning students that unconscious sociocultural stereotypes may influence clinical decision-making. Students were shown a videotape depicting five simulated patients, each with the same physical complaint. (Author/MLW)

  20. A Mixed Methodological Analysis of the Role of Culture in the Clinical Decision-Making Process

    ERIC Educational Resources Information Center

    Hays, Danica G.; Prosek, Elizabeth A.; McLeod, Amy L.

    2010-01-01

    Even though literature indicates that particular cultural groups receive more severe diagnoses at disproportionate rates, there has been minimal research that addresses how culture interfaces specifically with clinical decision making. This mixed methodological study of 41 counselors indicated that cultural characteristics of both counselors and…

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

    ERIC Educational Resources Information Center

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

    2008-01-01

    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…

  2. The Impact of Reading a Clinical Study on Treatment Decisions of Physicians and Residents.

    ERIC Educational Resources Information Center

    Bergman, David A.; Pantell, Robert H.

    1986-01-01

    A study of the effect of reading a recent clinical study on pediatricians', pediatric residents', and family practitioners' decisions concerning treatment of a common, potentially serious problem revealed a considerable influence but physician difficulty in using probability data and reliance on intuition rather than calculation. (MSE)

  3. The impact of goal-directed transvaginal ultrasonography on clinical decision-making for emergency physicians.

    PubMed

    Sayrac, Neslihan; Bektas, Firat; Soyuncu, Secgin; Sayrac, Vefa

    2015-07-01

    The aim of study was to determine the impact of "goal-directed transvaginal ultrasonography" (TVUSG) on real-time clinical decision making of attending emergency physicians evaluating their level of certainty for preliminary diagnosis, admission, surgery, treatment, additional laboratory, and discharge in patients presenting with acute pelvic pain to the emergency department (ED). This prospective cross-sectional clinical study was conducted on sexually active female patients older than 18 years who presented with acute pelvic pain in the ED. The level of certainty of clinical decision making as mentioned above was measured by a visual analogue scale from 0 to 100 mm with 100 mm being most certain before and after TVUSG. Statistical analysis was performed on 88 patients. The mean age was 31.7 ±8.3 years with a median of 30 years. Among clinical decisions, there was a significant difference between pre-TVUSG and post-TVUSG certainty of the decision to perform preliminary diagnoses derived from patient's history and physical examination but not in the other outcomes (treatment, admission, surgery, and discharge). (P = .05). Of the patients included in the study, 11 (12.5%) were admitted to hospital, and 2 (2.3%) of them were operated on. The remaining 75 (85.2%) patients were discharged from the ED; of the patients that had been discharged, 18 (20.5%) patients later consulted another physician, and no further pathology could be discovered. In conclusion, US performed by attending emergency physicians may affect the certainty of their decisions in patients presenting with acute pelvic pain. This effect statistically significantly on the decision to determine preliminary diagnosis. PMID:25963680

  4. Fuzzy-Arden-Syntax-based, Vendor-agnostic, Scalable Clinical Decision Support and Monitoring Platform.

    PubMed

    Adlassnig, Klaus-Peter; Fehre, Karsten; Rappelsberger, Andrea

    2015-01-01

    This study's objective is to develop and use a scalable genuine technology platform for clinical decision support based on Arden Syntax, which was extended by fuzzy set theory and fuzzy logic. Arden Syntax is a widely recognized formal language for representing clinical and scientific knowledge in an executable format, and is maintained by Health Level Seven (HL7) International and approved by the American National Standards Institute (ANSI). Fuzzy set theory and logic permit the representation of knowledge and automated reasoning under linguistic and propositional uncertainty. These forms of uncertainty are a common feature of patients' medical data, the body of medical knowledge, and deductive clinical reasoning. PMID:26262410

  5. Understanding clinical work practices for cross-boundary decision support in e-health.

    PubMed

    Tawfik, Hissam; Anya, Obinna; Nagar, Atulya K

    2012-07-01

    One of the major concerns of research in integrated healthcare information systems is to enable decision support among clinicians across boundaries of organizations and regional workgroups. A necessary precursor, however, is to facilitate the construction of appropriate awareness of local clinical practices, including a clinician's actual cognitive capabilities, peculiar workplace circumstances, and specific patient-centered needs based on real-world clinical contexts across work settings. In this paper, a user-centered study aimed to investigate clinical practices across three different geographical areas-the U.K., the UAE and Nigeria-is presented. The findings indicate that differences in clinical practices among clinicians are associated with differences in local work contexts across work settings, but are moderated by adherence to best practice guidelines and the need for patient-centered care. The study further reveals that an awareness especially of the ontological, stereotypical, and situated practices plays a crucial role in adapting knowledge for cross-boundary decision support. The paper then outlines a set of design guidelines for the development of enterprise information systems for e-health. Based on the guidelines, the paper proposes the conceptual design of CaDHealth, a practice-centered framework for making sense of clinical practices across work settings for effective cross-boundary e-health decision support. PMID:22345549

  6. [The impact of guidelines, standards and economic restrictions on clinical decision-making processes].

    PubMed

    Linden, Michael

    2004-05-01

    Guidelines aim at improving clinical decision-making. Contrary to textbooks and reviews that want to improve medical knowledge, guidelines try to influence medical behaviour. Scientific models of clinical decision-making such as the action theory and empirical data on the effects of guidelines suggest that guidelines will not always reach their goals but can instead even lead to a deterioration in the quality of medical care. Therefore there is a need for controlled clinical trials to investigate whether guideline-exposed physicians yield better patient outcomes than guideline-naïve physicians. Guidelines should only be regarded as evidence-based if their positive effects have been empirically demonstrated. PMID:15250387

  7. Neighborhood graph and learning discriminative distance functions for clinical decision support.

    PubMed

    Tsymbal, Alexey; Zhou, Shaohua Kevin; Huber, Martin

    2009-01-01

    There are two essential reasons for the slow progress in the acceptance of clinical case retrieval and similarity search-based decision support systems; the especial complexity of clinical data making it difficult to define a meaningful and effective distance function on them and the lack of transparency and explanation ability in many existing clinical case retrieval decision support systems. In this paper, we try to address these two problems by introducing a novel technique for visualizing inter-patient similarity based on a node-link representation with neighborhood graphs and by considering two techniques for learning discriminative distance function that help to combine the power of strong "black box" learners with the transparency of case retrieval and nearest neighbor classification. PMID:19964399

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

    PubMed Central

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

    2014-01-01

    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

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

    PubMed

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

    2003-07-01

    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

  10. Clinical decision support must be useful, functional is not enough: a qualitative study of computer-based clinical decision support in primary care

    PubMed Central

    2012-01-01

    Background Health information technology, particularly electronic decision support systems, can reduce the existing gap between evidence-based knowledge and health care practice but professionals have to accept and use this information. Evidence is scant on which features influence the use of computer-based clinical decision support (eCDS) in primary care and how different professional groups experience it. Our aim was to describe specific reasons for using or not using eCDS among primary care professionals. Methods The setting was a Finnish primary health care organization with 48 professionals receiving patient-specific guidance at the point of care. Multiple data (focus groups, questionnaire and spontaneous feedback) were analyzed using deductive content analysis and descriptive statistics. Results The content of the guidance is a significant feature of the primary care professional’s intention to use eCDS. The decisive reason for using or not using the eCDS is its perceived usefulness. Functional characteristics such as speed and ease of use are important but alone these are not enough. Specific information technology, professional, patient and environment features can help or hinder the use. Conclusions Primary care professionals have to perceive eCDS guidance useful for their work before they use it. PMID:23039113

  11. Comparing and using assessments of the value of information to clinical decision-making.

    PubMed Central

    Urquhart, C J; Hepworth, J B

    1996-01-01

    This paper discusses the Value project, which assessed the value to clinical decision-making of information supplied by National Health Service (NHS) library and information services. The project not only showed how health libraries in the United Kingdom help clinicians in decision-making but also provided quality assurance guidelines for these libraries to help make their information services more effective. The paper reviews methods and results used in previous studies of the value of health libraries, noting that methodological differences appear to affect the results. The paper also discusses aspects of user involvement, categories of clinical decision-making, the value of information to present and future clinical decisions, and the combination of quantitative and qualitative assessments of value, as applied to the Value project and the studies reviewed. The Value project also demonstrated that the value placed on information depends in part on the career stage of the physician. The paper outlines the structure of the quality assurance tool kit, which is based on the findings and methods used in the Value project. PMID:8913550

  12. Consensus Recommendations for Systematic Evaluation of Drug-Drug Interaction Evidence for Clinical Decision Support

    PubMed Central

    Scheife, Richard T.; Hines, Lisa E.; Boyce, Richard D.; Chung, Sophie P.; Momper, Jeremiah; Sommer, Christine D.; Abernethy, Darrell R.; Horn, John; Sklar, Stephen J.; Wong, Samantha K.; Jones, Gretchen; Brown, Mary; Grizzle, Amy J.; Comes, Susan; Wilkins, Tricia Lee; Borst, Clarissa; Wittie, Michael A.; Rich, Alissa; Malone, Daniel C.

    2015-01-01

    Background Healthcare organizations, compendia, and drug knowledgebase vendors use varying methods to evaluate and synthesize evidence on drug-drug interactions (DDIs). This situation has a negative effect on electronic prescribing and medication information systems that warn clinicians of potentially harmful medication combinations. Objective To provide recommendations for systematic evaluation of evidence from the scientific literature, drug product labeling, and regulatory documents with respect to DDIs for clinical decision support. Methods A conference series was conducted to develop a structured process to improve the quality of DDI alerting systems. Three expert workgroups were assembled to address the goals of the conference. The Evidence Workgroup consisted of 15 individuals with expertise in pharmacology, drug information, biomedical informatics, and clinical decision support. Workgroup members met via webinar from January 2013 to February 2014. Two in-person meetings were conducted in May and September 2013 to reach consensus on recommendations. Results We developed expert-consensus answers to three key questions: 1) What is the best approach to evaluate DDI evidence?; 2) What evidence is required for a DDI to be applicable to an entire class of drugs?; and 3) How should a structured evaluation process be vetted and validated? Conclusion Evidence-based decision support for DDIs requires consistent application of transparent and systematic methods to evaluate the evidence. Drug information systems that implement these recommendations should be able to provide higher quality information about DDIs in drug compendia and clinical decision support tools. PMID:25556085

  13. Assessing an Adolescent's Capacity for Autonomous Decision-Making in Clinical Care.

    PubMed

    Michaud, Pierre-André; Blum, Robert Wm; Benaroyo, Lazare; Zermatten, Jean; Baltag, Valentina

    2015-10-01

    The purpose of this article is to provide policy guidance on how to assess the capacity of minor adolescents for autonomous decision-making without a third party authorization, in the field of clinical care. In June 2014, a two-day meeting gathered 20 professionals from all continents, working in the field of adolescent medicine, neurosciences, developmental and clinical psychology, sociology, ethics, and law. Formal presentations and discussions were based on a literature search and the participants' experience. The assessment of adolescent decision-making capacity includes the following: (1) a review of the legal context consistent with the principles of the Convention on the Rights of the Child; (2) an empathetic relationship between the adolescent and the health care professional/team; (3) the respect of the adolescent's developmental stage and capacities; (4) the inclusion, if relevant, of relatives, peers, teachers, or social and mental health providers with the adolescent's consent; (5) the control of coercion and other social forces that influence decision-making; and (6) a deliberative stepwise appraisal of the adolescent's decision-making process. This stepwise approach, already used among adults with psychiatric disorders, includes understanding the different facets of the given situation, reasoning on the involved issues, appreciating the outcomes linked with the decision(s), and expressing a choice. Contextual and psychosocial factors play pivotal roles in the assessment of adolescents' decision-making capacity. The evaluation must be guided by a well-established procedure, and health professionals should be trained accordingly. These proposals are the first to have been developed by a multicultural, multidisciplinary expert panel. PMID:26281798

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

    PubMed

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

    2004-02-01

    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

  15. Decision theory and the evaluation of risks and benefits of clinical trials.

    PubMed

    Bernabe, Rosemarie D C; van Thiel, Ghislaine J M W; Raaijmakers, Jan A M; van Delden, Johannes J M

    2012-12-01

    Research ethics committees (RECs) are tasked to assess the risks and the benefits of a clinical trial. In previous studies, it was shown that RECs find this task difficult, if not impossible, to do. The current approaches to benefit-risk assessment (i.e. Component Analysis and the Net Risk Test) confound the various risk-benefit tasks, and as such, make balancing impossible. In this article, we show that decision theory, specifically through the expected utility theory and multiattribute utility theory, enable for an explicit and ethically weighted risk-benefit evaluation. This makes a balanced ethical justification possible, and thus a more rationally defensible decision making. PMID:22819925

  16. Clinical Decision Support Systems (CDSS) for preventive management of COPD patients

    PubMed Central

    2014-01-01

    Background The use of information and communication technologies to manage chronic diseases allows the application of integrated care pathways, and the optimization and standardization of care processes. Decision support tools can assist in the adherence to best-practice medicine in critical decision points during the execution of a care pathway. Objectives The objectives are to design, develop, and assess a clinical decision support system (CDSS) offering a suite of services for the early detection and assessment of chronic obstructive pulmonary disease (COPD), which can be easily integrated into a healthcare providers' work-flow. Methods The software architecture model for the CDSS, interoperable clinical-knowledge representation, and inference engine were designed and implemented to form a base CDSS framework. The CDSS functionalities were iteratively developed through requirement-adjustment/development/validation cycles using enterprise-grade software-engineering methodologies and technologies. Within each cycle, clinical-knowledge acquisition was performed by a health-informatics engineer and a clinical-expert team. Results A suite of decision-support web services for (i) COPD early detection and diagnosis, (ii) spirometry quality-control support, (iii) patient stratification, was deployed in a secured environment on-line. The CDSS diagnostic performance was assessed using a validation set of 323 cases with 90% specificity, and 96% sensitivity. Web services were integrated in existing health information system platforms. Conclusions Specialized decision support can be offered as a complementary service to existing policies of integrated care for chronic-disease management. The CDSS was able to issue recommendations that have a high degree of accuracy to support COPD case-finding. Integration into healthcare providers' work-flow can be achieved seamlessly through the use of a modular design and service-oriented architecture that connect to existing health

  17. Improving Decision Making about Genetic Testing in the Clinic: An Overview of Effective Knowledge Translation Interventions

    PubMed Central

    Légaré, France; Robitaille, Hubert; Gane, Claire; Hébert, Jessica; Labrecque, Michel; Rousseau, François

    2016-01-01

    Background Knowledge translation (KT) interventions are attempts to change behavior in keeping with scientific evidence. While genetic tests are increasingly available to healthcare consumers in the clinic, evidence about their benefits is unclear and decisions about genetic testing are thus difficult for all parties. Objective We sought to identify KT interventions that involved decisions about genetic testing in the clinical context and to assess their effectiveness for improving decision making in terms of behavior change, increased knowledge and wellbeing. Methods We searched for trials assessing KT interventions in the context of genetic testing up to March 2014 in all systematic reviews (n = 153) published by two Cochrane review groups: Effective Practice and Organisation of Care (EPOC) and Consumers and Communication. Results We retrieved 2473 unique trials of which we retained only 28 (1%). Two EPOC reviews yielded two trials of KT interventions: audit and feedback (n = 1) and educational outreach (n = 1). Both targeted health professionals and the KT intervention they assessed was found to be effective. Four Consumers and Communication reviews yielded 26 trials: decision aids (n = 15), communication of DNA-based disease risk estimates (n = 7), personalized risk communication (n = 3) and mobile phone messaging (n = 1). Among these, 25 trials targeted only health consumers or patients and the KT interventions were found to be effective in four trials, partly effective in seven, and ineffective in four. Lastly, only one trial targeted both physicians and patients and was found to be effective. Conclusions More research on the effectiveness of KT interventions regarding genetic testing in the clinical context may contribute to patients making informed value-based decisions and drawing the maximum benefit from clinical applications of genetic and genomic innovations. PMID:26938633

  18. Clinical decision support for whole genome sequence information leveraging a service-oriented architecture: a prototype.

    PubMed

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

    2014-01-01

    Whole genome sequence (WGS) information could soon be routinely available to clinicians to support the personalized care of their patients. At such time, clinical decision support (CDS) integrated into the clinical workflow will likely be necessary to support genome-guided clinical care. Nevertheless, developing CDS capabilities for WGS information presents many unique challenges that need to be overcome for such approaches to be effective. In this manuscript, we describe the development of a prototype CDS system that is capable of providing genome-guided CDS at the point of care and within the clinical workflow. To demonstrate the functionality of this prototype, we implemented a clinical scenario of a hypothetical patient at high risk for Lynch Syndrome based on his genomic information. We demonstrate that this system can effectively use service-oriented architecture principles and standards-based components to deliver point of care CDS for WGS information in real-time. PMID:25954430

  19. Computerized Grading of Anatomy Laboratory Practical Examinations

    ERIC Educational Resources Information Center

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

    2008-01-01

    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…

  20. Risks, dangers and competing clinical decisions on venous thromboembolism prophylaxis in hospital care.

    PubMed

    Boiko, Olga; Sheaff, Rod; Child, Susan; Gericke, Christian A

    2014-07-01

    Drawing on wider sociologies of risk, this article examines the complexity of clinical risks and their management, focusing on risk management systems, expert decision-making and safety standards in health care. At the time of this study preventing venous thromboembolism (VTE) among in-patients was one of the top priorities for hospital safety in the English National Health Service (NHS). An analysis of 50 interviews examining hospital professionals' perceptions about VTE risks and prophylaxis illuminates how National Institute for Health and Clinical Excellence (NICE) guidelines influenced clinical decision-making in four hospitals in one NHS region. We examine four themes: the identification of new risks, the institutionalisation and management of risk, the relationship between risk and danger and the tensions between risk management systems and expert decision-making. The implementation of NICE guidelines for VTE prevention extended managerial control over risk management but some irreducible clinical dangers remained that were beyond the scope of the new VTE risk management systems. Linking sociologies of risk with the realities of hospital risk management reveals the capacity of these theories to illuminate both the possibilities and the limits of managerialism in health care. PMID:24635764

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

    PubMed Central

    Brien, Sarah; Dibb, Bridget; Burch, Alex

    2011-01-01

    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

  2. EVIDENCE AND CLINICAL DECISIONS: Asking the Right Questions to Obtain Clinically Useful Answers

    PubMed Central

    Proffit, William R.

    2013-01-01

    Orthodontists need to know the effectiveness, efficiency and predictability of treatment approaches and methods, which can be learned only by carefully studying and evaluating treatment outcomes. The best data for outcomes come from randomized clinical trials (RCTs), but retrospective data can provide satisfactory evidence if the subjects were a well-defined patient group, all the patients were accounted for, and the percentages of patients with various possible outcomes are presented along with measures of the central tendency and variation. Meta-analysis of multiple RCTs done in a similar way and systematic reviews of the literature can strengthen clinically-useful evidence, but reviews that are too broadly based are more likely to blur than clarify the information clinicians need. Reviews that are tightly focused on seeking the answer to specific clinical questions and evaluating the quality of the evidence available to answer the question are much more likely to provide clinically useful data. PMID:24198455

  3. Designing a Clinical Framework to Guide Gross Motor Intervention Decisions for Infants and Young Children with Hypotonia

    ERIC Educational Resources Information Center

    Darrah, Johanna; O'Donnell, Maureen; Lam, Joyce; Story, Maureen; Wickenheiser, Diane; Xu, Kaishou; Jin, Xiaokun

    2013-01-01

    Clinical practice frameworks are a valuable component of clinical education, promoting informed clinical decision making based on the best available evidence and/or clinical experience. They encourage standardized intervention approaches and evaluation of practice. Based on an international project to support the development of an enhanced service…

  4. Multi-site evaluation of a clinical decision support system for radiation therapy

    NASA Astrophysics Data System (ADS)

    Deshpande, Ruchi; DeMarco, John; Kessel, Kerstin; Liu, Brent J.

    2016-03-01

    We have developed an imaging informatics based decision support system that learns from retrospective treatment plans to provide recommendations for healthy tissue sparing to prospective incoming patients. This system incorporates a model of best practices from previous cases, specific to tumor anatomy. Ultimately, our hope is to improve clinical workflow efficiency, patient outcomes and to increase clinician confidence in decision-making. The success of such a system depends greatly on the training dataset, which in this case, is the knowledge base that the data-mining algorithm employs. The size and heterogeneity of the database is essential for good performance. Since most institutions employ standard protocols and practices for treatment planning, the diversity of this database can be greatly increased by including data from different institutions. This work presents the results of incorporating cross-country, multi-institutional data into our decision support system for evaluation and testing.

  5. Clinical Decision Support using a Terminology Server to improve Patient Safety.

    PubMed

    Garcia-Jimenez, Alba; Moreno-Conde, Alberto; Martínez-García, Alicia; Marín-León, Ignacio; Medrano-Ortega, Francisco Javier; Parra-Calderón, Carlos L

    2015-01-01

    Clinical Decision Support Systems (CDSS) are software applications that support clinicians in making healthcare decisions providing relevant information for individual patients about their specific conditions. The lack of integration between CDSS and Electronic Health Record (EHR) has been identified as a significant barrier to CDSS development and adoption. Andalusia Healthcare Public System (AHPS) provides an interoperable health information infrastructure based on a Service Oriented Architecture (SOA) that eases CDSS implementation. This paper details the deployment of a CDSS jointly with the deployment of a Terminology Server (TS) within the AHPS infrastructure. It also explains a case study about the application of decision support to thromboembolism patients and its potential impact on improving patient safety. We will apply the inSPECt tool proposal to evaluate the appropriateness of alerts in this scenario. PMID:25991120

  6. Who Can Afford a Computerized Bookstore? Almost Anyone.

    ERIC Educational Resources Information Center

    Miller, Charles

    1982-01-01

    The decision to computerize operations in the DeAnza Community College bookstore was followed by a number of decisions about financing options (purchase, lease/purchase, lease, timesharing). A timesharing agreement was reached with a local bank, with no capital outlay and at a cost equivalent to an accountant's position. (MSE)

  7. THE IMPACT OF RACISM ON CLINICIAN COGNITION, BEHAVIOR, AND CLINICAL DECISION MAKING

    PubMed Central

    van Ryn, Michelle; Burgess, Diana J.; Dovidio, John F.; Phelan, Sean M.; Saha, Somnath; Malat, Jennifer; Griffin, Joan M.; Fu, Steven S.; Perry, Sylvia

    2014-01-01

    Over the past two decades, thousands of studies have demonstrated that Blacks receive lower quality medical care than Whites, independent of disease status, setting, insurance, and other clinically relevant factors. Despite this, there has been little progress towards eradicating these inequities. Almost a decade ago we proposed a conceptual model identifying mechanisms through which clinicians’ behavior, cognition, and decision making might be influenced by implicit racial biases and explicit racial stereotypes, and thereby contribute to racial inequities in care. Empirical evidence has supported many of these hypothesized mechanisms, demonstrating that White medical care clinicians: (1) hold negative implicit racial biases and explicit racial stereotypes, (2) have implicit racial biases that persist independently of and in contrast to their explicit (conscious) racial attitudes, and (3) can be influenced by racial bias in their clinical decision making and behavior during encounters with Black patients. This paper applies evidence from several disciplines to further specify our original model and elaborate on the ways racism can interact with cognitive biases to affect clinicians’ behavior and decisions and in turn, patient behavior and decisions. We then highlight avenues for intervention and make specific recommendations to medical care and grant-making organizations. PMID:24761152

  8. Decision making and senior management: the implementation of change projects covering clinical management in SUS hospitals.

    PubMed

    Pacheco, José Márcio da Cunha; Gomes, Romeu

    2016-08-01

    This paper analyses the decision making process for senior management in public hospitals that are a part of the National Health Service in Brazil (hereafter SUS) in relation to projects aimed at changing clinical management. The methodological design of this study is qualitative in nature taking a hermeneutics-dialectics perspective in terms of results. Hospital directors noted that clinical management projects changed the state of hospitals through: improving their organizations, mobilizing their staff in order to increase a sense of order and systemizing actions and available resources. Technical rationality was the principal basis used in the decision making process for managers. Due to the reality of many hospitals having fragmented organizations, this fact impeded the use of aspects related to rationality, such as economic and financial factors in the decision making process. The incremental model and general politics also play a role in this area. We concluded that the decision making process embraces a large array of factors including rational aspects such as the use of management techniques and the ability to analyze, interpret and summarize. It also incorporates subjective elements such as how to select values and dealing with people's working experiences. We recognized that management problems are wide in scope, ambiguous, complex and do not come with a lot of structure in practice. PMID:27557021

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

    PubMed Central

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

    2014-01-01

    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

  10. A Legal Framework to Enable Sharing of Clinical Decision Support Knowledge and Services across Institutional Boundaries

    PubMed Central

    Hongsermeier, Tonya; Maviglia, Saverio; Tsurikova, Lana; Bogaty, Dan; Rocha, Roberto A.; Goldberg, Howard; Meltzer, Seth; Middleton, Blackford

    2011-01-01

    The goal of the CDS Consortium (CDSC) is to assess, define, demonstrate, and evaluate best practices for knowledge management and clinical decision support in healthcare information technology at scale – across multiple ambulatory care settings and Electronic Health Record technology platforms. In the course of the CDSC research effort, it became evident that a sound legal foundation was required for knowledge sharing and clinical decision support services in order to address data sharing, intellectual property, accountability, and liability concerns. This paper outlines the framework utilized for developing agreements in support of sharing, accessing, and publishing content via the CDSC Knowledge Management Portal as well as an agreement in support of deployment and consumption of CDSC developed web services in the context of a research project under IRB oversight. PMID:22195151

  11. How Qualitative Research Informs Clinical and Policy Decision Making in Transplantation: A Review.

    PubMed

    Tong, Allison; Morton, Rachael L; Webster, Angela C

    2016-09-01

    Patient-centered care is no longer just a buzzword. It is now widely touted as a cornerstone in delivering quality care across all fields of medicine. However, patient-centered strategies and interventions necessitate evidence about patients' decision-making processes, values, priorities, and needs. Qualitative research is particularly well suited to understanding the experience and perspective of patients, donors, clinicians, and policy makers on a wide range of transplantation-related topics including organ donation and allocation, adherence to prescribed therapy, pretransplant and posttransplant care, implementation of clinical guidelines, and doctor-patient communication. In transplantation, evidence derived from qualitative research has been integrated into strategies for shared decision-making, patient educational resources, process evaluations of trials, clinical guidelines, and policies. The aim of this article is to outline key concepts and methods used in qualitative research, guide the appraisal of qualitative studies, and assist clinicians to understand how qualitative research may inform their practice and policy. PMID:27479165

  12. The perils of meta-regression to identify clinical decision support system success factors

    PubMed Central

    Fillmore, Christopher L.; Rommel, Casey A.; Welch, Brandon M.; Zhang, Mingyuan; Kawamoto, Kensaku

    2016-01-01

    Clinical decision support interventions are typically heterogeneous in nature, making it difficult to identify why some interventions succeed while others do not. One approach to identify factors important to the success of health information systems is the use of meta-regression techniques, in which potential explanatory factors are correlated with the outcome of interest. This approach, however, can result in misleading conclusions due to several issues. In this manuscript, we present a cautionary case study in the context of clinical decision support systems to illustrate the limitations of this type of analysis. We then discuss implications and recommendations for future work aimed at identifying success factors of medical informatics interventions. In particular, we identify the need for head-to-head trials in which the importance of system features is directly evaluated in a prospective manner. PMID:25998518

  13. WHAT ARE 'BEST INTERESTS'? A CRITICAL EVALUATION OF 'BEST INTERESTS' DECISION-MAKING IN CLINICAL PRACTICE.

    PubMed

    Taylor, Helen J

    2016-01-01

    Obtaining the patient's consent is usually a prerequisite of any clinical intervention. However, some cognitively impaired patients may not be able to give valid consent. Following years of consultation and legislative review, the Mental Capacity Act 2005 (MCA) provides a statutory framework of 'best interests' decision-making on behalf of incapacitated individuals. However, confusion over the meaning and application of the 'best interests' standard persists. This paper explores the variation in judicial interpretation of the standard and the complexities of best interests decision-making in clinical practice. Prevailing confusion and risk-aversive practices mean that the rights and interests of cognitively impaired individuals continue to be compromised, with evidence to suggest that 'best interests' may be conflated with the clinician's evaluation of 'best medical interests'. PMID:26979251

  14. Clinical judgment and decision making in wound assessment and management: is experience enough?

    PubMed

    Logan, Gemma

    2015-03-01

    The assessment and management of wounds forms a large proportion of community nurses' workload, often requiring judgment and decision-making in complex, challenging and uncertain circumstances. The processes through which nurses form judgments and make decisions within this context are reviewed in this article against existing theories on these on these subjects. There is variability in wound assessment and management practice which may be attributed to uncertainties within the context, a lack of knowledge in appropriate treatment choices and the inability to correctly value the importance of the clinical information presented. Nurses may be required to draw on intuition to guide their judgments and decision-making by association with experience and expertise. In addition, a step-by-step analytical approach underpinned by an evidence base may be required to ensure accuracy in practice. Developing an understanding of the different theories of judgment and decision-making may facilitate nurses' abilities to reflect on their own decision tasks, thereby enhancing the care provided. PMID:25790510

  15. The anatomy of clinical decision-making in multidisciplinary cancer meetings

    PubMed Central

    Soukup, Tayana; Petrides, Konstantinos V.; Lamb, Benjamin W.; Sarkar, Somita; Arora, Sonal; Shah, Sujay; Darzi, Ara; Green, James S. A.; Sevdalis, Nick

    2016-01-01

    Abstract In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable. The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision. This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons. We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis. The exploratory factor analysis produced 4 factors, labeled “Holistic and Clinical inputs” (patient views, psychosocial aspects, patient history, comorbidities, oncologists’, nurses’, and surgeons’ inputs), “Radiology” (radiology results, radiologists’ inputs), “Pathology” (pathology results, pathologists’ inputs), and “Meeting Management” (meeting chairs’ and coordinators’ inputs). A negative cross-loading was observed from surgeons’ input on the fourth factor with a follow-up analysis showing negative correlation (r = −0.19, P < 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P < 0.001). Hawthorne effect is the main limitation of the study. The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient profile and contributions to case review by all core

  16. A programmable rules engine to provide clinical decision support using HTML forms.

    PubMed

    Heusinkveld, J; Geissbuhler, A; Sheshelidze, D; Miller, R

    1999-01-01

    The authors have developed a simple method for specifying rules to be applied to information on HTML forms. This approach allows clinical experts, who lack the programming expertise needed to write CGI scripts, to construct and maintain domain-specific knowledge and ordering capabilities within WizOrder, the order-entry and decision support system used at Vanderbilt Hospital. The clinical knowledge base maintainers use HTML editors to create forms and spreadsheet programs for rule entry. A test environment has been developed which uses Netscape to display forms; the production environment displays forms using an embedded browser. PMID:10566470

  17. Editorial: The search for core symptoms - will this help clinical decision-making?

    PubMed

    Frazier Norbury, Courtenay

    2016-08-01

    Diagnosis is an important component of our clinical roles, and should also lead to particular treatment pathways. The diagnostic process may be challenged by co-occurring deficits that are neither specific nor universal to the diagnosis under consideration and may well be evident across a range of other clinical conditions. How important is it to refine our instruments so that they measure unique symptoms? Will this alter or improve intervention choices? This Editorial focuses on the extent to which fine tuning diagnostic instruments improves our decisions about treatment, in the context of articles published in this issue of JCPP. PMID:27445109

  18. Influence of Patients’ Socioeconomic Status on Clinical Management Decisions: A Qualitative Study

    PubMed Central

    Bernheim, Susannah M.; Ross, Joseph S.; Krumholz, Harlan M.; Bradley, Elizabeth H.

    2008-01-01

    PURPOSE Little is known about how patients’ socioeconomic status (SES) influences physicians’ clinical management decisions, although this information may have important implications for understanding inequities in health care quality. We investigated physician perspectives on how patients’ SES influences care. METHODS The study consisted of in-depth semistructured interviews with primary care physicians in Connecticut. Investigators coded interviews line by line and refined the coding structure and interview guide based on successive interviews. Recurrent themes emerged through iterative analysis of codes and tagged quotations. RESULTS We interviewed 18 physicians from varied practice settings, 6 female, 9 from minority racial backgrounds, and 3 of Hispanic ethnicity. Four themes emerged from our interviews: (1) physicians held conflicting views about the effect of patient SES on clinical management, (2) physicians believed that changes in clinical management based on the patient’s SES were made in the patient’s interest, (3) physicians varied in the degree to which they thought changes in clinical management influenced patient outcomes, and (4) physicians faced personal and financial strains when caring for patients of low SES. CONCLUSIONS Physicians indicated that patient SES did affect their clinical management decisions. As a result, physicians commonly undertook changes to their management plan in an effort to enhance patient outcomes, but they experienced numerous strains when trying to balance what they believed was feasible for the patient with what they perceived as established standards of care. PMID:18195315

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

    PubMed Central

    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

    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

  20. A collaborative teaching strategy for enhancing learning of evidence-based clinical decision-making.

    PubMed

    Scott, P J; Altenburger, P A; Kean, J

    2011-01-01

    The educational literature cites a lack of student motivation to learn how to use research evidence in clinical decision-making because the students do not observe clinicians using evidence. This lack of motivation presents a challenge to educators as they seek to instill the value of evidence-based clinical decision-making (EBCD) in students. One problem is that students in entry-level programs do not have the experience needed to know what to look for, and secondly, clinical decision-making is contextually based in a patient problem. Our approach offers one solution to bridging the gap between classroom teaching and real-world implementation of EBCD through a three-phase collaborative approach. Occupational and physical therapy students are partnered with clinicians to find and appraise evidence to answer the real-world questions posed by these therapists. This paper describes the implementation of the partnership, teaching/learning outcomes, logistics, and implications for clinicians. We found this approach increased student motivation and greatly enhanced the learning experience. Future directions include implementing a framework which allows for the assessment of the strategy on the facility and creates opportunities to integrate the use of EBCD in all aspects of facility practice. PMID:21927777

  1. A study of clinical decision making by certified registered nurse anesthetists.

    PubMed

    Kremer, Michael J; Faut-Callahan, Margaret; Hicks, Frank D

    2002-10-01

    Anesthesia outcomes and related risk factors have been studied for more than 100 years. Varying sample sizes and research methods have been used, with research findings that were open to multiple interpretations. Research with closed malpractice claims demonstrates that American Society of Anesthesiologists physical status II patients undergoing elective procedures are most likely to experience damaging events intraoperatively with resultant postoperative adverse outcomes. The process of care, including clinical decision making, contributes to adverse outcomes. Clinical decision making can be difficult to assess and measure. In this study, the cognitive psychology framework of information-processing theory and literature pertaining to the use of heuristics, or rules of thumb, and clinical biases, were used to analyze cases from the AANA Foundation closed malpractice claims database. This database contains more than 300 files involving St Paul Fire and Marine Insurance Company-covered CRNAs from across the United States. These files were analyzed by 10 CRNA investigators on the AANA Closed Claims research team. Variables such as inadequate preinduction activities, e.g., incomplete preanesthetic assessments, and use of cognitive biases and inaccurate probability estimation were associated with adverse outcomes in this research sample. Teaching of decision science in basic and continuing nurse anesthesia education is advocated. PMID:12425129

  2. Interoperability of clinical decision-support systems and electronic health records using archetypes: a case study in clinical trial eligibility.

    PubMed

    Marcos, Mar; Maldonado, Jose A; Martínez-Salvador, Begoña; Boscá, Diego; Robles, Montserrat

    2013-08-01

    Clinical decision-support systems (CDSSs) comprise systems as diverse as sophisticated platforms to store and manage clinical data, tools to alert clinicians of problematic situations, or decision-making tools to assist clinicians. Irrespective of the kind of decision-support task CDSSs should be smoothly integrated within the clinical information system, interacting with other components, in particular with the electronic health record (EHR). However, despite decades of developments, most CDSSs lack interoperability features. We deal with the interoperability problem of CDSSs and EHRs by exploiting the dual-model methodology. This methodology distinguishes a reference model and archetypes. A reference model is represented by a stable and small object-oriented model that describes the generic properties of health record information. For their part, archetypes are reusable and domain-specific definitions of clinical concepts in the form of structured and constrained combinations of the entities of the reference model. We rely on archetypes to make the CDSS compatible with EHRs from different institutions. Concretely, we use archetypes for modelling the clinical concepts that the CDSS requires, in conjunction with a series of knowledge-intensive mappings relating the archetypes to the data sources (EHR and/or other archetypes) they depend on. We introduce a comprehensive approach, including a set of tools as well as methodological guidelines, to deal with the interoperability of CDSSs and EHRs based on archetypes. Archetypes are used to build a conceptual layer of the kind of a virtual health record (VHR) over the EHR whose contents need to be integrated and used in the CDSS, associating them with structural and terminology-based semantics. Subsequently, the archetypes are mapped to the EHR by means of an expressive mapping language and specific-purpose tools. We also describe a case study where the tools and methodology have been employed in a CDSS to support

  3. Formative Evaluation of Clinician Experience with Integrating Family History-Based Clinical Decision Support into Clinical Practice

    PubMed Central

    Doerr, Megan; Edelman, Emily; Gabitzsch, Emily; Eng, Charis; Teng, Kathryn

    2014-01-01

    Family health history is a leading predictor of disease risk. Nonetheless, it is underutilized to guide care and, therefore, is ripe for health information technology intervention. To fill the family health history practice gap, Cleveland Clinic has developed a family health history collection and clinical decision support tool, MyFamily. This report describes the impact and process of implementing MyFamily into primary care, cancer survivorship and cancer genetics clinics. Ten providers participated in semi-structured interviews that were analyzed to identify opportunities for process improvement. Participants universally noted positive effects on patient care, including increases in quality, personalization of care and patient engagement. The impact on clinical workflow varied by practice setting, with differences observed in the ease of integration and the use of specific report elements. Tension between the length of the report and desired detail was appreciated. Barriers and facilitators to the process of implementation were noted, dominated by the theme of increased integration with the electronic medical record. These results fed real-time improvement cycles to reinforce clinician use. This model will be applied in future institutional efforts to integrate clinical genomic applications into practice and may be useful for other institutions considering the implementation of tools for personalizing medical management. PMID:25563219

  4. Reproductive Ethics in Commercial Surrogacy: Decision-Making in IVF Clinics in New Delhi, India.

    PubMed

    Tanderup, Malene; Reddy, Sunita; Patel, Tulsi; Nielsen, Birgitte Bruun

    2015-09-01

    As a neo-liberal economy, India has become one of the new health tourism destinations, with commercial gestational surrogacy as an expanding market. Yet the Indian Assisted Reproductive Technology (ART) Bill has been pending for five years, and the guidelines issued by the Indian Council of Medical Research are somewhat vague and contradictory, resulting in self-regulated practices of fertility clinics. This paper broadly looks at clinical ethics in reproduction in the practice of surrogacy and decision-making in various procedures. Through empirical research in New Delhi, the capital of India, from December 2011 to November 2012, issues of decision-making on embryo transfer, fetal reduction, and mode of delivery were identified. Interviews were carried out with doctors in eighteen ART clinics, agents from four agencies, and fourteen surrogates. In aiming to fulfil the commissioning parents' demands, doctors were willing to go to the greatest extent possible in their medical practice. Autonomy and decision-making regarding choice of the number of embryos to transfer and the mode of delivery lay neither with commissioning parents nor surrogate mothers but mostly with doctors. In order to ensure higher success rates, surrogates faced the risk of multiple pregnancy and fetal reduction with little information regarding the risks involved. In the globalized market of commercial surrogacy in India, and with clinics compromising on ethics, there is an urgent need for formulation of regulative law for the clinical practice and maintenance of principles of reproductive ethics in order to ensure that the interests of surrogate mothers are safeguarded. PMID:26133889

  5. Clinical Decision Support Tools for Osteoporosis Disease Management: A Systematic Review of Randomized Controlled Trials

    PubMed Central

    Straus, Sharon E.

    2008-01-01

    BACKGROUND Studies indicate a gap between evidence and clinical practice in osteoporosis management. Tools that facilitate clinical decision making at the point of care are promising strategies for closing these practice gaps. OBJECTIVE To systematically review the literature to identify and describe the effectiveness of tools that support clinical decision making in osteoporosis disease management. DATA SOURCES Medline, EMBASE, CINAHL, and EBM Reviews (CDSR, DARE, CCTR, and ACP J Club), and contact with experts in the field. REVIEW METHODS Randomized controlled trials (RCTs) in any language from 1966 to July 2006 investigating disease management interventions in patients at risk for osteoporosis. Outcomes included fractures and bone mineral density (BMD) testing. Two investigators independently assessed articles for relevance and study quality, and extracted data using standardized forms. RESULTS Of 1,246 citations that were screened for relevance, 13 RCTs met the inclusion criteria. Reported study quality was generally poor. Meta-analysis was not done because of methodological and clinical heterogeneity; 77% of studies included a reminder or education as a component of their intervention. Three studies of reminders plus education targeted to physicians and patients showed increased BMD testing (RR range 1.43 to 8.67) and osteoporosis medication use (RR range 1.60 to 8.67). A physician reminder plus a patient risk assessment strategy found reduced fractures [RR 0.58, 95% confidence interval (CI) 0.37 to 0.90] and increased osteoporosis therapy (RR 2.44, CI 1.43 to 4.17). CONCLUSION Multi-component tools that are targeted to physicians and patients may be effective for supporting clinical decision making in osteoporosis disease management. Electronic supplementary material The online version of this article (doi:10.1007/s11606-008-0812-9) contains supplementary material, which is available to authorized users. PMID:18836782

  6. Clinical Recommendations in Medical Practice: A Proposed Framework to Reduce Bias and Improve the Quality of Medical Decisions.

    PubMed

    Alfandre, David

    2016-01-01

    Patients rely on, benefit from, and are strongly influenced by physicians' recommendations. In spite of the centrality and importance of physicians' recommendations to clinical care, there is only a scant literature describing the conceptual process of forming a clinical recommendation, and no discrete professional standards for making individual clinical recommendations. Evidence-based medicine and shared decision making together are intended to improve medical decision making, but there has been limited attention to how a recommendation is discretely formulated from either of those processes or how patients' preferences ought to be considered and how much weight they should hold. Moreover, physicians' bias has been reported to strongly influence how a recommendation is derived, thereby undermining the quality of healthcare decisions and patients' trust. To demonstrate a potential for improving the quality of decisions, this article proposes a conceptual framework for how physicians should reach a clinical recommendation and apply the process in practice. For preference-sensitive clinical decisions-that is, clinical decisions when patients' values and preferences are relevant-the process for reaching a recommendation should be transparent to patients and should be based solely on the medical evidence and patients' values and preferences. When patients' preferences for care do not prioritize health, physicians decide whether their recommendation will prioritize a welfare-enhancing versus an autonomy-enhancing approach. When there are gaps in understanding how physicians derive their clinical recommendations and how to further improve the quality of the decisions, the author calls for further empiric research. PMID:27045301

  7. Physician Attitudes toward Adopting Genome-Guided Prescribing through Clinical Decision Support.

    PubMed

    Overby, Casey Lynnette; Erwin, Angelika Ludtke; Abul-Husn, Noura S; Ellis, Stephen B; Scott, Stuart A; Obeng, Aniwaa Owusu; Kannry, Joseph L; Hripcsak, George; Bottinger, Erwin P; Gottesman, Omri

    2014-01-01

    This study assessed physician attitudes toward adopting genome-guided prescribing through clinical decision support (CDS), prior to enlisting in the Clinical Implementation of Personalized Medicine through Electronic Health Records and Genomics pilot pharmacogenomics project (CLIPMERGE PGx). We developed a survey instrument that includes the Evidence Based Practice Attitude Scale, adapted to measure attitudes toward adopting genome-informed interventions (EBPAS-GII). The survey also includes items to measure physicians' characteristics (awareness, experience, and perceived usefulness), attitudes about personal genome testing (PGT) services, and comfort using technology. We surveyed 101 General Internal Medicine physicians from the Icahn School of Medicine at Mount Sinai (ISMMS). The majority were residency program trainees (~88%). Prior to enlisting into CLIPMERGE PGx, most physicians were aware of and had used decision support aids. Few physicians, however, were aware of and had used genome-guided prescribing. The majority of physicians viewed decision support aids and genotype data as being useful for making prescribing decisions. Most physicians had not heard of, but were willing to use, PGT services and felt comfortable interpreting PGT results. Most physicians were comfortable with technology. Physicians who perceived genotype data to be useful in making prescribing decisions, had more positive attitudes toward adopting genome-guided prescribing through CDS. Our findings suggest that internal medicine physicians have a deficit in their familiarity and comfort interpreting and using genomic information. This has reinforced the importance of gathering feedback and guidance from our enrolled physicians when designing genome-guided CDS and the importance of prioritizing genomic medicine education at our institutions. PMID:25562141

  8. Seismic Computerized Alert Network

    USGS Publications Warehouse

    1986-01-01

    In 1985 the USGS devised a model for a Seismic Computerized Alert Network (SCAN) that would use continuous monitoring of seismic data from existing types of instruments to provide automatic, highly-reliable early warnings of earthquake shaking. In a large earthquake, substantial damaging ground motions may occur at great distances from the earthquake's epicenter.

  9. The History Computerization Project.

    ERIC Educational Resources Information Center

    Clark, David L.

    1992-01-01

    Description of the History Computerization Project, which is being developed for the exchange of information between researchers, librarians, archivists, museum curators, preservation groups, and historical societies, focuses on workshops that teach the use of computer database management for historical cataloging and research. (LRW)

  10. Adaptive Computerized Instruction.

    ERIC Educational Resources Information Center

    Ray, Roger D.; And Others

    1995-01-01

    Describes an artificially intelligent multimedia computerized instruction system capable of developing a conceptual image of what a student is learning while the student is learning it. It focuses on principles of learning and adaptive behavioral control systems theory upon which the system is designed and demonstrates multiple user modes.…

  11. Computerized Fleet Maintenance.

    ERIC Educational Resources Information Center

    Cataldo, John J.

    The computerization of school bus maintenance records by the Niskayuna (New York) Central School District enabled the district's transportation department to engage in management practices resulting in significant savings. The district obtains computer analyses of the work performed on all vehicles, including time spent, parts, labor, costs,…

  12. Impact of clinical decision support preventing the use of QT-prolonging medications for patients at risk for torsade de pointes.

    PubMed

    Sorita, Atsushi; Bos, J Martijn; Morlan, Bruce W; Tarrell, Robert F; Ackerman, Michael J; Caraballo, Pedro J

    2015-04-01

    We developed and implemented a 'CPOE-QT Alert' system, that is, clinical decision support integrated in the computerized physician order entry system (CPOE), in 2011. The system identifies any attempts to order medications with risk of torsade de pointes (TdP) for patients with a history of significant QT prolongation (QTc ≥500 ms) and alerts the provider entering the order. We assessed its impact by comparing orders and subsequent medication administration before and after activation of the system. We found a significant decrease in the proportion of completed order per ordering attempt after system activation (94% (1293/1379) vs 77% (1888/2453), difference 16.8%; p<0.001). This resulted in a 13.9% reduction in the administration of those medications to patients. A significant decrease was observed across all provider types, educational levels, and specialties. The CPOE-QT Alert system successfully reduced exposure to QT-prolonging medications in high risk patients. PMID:25324555

  13. Exploring Decision-Making of HIV-Infected Hispanics and African Americans Participating in Clinical Trials

    PubMed Central

    Rivera-Goba, Migdalia V.; Dominguez, Dinora C.; Stoll, Pamela; Grady, Christine; Ramos, Catalina; Mican, JoAnn M.

    2011-01-01

    Underrepresentation of HIV-infected Hispanics and African Americans in clinical trials seriously limits our understanding of the benefits and risks of treatment in these populations. This qualitative study examined factors that racial/ethnic minority patients consider when making decisions regarding research participation. Thirty-five HIV-infected Hispanic and African American patients enrolled in clinical research protocols at the National Institutes of Health were recruited to participate in focus groups and in-depth interviews. The sample of mostly men (n = 22), had a mean age of 45, nearly equal representation of race/ethnicity, and diagnosed 2 to 22 years ago. Baseline questionnaires included demographics and measures of social support and acculturation. Interviewers had similar racial/ethnic, cultural, and linguistic backgrounds as the participants. Four major themes around participants’ decisions to enroll in clinical trials emerged: Enhancers, Barriers, Beliefs, and Psychosocial Context. Results may help researchers develop strategies to facilitate inclusion of HIV-infected Hispanics and African Americans into clinical trials. PMID:21256054

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

    PubMed

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

    1986-09-01

    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

  15. A Framework for Usable and Effective Clinical Decision Support: Experience from the iCPR Randomized Clinical Trial

    PubMed Central

    Kannry, Joseph; McCullagh, Lauren; Kushniruk, Andre; Mann, Devin; Edonyabo, Daniel; McGinn, Thomas

    2015-01-01

    Introduction: The promise of Clinical Decision Support (CDS) has always been to transform patient care and improve patient outcomes through the delivery of timely and appropriate recommendations that are patient specific and, more often than not, are appropriately actionable. However, the users of CDS—providers—are frequently bombarded with inappropriate and inapplicable CDS that often are not informational, not integrated into the workflow, not patient specific, and that may present out of date and irrelevant recommendations. Methods: The integrated clinical prediction rule (iCPR) project was a randomized clinical trial (RCT) conducted to determine if a novel form of CDS, i.e., clinical prediction rules (CPRs), could be efficiently integrated into workflow and result in changes in outcomes (e.g., antibiotic ordering) when embedded within a commercial electronic health record (EHR). We use the lessons learned from the iCPR project to illustrate a framework for constructing usable, useful, and effective actionable CDS while employing off-the-shelf functionality in a production system. Innovations that make up the framework combine the following: (1) active and actionable decision support, (2) multiple rounds of usability testing with iterative development for user acceptance, (3) numerous context sensitive triggers, (4) dedicated training and support for users of the CDS tool for user adoption, and (5) support from clinical and administrative leadership. We define “context sensitive triggers” as being workflow events (i.e., context) that result in a CDS intervention. Discussion: Success of the framework can be measured by CDS adoption (i.e., intervention is being used), acceptance (compliance with recommendations), and clinical outcomes (where appropriate). This framework may have broader implications for the deployment of Health Information Technology (HIT). Results and Conclusion: iCPR was well adopted(57.4% of users) and accepted (42.7% of users

  16. The Utilization of a Clinical Decision Support System to Manage Adult Type 2 Diabetes: A Correlational Study

    ERIC Educational Resources Information Center

    Faught, I. Charie

    2012-01-01

    While the Institute of Medicine (2001) has promoted health information technology to improve the process of care such as compliance with clinical practice guidelines and quicker access to clinical information, diagnostic tests, and treatment results, very little was known about how a clinical decision support system can contribute to diabetes…

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

    PubMed Central

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

    2012-01-01

    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

  18. Clinical Decisions: Determining When to Save or Remove an Ailing Implant.

    PubMed

    Tarnow, Dennis P; Chu, Stephen J; Fletcher, Paul D

    2016-04-01

    The basis for the decision to either save or remove an ailing implant is multifactorial, and, as such, it has become one of the more controversial topics in the field of dental implantology. While bone lost to peri-implant disease can now be augmented with increasing predictability, the degree of success still varies depending on the size and configuration of the osseous defect. Concurrently, with the development of improved high-reverse torque instrumentation, minimally invasive techniques can be used to easily remove an implant that is malpositioned, causing an esthetic problem, or showing advanced bone loss. Any eventual decision regarding the retention or removal of an ailing implant must also be balanced with the desires of the patient, who typically will have already invested significant time and money to have the implant initially placed and restored. This article will present the variables involved in the decision-making process for when to save or remove an ailing implant. Clinical examples illustrating the management for these factors will be offered, providing clinicians a variety of alternatives available for managing different clinical circumstances that may be encountered. PMID:27136118

  19. A UMLS-based Knowledge Acquisition Tool for Rule-based Clinical Decision Support System Development

    PubMed Central

    Achour, Soumeya L.; Dojat, Michel; Rieux, Claire; Bierling, Philippe; Lepage, Eric

    2001-01-01

    Decision support systems in the medical field have to be easily modified by medical experts themselves. The authors have designed a knowledge acquisition tool to facilitate the creation and maintenance of a knowledge base by the domain expert and its sharing and reuse by other institutions. The Unified Medical Language System (UMLS) contains the domain entities and constitutes the relations repository from which the expert builds, through a specific 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 clinical decision-making processes. Corresponding medical logic modules are eventually generated. The application of this knowledge acquisition tool to the construction of a decision support system in blood transfusion demonstrates the value of such a pragmatic methodology for the design of rule-based clinical systems that rely on the highly progressive knowledge embedded in hospital information systems. PMID:11418542

  20. Understanding the impact of economic evidence on clinical decision making: a discrete choice experiment in cardiology.

    PubMed

    Torbica, Aleksandra; Fattore, Giovanni

    2010-05-01

    The present study aims to evaluate the impact of cost-effectiveness information on clinical decision making using discrete choice experiment (DCE) methodology. Data were collected through a self-completed questionnaire administered to Italian cardiologists in June 2007 (n = 129 respondents, 1143 observations). The questionnaire asked clinicians to make choices between paired scenarios, across which three key dimensions were identified and varied: (1) quality of clinical evidence, (2) size of health gain (reduction of relative and absolute risk), and (3) economic impact (incremental cost-effectiveness ratio). A random effects probit model was used to estimate clinicians' preferences for the different dimensions, while the heterogeneity of preferences was tested in a model with interaction terms. Dominance tests were used to assess the consistency of responses. The results indicate that Italian cardiologists regard economic impact (cost-effectiveness) as an important factor in their decision making. Economic evidence is valued more highly among clinicians with a higher self-assessed level of knowledge regarding economic evaluation techniques, as well as among younger professionals (age<45). While relevant study limitations should be acknowledged, our results suggest that DCEs can be used to elicit clinicians' decision-making criteria and to inform the allocation of resources for future research in a logical manner. Italian cardiologists appear to take cost-effectiveness information into account when deciding whether to use new treatments. PMID:20207466

  1. Development of a formal structure for clinical management decisions: a mathematical analysis.

    PubMed

    Card, W I

    1975-01-01

    Decision theory and the calculating power of the computer now enables us to contemplate the development of formal methods for making decisions about clinical management. In the simplest model, it is first necessary to define all treatment decisions as an exhaustive and mutually exclusive set and similarly to define the set of consequences or outcomes of treatment. The probability of each outcome conditional on treatment has to be estimated and this consequent state of health has to be quantified as a utility. Possible methods of estimating utilities of states of health are discussed and the construction of a unidimensional utility function based on a sequence of wagers. The states of health consequent on severe brain damage can only be described multidimensionally and the model has to be extended to include this case. While such a model would allow simple treatment decisions to be formalized, it could not decide whether the cost of treatment was worth while nor whether it would pay to carry out further investigative tests and thus buy more evidence. If these additional variables are to be included in the model, it is necessary to introduce the motion of an equivalence between monetary values and utilities. This implies attaching a monetary value to any given state of health. PMID:1045996

  2. [Human body meridian spatial decision support system for clinical treatment and teaching of acupuncture and moxibustion].

    PubMed

    Wu, Dehua

    2016-01-01

    The spatial position and distribution of human body meridian are expressed limitedly in the decision support system (DSS) of acupuncture and moxibustion at present, which leads to the failure to give the effective quantitative analysis on the spatial range and the difficulty for the decision-maker to provide a realistic spatial decision environment. Focusing on the limit spatial expression in DSS of acupuncture and moxibustion, it was proposed that on the basis of the geographic information system, in association of DSS technology, the design idea was developed on the human body meridian spatial DSS. With the 4-layer service-oriented architecture adopted, the data center integrated development platform was taken as the system development environment. The hierarchical organization was done for the spatial data of human body meridian via the directory tree. The structured query language (SQL) server was used to achieve the unified management of spatial data and attribute data. The technologies of architecture, configuration and plug-in development model were integrated to achieve the data inquiry, buffer analysis and program evaluation of the human body meridian spatial DSS. The research results show that the human body meridian spatial DSS could reflect realistically the spatial characteristics of the spatial position and distribution of human body meridian and met the constantly changeable demand of users. It has the powerful spatial analysis function and assists with the scientific decision in clinical treatment and teaching of acupuncture and moxibustion. It is the new attempt to the informatization research of human body meridian. PMID:26946752

  3. Clinical evaluation of the DIABETES expert system for decision support by multiple regimen insulin dose adjustment.

    PubMed

    Ambrosiadou, B V; Goulis, D G; Pappas, C

    1996-01-01

    A performance evaluation of the DIABETES rule-based expert system prototype for clinical decision making is presented. The system facilitates multiple insulin regimen and dose adjustment of insulin dependent Type I or II diabetic patients. The study was performed on 600 subjects from two diabetological centres and three diabetological offices of Greek hospitals. The responses of the attendant medical doctors were compared with those of the DIABETES system, with the aid of a specifically devised valuation range (0-5 degrees, 0 indicating full agreement and 5 full disagreement). The capabilities and the weakness of the system in terms of its practicality for decision support in assisting therapy of diabetes mellitus by blood glucose monitoring and subsequent insulin dose adjustment are discussed. The potential benefits of decision support systems for diabetic patient management are seen to be the cost saving they provide in terms of man-hours of verbal instruction by medical experts, the support in terms of objective and consistent decision making, as well as the recording of medical knowledge in the ill-defined field of insulin administration, thus aiding the education and training of medical personnel. PMID:8646833

  4. Test Case Selection in Pre-Deployment Testing of Complex Clinical Decision Support Systems.

    PubMed

    Tso, Geoffrey J; Yuen, Kaeli; Martins, Susana; Tu, Samson W; Ashcraft, Michael; Heidenreich, Paul; Hoffman, Brian B; Goldstein, Mary K

    2016-01-01

    Clinical decision support (CDS) systems with complex logic are being developed. Ensuring the quality of CDS is imperative, but there is no consensus on testing standards. We tested ATHENA-HTN CDS after encoding updated hypertension guidelines into the system. A logic flow and a complexity analysis of the encoding were performed to guide testing. 100 test cases were selected to test the major pathways in the CDS logic flow, and the effectiveness of the testing was analyzed. The encoding contained 26 decision points and 3120 possible output combinations. The 100 cases selected tested all of the major pathways in the logic, but only 1% of the possible output combinations. Test case selection is one of the most challenging aspects in CDS testing and has a major impact on testing coverage. A test selection strategy should take into account the complexity of the system, identification of major logic pathways, and available resources. PMID:27570678

  5. Test Case Selection in Pre-Deployment Testing of Complex Clinical Decision Support Systems

    PubMed Central

    Tso, Geoffrey J.; Yuen, Kaeli; Martins, Susana; Tu, Samson W.; Ashcraft, Michael; Heidenreich, Paul; Hoffman, Brian B.; Goldstein, Mary K.

    2016-01-01

    Clinical decision support (CDS) systems with complex logic are being developed. Ensuring the quality of CDS is imperative, but there is no consensus on testing standards. We tested ATHENA-HTN CDS after encoding updated hypertension guidelines into the system. A logic flow and a complexity analysis of the encoding were performed to guide testing. 100 test cases were selected to test the major pathways in the CDS logic flow, and the effectiveness of the testing was analyzed. The encoding contained 26 decision points and 3120 possible output combinations. The 100 cases selected tested all of the major pathways in the logic, but only 1% of the possible output combinations. Test case selection is one of the most challenging aspects in CDS testing and has a major impact on testing coverage. A test selection strategy should take into account the complexity of the system, identification of major logic pathways, and available resources. PMID:27570678

  6. Perforated mucinous cystadenoma of the vermiform appendix: an overview in reasoning clinical decisions

    PubMed Central

    Papadopoulos, Iordanis N; Christodoulou, Spyridon; Kokoropoulos, Panayiotis; Konstantudakis, George; Economopoulos, Nikolaos; Leontara, Vassilia

    2011-01-01

    Recent advances in the management of appendiceal mucinous neoplasms (AMN) such as peritonectomy combined with hyperthermic intraperitoneal chemotherapy have introduced new standards of care. However, many dilemmas are encountered in decision making as in the following patient. A 74-year-old woman was admitted with an appendiceal cystadenoma found in a preadmission CT scan. However, the tumour was not documented by the in hospital investigation due to its perforation and its reduction in size. Consequently, a series of management dilemmas were encountered that were solved by cautious evaluation of the pre and peroperative findings. She was submitted to a right hemicolectomy. A spontaneous perforation was suspected, but the accurate diagnosis was documented postoperatively by histopathology. This paradigm motivated this review which concluded that reasoning clinical decisions in the light of recent advances and appropriate care based on the disease-stage are essential for an optimal outcome in the management of AMN. PMID:22689271

  7. Assessing the Clinical Impact of Risk Prediction Models With Decision Curves: Guidance for Correct Interpretation and Appropriate Use.

    PubMed

    Kerr, Kathleen F; Brown, Marshall D; Zhu, Kehao; Janes, Holly

    2016-07-20

    The decision curve is a graphical summary recently proposed for assessing the potential clinical impact of risk prediction biomarkers or risk models for recommending treatment or intervention. It was applied recently in an article in Journal of Clinical Oncology to measure the impact of using a genomic risk model for deciding on adjuvant radiation therapy for prostate cancer treated with radical prostatectomy. We illustrate the use of decision curves for evaluating clinical- and biomarker-based models for predicting a man's risk of prostate cancer, which could be used to guide the decision to biopsy. Decision curves are grounded in a decision-theoretical framework that accounts for both the benefits of intervention and the costs of intervention to a patient who cannot benefit. Decision curves are thus an improvement over purely mathematical measures of performance such as the area under the receiver operating characteristic curve. However, there are challenges in using and interpreting decision curves appropriately. We caution that decision curves cannot be used to identify the optimal risk threshold for recommending intervention. We discuss the use of decision curves for miscalibrated risk models. Finally, we emphasize that a decision curve shows the performance of a risk model in a population in which every patient has the same expected benefit and cost of intervention. If every patient has a personal benefit and cost, then the curves are not useful. If subpopulations have different benefits and costs, subpopulation-specific decision curves should be used. As a companion to this article, we released an R software package called DecisionCurve for making decision curves and related graphics. PMID:27247223

  8. Comparison of Computer-based Clinical Decision Support Systems and Content for Diabetes Mellitus

    PubMed Central

    Kantor, M.; Wright, A.; Burton, M.; Fraser, G.; Krall, M.; Maviglia, S.; Mohammed-Rajput, N.; Simonaitis, L.; Sonnenberg, F.; Middleton, B.

    2011-01-01

    Background Computer-based clinical decision support (CDS) systems have been shown to improve quality of care and workflow efficiency, and health care reform legislation relies on electronic health records and CDS systems to improve the cost and quality of health care in the United States; however, the heterogeneity of CDS content and infrastructure of CDS systems across sites is not well known. Objective We aimed to determine the scope of CDS content in diabetes care at six sites, assess the capabilities of CDS in use at these sites, characterize the scope of CDS infrastructure at these sites, and determine how the sites use CDS beyond individual patient care in order to identify characteristics of CDS systems and content that have been successfully implemented in diabetes care. Methods We compared CDS systems in six collaborating sites of the Clinical Decision Support Consortium. We gathered CDS content on care for patients with diabetes mellitus and surveyed institutions on characteristics of their site, the infrastructure of CDS at these sites, and the capabilities of CDS at these sites. Results The approach to CDS and the characteristics of CDS content varied among sites. Some commonalities included providing customizability by role or user, applying sophisticated exclusion criteria, and using CDS automatically at the time of decision-making. Many messages were actionable recommendations. Most sites had monitoring rules (e.g. assessing hemoglobin A1c), but few had rules to diagnose diabetes or suggest specific treatments. All sites had numerous prevention rules including reminders for providing eye examinations, influenza vaccines, lipid screenings, nephropathy screenings, and pneumococcal vaccines. Conclusion Computer-based CDS systems vary widely across sites in content and scope, but both institution-created and purchased systems had many similar features and functionality, such as integration of alerts and reminders into the decision-making workflow of the

  9. Development and impact of computerised decision support systems for clinical management of depression: A systematic review.

    PubMed

    Triñanes, Yolanda; Atienza, Gerardo; Louro-González, Arturo; de-las-Heras-Liñero, Elena; Alvarez-Ariza, María; Palao, Diego J

    2015-01-01

    One of the proposals for improving clinical practice is to introduce computerised decision support systems (CDSS) and integrate these with electronic medical records. Accordingly, this study sought to systematically review evidence on the effectiveness of CDSS in the management of depression. A search was performed in Medline, EMBASE and PsycInfo, in order to do this. The quality of quantitative studies was assessed using the SIGN method, and qualitative studies using the CASPe checklist. Seven studies were identified (3 randomised clinical trials, 3 non-randomised trials, and one qualitative study). The CDSS assessed incorporated content drawn from guidelines and other evidence-based products. In general, the CDSS had a positive impact on different aspects, such as the screening and diagnosis, treatment, improvement in depressive symptoms and quality of life, and referral of patients. The use of CDSS could thus serve to optimise care of depression in various scenarios by providing recommendations based on the best evidence available and facilitating decision-making in clinical practice. PMID:25500093

  10. Teaching clinical decision-making to pediatric residents in an era of managed care.

    PubMed

    Chessare, J B

    1998-04-01

    The growth of managed care has brought a new focus on physician competency in the appropriate use of resources to help patients. The community of pediatric educators must improve residency curricula and teaching methodologies to ensure that graduates of their programs can effectively and efficiently meet the needs of children and their families. The educational approach in many pediatric residency programs is an implicit apprenticeship model, with which the residents follow the actions of attending physicians with little attention to scrutiny of the clinical evidence for and against diagnostic and treatment strategies. Evidence-based medicine stresses to the trainee the importance of the evaluation of evidence from clinical research and cautions against the use of intuition, unsystematic clinical experience, and untested pathophysiologic reasoning as sufficient for medical decision-making. Managed care also has helped to create a heightened awareness of the need to educate residents to incorporate the preferences of patients and families into diagnostic and treatment decisions. Trainees must know how to balance their duty to maximize the health of populations at the lowest resource use with their duty to each individual patient and family. Changes in the residency curriculum will bring change in educational settings and the structure of rotations. Potential barriers to implementation will include the need for faculty development and financial resources for information technology. PMID:9544180

  11. Sources of non-compliance with clinical practice guidelines in trauma triage: a decision science study

    PubMed Central

    2012-01-01

    Background United States trauma system guidelines specify when to triage patients to specialty centers. Nonetheless, many eligible patients are not transferred as per guidelines. One possible reason is emergency physician decision-making. The objective of the study was to characterize sensory and decisional determinants of emergency physician trauma triage decision-making. Methods We conducted a decision science study using a signal detection theory-informed approach to analyze physician responses to a web-based survey of 30 clinical vignettes of trauma cases. We recruited a national convenience sample of emergency medicine physicians who worked at hospitals without level I/II trauma center certification. Using trauma triage guidelines as our reference standard, we estimated physicians’ perceptual sensitivity (ability to discriminate between patients who did and did not meet guidelines for transfer) and decisional threshold (tolerance for false positive or false negative decisions). Results We recruited 280 physicians: 210 logged in to the website (response rate 74%) and 168 (80%) completed the survey. The regression coefficient on American College of Surgeons – Committee on Trauma (ACS-COT) guidelines for transfer (perceptual sensitivity) was 0.77 (p<0.01, 95% CI 0.68 – 0.87) indicating that the probability of transfer weakly increased as the ACS-COT guidelines would recommend transfer. The intercept (decision threshold) was 1.45 (p<0.01, 95% CI 1.27 – 1.63), indicating that participants had a conservative threshold for transfer, erring on the side of not transferring patients. There was significant between-physician variability in perceptual sensitivity and decisional thresholds. No physician demographic characteristics correlated with perceptual sensitivity, but men and physicians working at non-trauma centers without a trauma-center affiliation had higher decisional thresholds. Conclusions On a case vignette-based questionnaire, both sensory and

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

    PubMed Central

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

    2008-01-01

    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 team on the implementation of SDM in clinical practice using a theory-based dyadic perspective. Methods Participants include researchers from Canada, US, UK, and Netherlands, representing medicine, nursing, psychology, community health and epidemiology. In order to develop a collaborative research network that takes advantage of the expertise of the team members, the following research activities are planned: 1) establish networking and on-going communication through internet-based forum, conference calls, and a bi-weekly e-bulletin; 2) hold a two-day workshop with two key experts (one in theoretical underpinnings of behavioral change, and a second in dyadic data analysis), and invite all investigators to present their views on the challenges related to the implementation of SDM in clinical practices; 3) conduct a secondary analyses of existing dyadic datasets to ensure that discussion among team members is grounded in empirical data; 4) build capacity with involvement of graduate students in the workshop and online forum; and 5) elaborate a position paper and an international multi-site study protocol. Discussion This study protocol aims to inform researchers, educators, and clinicians interested in improving their understanding of effective strategies to implement shared decision-making in clinical practice using a theory-based dyadic perspective. PMID:18194521

  13. Integrating complex business processes for knowledge-driven clinical decision support systems.

    PubMed

    Kamaleswaran, Rishikesan; McGregor, Carolyn

    2012-01-01

    This paper presents in detail the component of the Complex Business Process for Stream Processing framework that is responsible for integrating complex business processes to enable knowledge-driven Clinical Decision Support System (CDSS) recommendations. CDSSs aid the clinician in supporting the care of patients by providing accurate data analysis and evidence-based recommendations. However, the incorporation of a dynamic knowledge-management system that supports the definition and enactment of complex business processes and real-time data streams has not been researched. In this paper we discuss the process web service as an innovative method of providing contextual information to a real-time data stream processing CDSS. PMID:23366138

  14. Laboratory Medicine in the Clinical Decision Support for Treatment of Hypercholesterolemia: Pharmacogenetics of Statins.

    PubMed

    Ruaño, Gualberto; Seip, Richard; Windemuth, Andreas; Wu, Alan H B; Thompson, Paul D

    2016-09-01

    Statin responsiveness is an area of great research interest given the success of the drug class in the treatment of hypercholesterolemia and in primary and secondary prevention of cardiovascular disease. Interrogation of the patient's genome for gene variants will eventually guide anti-hyperlipidemic intervention. In this review, we discuss methodological approaches to discover genetic markers predictive of class-wide and drug-specific statin efficacy and safety. Notable pharmacogenetic findings are summarized from hypothesis-free genome wide and hypothesis-led candidate gene association studies. Physiogenomic models and clinical decision support systems will be required for DNA-guided statin therapy to reach practical use in medicine. PMID:27514463

  15. Magnetic resonance imaging of the vagina: an overview for radiologists with emphasis on clinical decision making*

    PubMed Central

    Ferreira, Daian Miranda; Bezerra, Régis Otaviano França; Ortega, Cinthia Denise; Blasbalg, Roberto; Viana, Públio César Cavalcante; de Menezes, Marcos Roberto; Rocha, Manoel de Souza

    2015-01-01

    Magnetic resonance imaging is a method with high contrast resolution widely used in the assessment of pelvic gynecological diseases. However, the potential of such method to diagnose vaginal lesions is still underestimated, probably due to the scarce literature approaching the theme, the poor familiarity of radiologists with vaginal diseases, some of them relatively rare, and to the many peculiarities involved in the assessment of the vagina. Thus, the authors illustrate the role of magnetic resonance imaging in the evaluation of vaginal diseases and the main relevant findings to be considered in the clinical decision making process. PMID:26379324

  16. Performance of online drug information databases as clinical decision support tools in infectious disease medication management.

    PubMed

    Polen, Hyla H; Zapantis, Antonia; Clauson, Kevin A; Clauson, Kevin Alan; Jebrock, Jennifer; Paris, Mark

    2008-01-01

    Infectious disease (ID) medication management is complex and clinical decision support tools (CDSTs) can provide valuable assistance. This study evaluated scope and completeness of ID drug information found in online databases by evaluating their ability to answer 147 question/answer pairs. Scope scores produced highest rankings (%) for: Micromedex (82.3), Lexi-Comp/American Hospital Formulary Service (81.0), and Medscape Drug Reference (81.0); lowest includes: Epocrates Online Premium (47.0), Johns Hopkins ABX Guide (45.6), and PEPID PDC (40.8). PMID:18999059

  17. Clinical decision support, systems methodology, and telemedicine: their role in the management of chronic disease.

    PubMed

    Carson, E R; Cramp, D G; Morgan, A; Roudsari, A V

    1998-06-01

    In this paper, the design and evaluation of decision support systems, including those incorporating a telematic component, are considered. It is argued that effective design and evaluation are dependent upon the adoption of appropriate methodology set firmly within a systemic framework. Systems modeling is proposed as an approach to system design, with evaluation adopting an approach incorporating evaluability analysis and formative and summative evaluation, including the use of stakeholder matrix analysis. The relevance of such systemic methodology is demonstrated in the context of diabetes and end-stage renal disease as examples of the generic clinical problem of the management of chronic disease. PMID:10719517

  18. A Component-Based Evaluation Protocol for Clinical Decision Support Interfaces

    PubMed Central

    Febretti, Alessandro; Lopez, Karen D.; Stifter, Janet; Johnson, Andrew E.; Keenan, Gail M.; Wilkie, Diana J.

    2016-01-01

    In this paper we present our experience in designing and applying an evaluation protocol for assessing usability of a clinical decision support (CDS) system. The protocol is based on component-based usability testing, cognitive interviewing, and a rigorous coding scheme cross-referenced to a component library. We applied this protocol to evaluate alternate designs of a CDS interface for a nursing plan of care tool. The protocol allowed us to aggregate and analyze usability data at various granularity levels, supporting both validation of existing components and providing guidance for targeted redesign.

  19. Pharmacists’ Perceptions of the Influence of Interactions with the Pharmaceutical Industry on Clinical Decision-Making

    PubMed Central

    Tejani, Aaron M; Loewen, Peter; Bachand, Richard; Harder, Curtis K

    2015-01-01

    Background: There is a paucity of literature examining the perceptions of Canadian pharmacists toward drug promotion by the pharmaceutical industry and pharmacist–industry interactions. Objectives: To determine whether hospital pharmacists perceive their interactions with the pharmaceutical industry as influencing their clinical decision-making or that of their colleagues and whether hospital pharmacists perceive that interactions with the pharmaceutical industry create a conflict of interest. Methods: A cross-sectional survey of the complete sample of hospital pharmacists practising in 3 large health authorities in a single Canadian province was conducted from February to April 2010. Results: A total of 224 responses were received from the approximately 480 pharmacists in the target health authorities (response rate approximately 47%). Fifty-eight percent of respondents (127/218) did not believe that information received at industry-sponsored events influenced their clinical decision-making. Most (142/163 [87%]) disagreed that small gifts influenced their clinical decision-making, whereas responses were divided for large gifts. Respondents were also divided on the issue of whether their interactions created conflicts of interest, with most of those who had received gifts agreeing that large gifts would create a conflict of interest (134/163 [82%]) whereas small gifts would not (100/163 [61%]). There were positive correlations between respondents’ beliefs about their own susceptibility to influence from sponsored events or receipt of small or large gifts and the susceptibility of others, but 22% of respondents (28/127) expressed a different perception about sponsored events, all believing themselves to be less influenced than their colleagues. Only 6% (4/64) of those who received large gifts and 4% (5/142) of those who received small gifts and felt they were not influenced by these gifts reported that it was likely others would be influenced by the receipt of

  20. Mobile Clinical Decision Support Systems in Our Hands - Great Potential but also a Concern.

    PubMed

    Masic, Izet; Begic, Edin

    2016-01-01

    Due to the powerful computer resources as well as the availability of today's mobile devices, a special field of mobile systems for clinical decision support in medicine has been developed. The benefits of these applications (systems) are: availability of necessary hardware (mobile phones, tablets and phablets are widespread, and can be purchased at a relatively affordable price), availability of mobile applications (free or for a "small" amount of money) and also mobile applications are tailored for easy use and save time of clinicians in their daily work. In these systems lies a huge potential, and certainly a great economic benefit, so this issue must be approached multidisciplinary. PMID:27350467

  1. Implementation of a Clinical Decision Support Alert for the Management of Clostridium difficile Infection

    PubMed Central

    Revolinski, Sara

    2015-01-01

    Clostridium difficile infections are common in hospitalized patients and can result in significant morbidity and mortality. It is imperative to optimize the management of C. difficile infections to help minimize disease complications. Antimicrobial stewardship techniques including guidelines, order sets and other clinical decision support functionalities may be utilized to assist with therapy optimization. We implemented a novel alert within our electronic medical record to direct providers to the C. difficile order set in order to assist with initiating therapy consistent with institutional guideline recommendations. The alert succeeded in significantly increasing order set utilization, but guideline compliance was unchanged. PMID:27025646

  2. Computerizing Audit Studies

    PubMed Central

    Lahey, Joanna N.; Beasley, Ryan A.

    2014-01-01

    This paper briefly discusses the history, benefits, and shortcomings of traditional audit field experiments to study market discrimination. Specifically it identifies template bias and experimenter bias as major concerns in the traditional audit method, and demonstrates through an empirical example that computerization of a resume or correspondence audit can efficiently increase sample size and greatly mitigate these concerns. Finally, it presents a useful meta-tool that future researchers can use to create their own resume audits. PMID:24904189

  3. Computerized leak training

    SciTech Connect

    Parella, C.; Monroe, A.

    1985-11-01

    Niagara Mohawk Power Corporation's computerized leak detection training system is discussed. The system is able to simulate gas leak situations by means of a computer. The training setup includes actual visual display via slides of houses represented on a plotting board; computer with plotter board in front that simulates an area and various leakage situations; a typical handheld CGI; and a control pad for the computer. The training system has filled a valuable need in the area of emergency training.

  4. Clinical decision making in response to performance validity test failure in a psychiatric setting.

    PubMed

    Marcopulos, Bernice A; Caillouet, Beth A; Bailey, Christopher M; Tussey, Chriscelyn; Kent, Julie-Ann; Frederick, Richard

    2014-01-01

    This study examined the clinical utility of a performance validity test (PVT) for screening consecutive referrals (N = 436) to a neuropsychology service at a state psychiatric hospital treating both civilly committed and forensic patients. We created a contingency table with Test of Memory Malingering (TOMM) pass/fail (355/81) and secondary gain present/absent (181/255) to examine pass rates associated with patient demographic, clinical and forensic status characteristics. Of the 81 failed PVTs, 48 had secondary gain defined as active criminal legal charges; 33 failed PVTs with no secondary gain. These individuals tended to be older, female, Caucasian, and civilly committed compared with the group with secondary gain who failed. From estimations of TOMM False Positive Rate and True Positive Rate we estimated base rates of neurocognitive malingering for our clinical population using the Test Validation Summary (TVS; Frederick & Bowden, 2009 ). Although PVT failure is clearly more common in a group with secondary gain (31%), there were a number of false positives (11%). Clinical ratings of patients without gain who failed suggested cognitive deficits, behavioral issues, and inattention. Low scores on PVTs in the absence of secondary gain provide useful information on test engagement and can inform clinical decisions about testing. PMID:24678658

  5. Computerized tomography calibrator

    NASA Technical Reports Server (NTRS)

    Engel, Herbert P. (Inventor)

    1991-01-01

    A set of interchangeable pieces comprising a computerized tomography calibrator, and a method of use thereof, permits focusing of a computerized tomographic (CT) system. The interchangeable pieces include a plurality of nestable, generally planar mother rings, adapted for the receipt of planar inserts of predetermined sizes, and of predetermined material densities. The inserts further define openings therein for receipt of plural sub-inserts. All pieces are of known sizes and densities, permitting the assembling of different configurations of materials of known sizes and combinations of densities, for calibration (i.e., focusing) of a computerized tomographic system through variation of operating variables thereof. Rather than serving as a phanton, which is intended to be representative of a particular workpiece to be tested, the set of interchangeable pieces permits simple and easy standardized calibration of a CT system. The calibrator and its related method of use further includes use of air or of particular fluids for filling various openings, as part of a selected configuration of the set of pieces.

  6. Knowledge of Fecal Calprotectin and Infliximab Trough Levels Alters Clinical Decision-making for IBD Outpatients on Maintenance Infliximab Therapy

    PubMed Central

    Prosser, Connie; Kroeker, Karen I.; Wang, Haili; Shalapay, Carol; Dhami, Neil; Fedorak, Darryl K.; Halloran, Brendan; Dieleman, Levinus A.; Goodman, Karen J.; Fedorak, Richard N.

    2015-01-01

    Background: Infliximab is an effective therapy for inflammatory bowel disease (IBD). However, more than 50% of patients lose response. Empiric dose intensification is not effective for all patients because not all patients have objective disease activity or subtherapeutic drug level. The aim was to determine how an objective marker of disease activity or therapeutic drug monitoring affects clinical decisions regarding maintenance infliximab therapy in outpatients with IBD. Methods: Consecutive patients with IBD on maintenance infliximab therapy were invited to participate by providing preinfusion stool and blood samples. Fecal calprotectin (FCP) and infliximab trough levels (ITLs) were measured by enzyme linked immunosorbent assay. Three decisions were compared: (1) actual clinical decision, (2) algorithmic FCP or ITL decisions, and (3) expert panel decision based on (a) clinical data, (b) clinical data plus FCP, and (c) clinical data plus FCP plus ITL. In secondary analysis, Receiver-operating curves were used to assess the ability of FCP and ITL in predicting clinical disease activity or remission. Results: A total of 36 sets of blood and stool were available for analysis; median FCP 191.5 μg/g, median ITLs 7.3 μg/mL. The actual clinical decision differed from the hypothetical decision in 47.2% (FCP algorithm); 69.4% (ITL algorithm); 25.0% (expert panel clinical decision); 44.4% (expert panel clinical plus FCP); 58.3% (expert panel clinical plus FCP plus ITL) cases. FCP predicted clinical relapse (area under the curve [AUC] = 0.417; 95% confidence interval [CI], 0.197–0.641) and subtherapeutic ITL (AUC = 0.774; 95% CI, 0.536–1.000). ITL predicted clinical remission (AUC = 0.498; 95% CI, 0.254–0.742) and objective remission (AUC = 0.773; 95% CI, 0.622–0.924). Conclusions: Using FCP and ITLs in addition to clinical data results in an increased number of decisions to optimize management in outpatients with IBD on stable maintenance infliximab therapy. PMID

  7. Ethics of Clinical Decision-Making for Older Drivers: Reporting Health-Related Driving Risk.

    PubMed

    Mazer, Barbara; Laliberté, Maude; Hunt, Matthew; Lemoignan, Josée; Gélinas, Isabelle; Vrkljan, Brenda; Naglie, Gary; Marshall, Shawn

    2016-06-01

    The number of older drivers will continue to increase as the population ages. Health care professionals have the responsibility of providing care and maintaining confidentiality for their patients while ensuring public safety. This article discusses the ethics of clinical decision-making pertaining to reporting health-related driving risk of older drivers to licensing authorities. Ethical considerations inherent in reporting driving risk, including autonomy, confidentiality, therapeutic relationships, and the uncertainty about determining individual driving safety and risk, are discussed. We also address the moral agency of reporting health-related driving risk and raise the question of whose responsibility it is to report. Issues of uncertainty surrounding clinical reasoning and concepts related to risk assessment are also discussed. Finally, we present two case studies to illustrate some of the issues and challenges faced by health care professionals as they seek to balance their responsibilities for their patients while ensuring road safety for all citizens. PMID:27117942

  8. Extraction Of Adverse Events From Clinical Documents To Support Decision Making Using Semantic Preprocessing.

    PubMed

    Gaebel, Jan; Kolter, Till; Arlt, Felix; Denecke, Kerstin

    2015-01-01

    Clinical documentation is usually stored in unstructured format in electronic health records (EHR). Processing the information is inconvenient and time consuming and should be enhanced by computer systems. In this paper, a rule-based method is introduced that identifies adverse events documented in the EHR that occurred during treatment. For this purpose, clinical documents are transformed into a semantic structure from which adverse events are extracted. The method is evaluated in a user study with neurosurgeons. In comparison to a bag of word classification using support vector machines, our approach achieved comparably good results of 65% recall and 78% precision. In conclusion, the rule-based method generates promising results that can support physicians' decision making. Because of the structured format the data can be reused for other purposes as well. PMID:26262330

  9. Modeling the costs of clinical decision support for genomic precision medicine.

    PubMed

    Mathias, Patrick C; Tarczy-Hornoch, Peter; Shirts, Brian H

    2016-01-01

    Clinical decision support (CDS) within the electronic health record represents a promising mechanism to provide important genomic findings within clinical workflows. To better understand the current and possible future costs of genomic CDS, we leveraged our local CDS experience to assemble a simple model with inputs such as initial cost and numbers of patients, rules, and institutions. Our model assumed efficiencies of scale and allowed us to perform a one-way sensitivity analysis of the impact of each model input. The number of patients with genomic results per institution was the only single variable that could decrease the cost of CDS per useful alert below projected genomic sequencing costs. Because of the prohibitive upfront cost of sequencing large numbers of individuals, increasing the number of institutions using genomic CDS and improving the efficiency of sharing CDS infrastructure represent the most promising paths to making genomic CDS cost-effective. PMID:27570652

  10. Clinician Perspectives on the Quality of Patient Data Used for Clinical Decision Support: A Qualitative Study

    PubMed Central

    McCormack, James L.; Ash, Joan S.

    2012-01-01

    Objective: Clinical decision support (CDS), defined broadly as patient-specific information and knowledge provided at the point of care, depends on a foundation of high quality electronic patient data. Little is known about how clinicians perceive the quality and value of data used to support CDS within an electronic health record (EHR) environment. Methods: During a three-year research study, we collected ethnographic data from ten diverse organizations, including community hospitals, academic medical centers and ambulatory clinics. Results: An in-depth analysis of the theme “data as a foundation for CDS” yielded a descriptive framework incorporating five subthemes related to data quality: completeness, accessibility, context specificity, accuracy, and reliability. Conclusion: We identified several multi-dimensional models that might be used to conceptualize data quality characteristics for future research. These results could provide new insights to system designers and implementers on the importance clinicians place on specific data quality characteristics regarding electronic patient data for CDS. PMID:23304409

  11. Modeling the costs of clinical decision support for genomic precision medicine

    PubMed Central

    Mathias, Patrick C.; Tarczy-Hornoch, Peter; Shirts, Brian H.

    2016-01-01

    Clinical decision support (CDS) within the electronic health record represents a promising mechanism to provide important genomic findings within clinical workflows. To better understand the current and possible future costs of genomic CDS, we leveraged our local CDS experience to assemble a simple model with inputs such as initial cost and numbers of patients, rules, and institutions. Our model assumed efficiencies of scale and allowed us to perform a one-way sensitivity analysis of the impact of each model input. The number of patients with genomic results per institution was the only single variable that could decrease the cost of CDS per useful alert below projected genomic sequencing costs. Because of the prohibitive upfront cost of sequencing large numbers of individuals, increasing the number of institutions using genomic CDS and improving the efficiency of sharing CDS infrastructure represent the most promising paths to making genomic CDS cost-effective. PMID:27570652

  12. Multidisciplinary Modelling of Symptoms and Signs with Archetypes and SNOMED-CT for Clinical Decision Support.

    PubMed

    Marco-Ruiz, Luis; Maldonado, J Alberto; Karlsen, Randi; Bellika, Johan G

    2015-01-01

    Clinical Decision Support Systems (CDSS) help to improve health care and reduce costs. However, the lack of knowledge management and modelling hampers their maintenance and reuse. Current EHR standards and terminologies can allow the semantic representation of the data and knowledge of CDSS systems boosting their interoperability, reuse and maintenance. This paper presents the modelling process of respiratory conditions' symptoms and signs by a multidisciplinary team of clinicians and information architects with the help of openEHR, SNOMED and clinical information modelling tools for a CDSS. The information model of the CDSS was defined by means of an archetype and the knowledge model was implemented by means of an SNOMED-CT based ontology. PMID:25991115

  13. Implementing clinical practice guidelines about health promotion and disease prevention through shared decision making.

    PubMed

    Politi, Mary C; Wolin, Kathleen Y; Légaré, France

    2013-06-01

    Clinical practice guidelines aim to improve the health of patients by guiding individual care in clinical settings. Many guidelines specifically about health promotion or primary disease prevention are beginning to support informed patient choice, and suggest that clinicians and patients engage in shared discussions to determine how best to tailor guidelines to individuals. However, guidelines generally do not address how to translate evidence from the population to the individual in clinical practice, or how to engage patients in these discussions. In addition, they often fail to reconcile patients' preferences and social norms with best evidence. Shared decision making (SDM) is one solution to bridge guidelines about health promotion and disease prevention with clinical practice. SDM describes a collaborative process between patients and their clinicians to reach agreement about a health decision involving multiple medically appropriate treatment options. This paper discusses: 1) a brief overview of SDM; 2) the potential role of SDM in facilitating the implementation of prevention-focused practice guidelines for both preference-sensitive and effective care decisions; and 3) avenues for future empirical research to test how best to engage individual patients and clinicians in these complex discussions about prevention guidelines. We suggest that SDM can provide a structure for clinicians to discuss clinical practice guidelines with patients in a way that is evidence-based, patient-centered, and incorporates patients' preferences. In addition to providing a model for communicating about uncertainty at the individual level, SDM can provide a platform for engaging patients in a conversation. This process can help manage patients' and clinicians' expectations about health behaviors. SDM can be used even in situations with strong evidence for benefits at the level of the population, by helping patients and clinicians prioritize behaviors during time-pressured medical

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

    PubMed

    Oladipo, Idris; Ayoade, Adedokun

    2012-09-01

    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

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

    PubMed

    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

    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

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

    PubMed Central

    2011-01-01

    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

  17. Functional Assessment of Genetic Variants with Outcomes Adapted to Clinical Decision-Making

    PubMed Central

    Thouvenot, Pierre; Ben Yamin, Barbara; Fourrière, Lou; Lescure, Aurianne; Boudier, Thomas; Del Nery, Elaine; Chauchereau, Anne; Goldgar, David E.; Stoppa-Lyonnet, Dominique; Nicolas, Alain; Millot, Gaël A.

    2016-01-01

    Understanding the medical effect of an ever-growing number of human variants detected is a long term challenge in genetic counseling. Functional assays, based on in vitro or in vivo evaluations of the variant effects, provide essential information, but they require robust statistical validation, as well as adapted outputs, to be implemented in the clinical decision-making process. Here, we assessed 25 pathogenic and 15 neutral missense variants of the BRCA1 breast/ovarian cancer susceptibility gene in four BRCA1 functional assays. Next, we developed a novel approach that refines the variant ranking in these functional assays. Lastly, we developed a computational system that provides a probabilistic classification of variants, adapted to clinical interpretation. Using this system, the best functional assay exhibits a variant classification accuracy estimated at 93%. Additional theoretical simulations highlight the benefit of this ready-to-use system in the classification of variants after functional assessment, which should facilitate the consideration of functional evidences in the decision-making process after genetic testing. Finally, we demonstrate the versatility of the system with the classification of siRNAs tested for human cell growth inhibition in high throughput screening. PMID:27272900

  18. Functional Assessment of Genetic Variants with Outcomes Adapted to Clinical Decision-Making.

    PubMed

    Thouvenot, Pierre; Ben Yamin, Barbara; Fourrière, Lou; Lescure, Aurianne; Boudier, Thomas; Del Nery, Elaine; Chauchereau, Anne; Goldgar, David E; Houdayer, Claude; Stoppa-Lyonnet, Dominique; Nicolas, Alain; Millot, Gaël A

    2016-06-01

    Understanding the medical effect of an ever-growing number of human variants detected is a long term challenge in genetic counseling. Functional assays, based on in vitro or in vivo evaluations of the variant effects, provide essential information, but they require robust statistical validation, as well as adapted outputs, to be implemented in the clinical decision-making process. Here, we assessed 25 pathogenic and 15 neutral missense variants of the BRCA1 breast/ovarian cancer susceptibility gene in four BRCA1 functional assays. Next, we developed a novel approach that refines the variant ranking in these functional assays. Lastly, we developed a computational system that provides a probabilistic classification of variants, adapted to clinical interpretation. Using this system, the best functional assay exhibits a variant classification accuracy estimated at 93%. Additional theoretical simulations highlight the benefit of this ready-to-use system in the classification of variants after functional assessment, which should facilitate the consideration of functional evidences in the decision-making process after genetic testing. Finally, we demonstrate the versatility of the system with the classification of siRNAs tested for human cell growth inhibition in high throughput screening. PMID:27272900

  19. [The role of PET/CT in decision-making during cancer treatment. Clinical experience].

    PubMed

    Sinkó, Dániel; Landherr, László

    2012-12-01

    Nowadays PET/CT examinations have got more and more important role during cancer treatment. It has importance not only in diagnostic examination and staging but also in the radiation planning process and measuring the therapeutic effect. From November 2006 to November 2010 there were 153 PET/CT examinations requested by the Oncology Outpatient Clinic, Uzsoki Hospital. Nine patients were excluded from the examination. In the clinical trial we have aimed to measure what the correlation between the oncologists' questions and the PET/CT results was, in how many cases the PET/CT had influence on therapeutic decision-making. In the case of the patients waiting for the operation we compared the results of the pathological examinations to the results of the PET/CT. The oncologists got the expected answers in 79 cases, while in 45 cases the answers were negative. In 10 cases there were no definite answers. Ten cases proved to be false negative or false positive based on the later pathological examination. As a result of the PET/CT findings the originally planned therapeutic decisions or the therapies in process have been modified in 77 cases. To sum up, the PET/CT gave the expected answers to the oncologists' questions in more than half of the cases (54.9%) and modified the originally prescribed therapy in 53.5% of the cases. PMID:23236592

  20. Using statistical process control to make data-based clinical decisions.

    PubMed Central

    Pfadt, A; Wheeler, D J

    1995-01-01

    Applied behavior analysis is based on an investigation of variability due to interrelationships among antecedents, behavior, and consequences. This permits testable hypotheses about the causes of behavior as well as for the course of treatment to be evaluated empirically. Such information provides corrective feedback for making data-based clinical decisions. This paper considers how a different approach to the analysis of variability based on the writings of Walter Shewart and W. Edwards Deming in the area of industrial quality control helps to achieve similar objectives. Statistical process control (SPC) was developed to implement a process of continual product improvement while achieving compliance with production standards and other requirements for promoting customer satisfaction. SPC involves the use of simple statistical tools, such as histograms and control charts, as well as problem-solving techniques, such as flow charts, cause-and-effect diagrams, and Pareto charts, to implement Deming's management philosophy. These data-analytic procedures can be incorporated into a human service organization to help to achieve its stated objectives in a manner that leads to continuous improvement in the functioning of the clients who are its customers. Examples are provided to illustrate how SPC procedures can be used to analyze behavioral data. Issues related to the application of these tools for making data-based clinical decisions and for creating an organizational climate that promotes their routine use in applied settings are also considered. PMID:7592154

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

    PubMed Central

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

    2010-01-01

    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

  2. Decisions in complex clinical situations: Prevalence and factors associated in general public.

    PubMed

    Gomez-Martinez, Maria D; Luna, Aurelio; Perez-Carceles, Maria D

    2016-01-01

    Many studies have focused on advanced directives. However, the type of treatment that citizens would choose in critical health situations and whether their decision varies with their sociodemographic characteristics and their experiences of life both within and outside the family context, are unknown. This study analyzes the factors associated with choosing or refusing life support treatment in hypothetical situations of differing clinical complexity. This transversal descriptive study was carried out by questionnaires given to 1051 participants from primary care centres. The Life Support Preferences Questionnaire (LSPQ) used to assess preferences of life-sustaining treatment, describes six scenarios with different prognoses. Analysis of the sociodemographic characteristics and life experiences of the subjects led to the following findings. In situations of very severe prognosis, treatment is mostly rejected. When there is chance of recovery, treatment is mostly accepted, especially in the least aggressive cases and when deciding for another person. A greater propensity to reject treatment was observed among subjects over 55 years, those in poor health and those who had observed a terminal illness in a family member. Practising Catholics are more likely to accept treatment in all medical situations described. Preferences for life support treatment are linked to sociodemographic characteristics and life experiences of patients. Physicians should bear in mind these characteristics when confronted with critical clinical situations, involving difficult decisions. PMID:26952384

  3. Clinical decision aids for chest pain in the emergency department: identifying low-risk patients

    PubMed Central

    Alley, William; Mahler, Simon A

    2015-01-01

    Chest pain is one of the most common presenting complaints in the emergency department, though only a small minority of patients are subsequently diagnosed with acute coronary syndrome (ACS). However, missing the diagnosis has potential for significant morbidity and mortality. ACS presentations can be atypical, and their workups are often prolonged and costly. In order to risk-stratify patients and better direct the workup and care given, many decision aids have been developed. While each may have merit in certain clinical settings, the most useful aid in the emergency department is one that finds all cases of ACS while also identifying a substantial subset of patients at low risk who can be discharged without stress testing or coronary angiography. This review describes several of the chest pain decision aids developed and studied through the recent past, starting with the thrombolysis in myocardial infarction (TIMI) risk score and Global Registry of Acute Coronary Events (GRACE) scores, which were developed as prognostic aids for patients already diagnosed with ACS, then subsequently validated in the undifferentiated chest pain population. Asia-Pacific Evaluation of Chest Pain Trial (ASPECT); Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins (ADAPT); North American Chest Pain Rule (NACPR); and History, Electrocardiogram, Age, Risk factors, Troponin (HEART) score have been developed exclusively for use in the undifferentiated chest pain population as well, with improved performance compared to their predecessors. This review describes the relative merits and limitations of these decision aids so that providers can determine which tool fits the needs of their clinical practice setting. PMID:27147894

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

    PubMed Central

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

    2014-01-01

    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. PMID:25411644

  5. A proposed clinical decision support architecture capable of supporting whole genome sequence information.

    PubMed

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

    2014-04-01

    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. PMID:25411644

  6. Lung cancer patients' decisions about clinical trials and the theory of planned behavior.

    PubMed

    Quinn, Gwendolyn P; Pratt, Christie L; Bryant-George, Kathy; Caraway, Vicki D; Paternoster, Bonnie; Roldan, Tere; Shaffer, Andrea; Shimizu, Cynthia O; Vaughn, Elizabeth J; Williams, Charles; Bepler, Gerold

    2011-12-01

    The theory of planned behavior explores the relationship between behavior, beliefs, attitudes, and intentions presupposing that behavioral intention is influenced by a person's attitude about the behavior and beliefs about whether individuals, who are important to them, approve or disapprove of the behavior (subjective norm). An added dimension to the theory is the idea of perceived behavioral control, or the belief that one has control over performing the behavior. The theory of planned behavior suggests that people may make greater efforts to perform a behavior if they feel they have a high level of control over it. In this examination of data, we explored the application of the theory of planned behavior to patient's decisions about participating in a clinic trial. Twelve respondents in this study had previously participated in a clinical trial for lung cancer and nine respondents had declined a clinical trial for lung cancer. The data were analyzed with regard to the four constructs associated with the theory of planned behavior: behavioral intention, attitude, subjective norm, and perceived behavioral control. Results indicate that the theory of planned behavior may be a useful tool to examine psychosocial needs in relation to behavioral intention of clinical trial participation. PMID:20949381

  7. Pilot Program Using Medical Simulation in Clinical Decision-Making Training for Internal Medicine Interns

    PubMed Central

    Miloslavsky, Eli M.; Hayden, Emily M.; Currier, Paul F.; Mathai, Susan K.; Contreras-Valdes, Fernando; Gordon, James A.

    2012-01-01

    Background The use of high-fidelity medical simulation in cognitive skills training within internal medicine residency programs remains largely unexplored. Objective To design a pilot study to introduce clinical decision-making training using simulation into a large internal medicine residency program, explore the practicability of using junior and senior residents as facilitators, and examine the feasibility of using the program to improve interns' clinical skills. Methods Interns on outpatient rotations participated in a simulation curriculum on a voluntary basis. The curriculum consisted of 8 cases focusing on acute clinical scenarios encountered on the wards. One-hour sessions were offered twice monthly from August 2010 to February 2011. Internal medicine residents and simulation faculty served as facilitators. Results A total of 36 of 75 total interns volunteered to participate in the program, with 42% attending multiple sessions. Of all participants, 88% rated the sessions as “excellent,” 97% felt that the program improved their ability to function as an intern and generate a plan, and 81% reported improvement in differential diagnosis skills. Conclusions Simulation training was well received by the learners and improved self-reported clinical skills. Using residents as facilitators, supervised by faculty, was well received by the learners and enabled the implementation of the curriculum in a large training program. Simulation can provide opportunities for deliberate practice, and learners perceive this modality to be effective. PMID:24294427

  8. Myocardial strain imaging: how useful is it in clinical decision making?

    PubMed Central

    Smiseth, Otto A.; Torp, Hans; Opdahl, Anders; Haugaa, Kristina H.; Urheim, Stig

    2016-01-01

    Myocardial strain is a principle for quantification of left ventricular (LV) function which is now feasible with speckle-tracking echocardiography. The best evaluated strain parameter is global longitudinal strain (GLS) which is more sensitive than left ventricular ejection fraction (LVEF) as a measure of systolic function, and may be used to identify sub-clinical LV dysfunction in cardiomyopathies. Furthermore, GLS is recommended as routine measurement in patients undergoing chemotherapy to detect reduction in LV function prior to fall in LVEF. Intersegmental variability in timing of peak myocardial strain has been proposed as predictor of risk of ventricular arrhythmias. Strain imaging may be applied to guide placement of the LV pacing lead in patients receiving cardiac resynchronization therapy. Strain may also be used to diagnose myocardial ischaemia, but the technology is not sufficiently standardized to be recommended as a general tool for this purpose. Peak systolic left atrial strain is a promising supplementary index of LV filling pressure. The strain imaging methodology is still undergoing development, and further clinical trials are needed to determine if clinical decisions based on strain imaging result in better outcome. With this important limitation in mind, strain may be applied clinically as a supplementary diagnostic method. PMID:26508168

  9. Clinical decision support systems for improving diagnostic accuracy and achieving precision medicine.

    PubMed

    Castaneda, Christian; Nalley, Kip; Mannion, Ciaran; Bhattacharyya, Pritish; Blake, Patrick; Pecora, Andrew; Goy, Andre; Suh, K Stephen

    2015-01-01

    , and logistical concerns. Ensuring data security and protection of patient rights while simultaneously facilitating standardization is paramount to maintaining public support. The capabilities of supercomputing need to be applied strategically. A standardized, methodological implementation must be applied to developed artificial intelligence systems with the ability to integrate data and information into clinically relevant knowledge. Ultimately, the integration of bioinformatics and clinical data in a clinical decision support system promises precision medicine and cost effective and personalized patient care. PMID:25834725

  10. Design, Development, and Initial Evaluation of a Terminology for Clinical Decision Support and Electronic Clinical Quality Measurement

    PubMed Central

    Lin, Yanhua; Staes, Catherine J; Shields, David E; Kandula, Vijay; Welch, Brandon M; Kawamoto, Kensaku

    2015-01-01

    When coupled with a common information model, a common terminology for clinical decision support (CDS) and electronic clinical quality measurement (eCQM) could greatly facilitate the distributed development and sharing of CDS and eCQM knowledge resources. To enable such scalable knowledge authoring and sharing, we systematically developed an extensible and standards-based terminology for CDS and eCQM in the context of the HL7 Virtual Medical Record (vMR) information model. The development of this terminology entailed three steps: (1) systematic, physician-curated concept identification from sources such as the Health Information Technology Standards Panel (HITSP) and the SNOMED-CT CORE problem list; (2) concept de-duplication leveraging the Unified Medical Language System (UMLS) MetaMap and Metathesaurus; and (3) systematic concept naming using standard terminologies and heuristic algorithms. This process generated 3,046 concepts spanning 68 domains. Evaluation against representative CDS and eCQM resources revealed approximately 50–70% concept coverage, indicating the need for continued expansion of the terminology. PMID:26958220

  11. Design, Development, and Initial Evaluation of a Terminology for Clinical Decision Support and Electronic Clinical Quality Measurement.

    PubMed

    Lin, Yanhua; Staes, Catherine J; Shields, David E; Kandula, Vijay; Welch, Brandon M; Kawamoto, Kensaku

    2015-01-01

    When coupled with a common information model, a common terminology for clinical decision support (CDS) and electronic clinical quality measurement (eCQM) could greatly facilitate the distributed development and sharing of CDS and eCQM knowledge resources. To enable such scalable knowledge authoring and sharing, we systematically developed an extensible and standards-based terminology for CDS and eCQM in the context of the HL7 Virtual Medical Record (vMR) information model. The development of this terminology entailed three steps: (1) systematic, physician-curated concept identification from sources such as the Health Information Technology Standards Panel (HITSP) and the SNOMED-CT CORE problem list; (2) concept de-duplication leveraging the Unified Medical Language System (UMLS) MetaMap and Metathesaurus; and (3) systematic concept naming using standard terminologies and heuristic algorithms. This process generated 3,046 concepts spanning 68 domains. Evaluation against representative CDS and eCQM resources revealed approximately 50-70% concept coverage, indicating the need for continued expansion of the terminology. PMID:26958220

  12. Usability Testing and Adaptation of the Pediatric Cardiovascular Risk Reduction Clinical Decision Support Tool

    PubMed Central

    Furberg, Robert D; Bagwell, Jacqueline E; LaBresh, Kenneth A

    2016-01-01

    Background Cardiovascular disease (CVD) is 1 of the leading causes of death, years of life lost, and disability-adjusted years of life lost worldwide. CVD prevention for children and teens is needed, as CVD risk factors and behaviors beginning in youth contribute to CVD development. In 2012, the National Heart, Lung, and Blood Institute released their “Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents” for clinicians, describing CVD risk factors they should address with patients at primary care preventative visits. However, uptake of new guidelines is slow. Clinical decision support (CDS) tools can improve guideline uptake. In this paper, we describe our process of testing and adapting a CDS tool to help clinicians evaluate patient risk, recommend behaviors to prevent development of risk, and complete complex calculations to determine appropriate interventions as recommended by the guidelines, using a user-centered design approach. Objective The objective of the study was to assess the usability of a pediatric CVD risk factor tool by clinicians. Methods The tool was tested using one-on-one in-person testing and a “think aloud” approach with 5 clinicians and by using the tool in clinical practice along with formal usability metrics with 14 pediatricians. Thematic analysis of the data from the in-person testing and clinical practice testing identified suggestions for change in 3 major areas: user experience, content refinement, and technical deployment. Descriptive statistical techniques were employed to summarize users’ overall experience with the tool. Results Data from testers showed that general reactions toward the CDS tool were positive. Clinical practice testers suggested revisions to make the application more user-friendly, especially for clinicians using the application on the iPhone, and called for refining recommendations to be more succinct and better tailored to the patient. Tester feedback was

  13. Referring periodontal patients: clinical decision making by dental and dental hygiene students.

    PubMed

    Williams, Karen B; Burgardt, Grayson J; Rapley, John W; Bray, Kimberly K; Cobb, Charles M

    2014-03-01

    Referral of periodontal patients requires development of a complex set of decision making skills. This study was conducted to determine criteria used by dental and dental hygiene students regarding the referral of periodontal patients for specialty care. Using mixed methods, a thirteen-item survey was developed to elicit the students' perceptions of their knowledge, confidence regarding managing patients, and clinical reasoning related to periodontal patients. The instrument was administered during the summer prior to (T1) and at the end of the students' final year (T2) of training. Seventy-nine dental students (81 percent of total class) and thirty dental hygiene students (83 percent of total class) completed T1. At T2, forty-two dental (44 percent of total class) and twenty-six dental hygiene students (87 percent of total class) completed the questionnaire. While 90 percent of dental and 96 percent of dental hygiene respondents reported a willingness to refer patients with active disease to specialists, only 40 percent of dental and 36 percent of dental hygiene respondents reported confidence in diagnosing, treating, and appropriately referring such patients. The students' ability to recognize critical disease and risk factors influencing referral was good; however, clinical application of that knowledge indicated a gap between knowledge and applied reasoning. The students' attitudes about the importance of periodontal disease and their perceived competence to identify critical disease risk factors were not significantly related (p>0.05) to correct clinical decisions in the case scenarios. The study concludes that dental and dental hygiene curricula should emphasize both the acquisition and application of knowledge regarding criteria for referral of periodontal patients. PMID:24609346

  14. The evaluation of a rectal cancer decision aid and the factors influencing its implementation in clinical practice

    PubMed Central

    2014-01-01

    Background Colorectal cancer is common in North America. Two surgical options exist for rectal cancer patients: low anterior resection with re-establishment of bowel continuity, and abdominoperineal resection with a permanent stoma. A rectal cancer decision aid was developed using the International Patient Decision Aid Standards to facilitate patients being more actively involved in making this decision with the surgeon. The overall aim of this study is to evaluate this decision aid and explore barriers and facilitators to implementing in clinical practice. Methods First, a pre- and post- study will be guided by the Ottawa Decision Support Framework. Eligible patients from a colorectal cancer center include: 1) adult patients diagnosed with rectal cancer, 2) tumour at a maximum of 10 cm from anal verge, and 3) surgeon screened candidates eligible to consider both low anterior resection and abdominoperineal resection. Patients will be given a paper-version and online link to the decision aid to review at home. Using validated tools, the primary outcomes will be decisional conflict and knowledge of surgical options. Secondary outcomes will be patient’s preference, values associated with options, readiness for decision-making, acceptability of the decision aid, and feasibility of its implementation in clinical practice. Proposed analysis includes paired t-test, Wilcoxon, and descriptive statistics. Second, a survey will be conducted to identify the barriers and facilitators of using the decision aid in clinical practice. Eligible participants include Canadian surgeons working with rectal cancer patients. Surgeons will be given a pre-notification, questionnaire, and three reminders. The survey package will include the patient decision aid and a facilitators and barriers survey previously validated among physicians and nurses. Principal component analysis will be performed to determine common themes, and logistic regression will be used to identify variables

  15. Computerized design of CAD

    NASA Astrophysics Data System (ADS)

    Paul, B. E.; Pham, T. A.

    1982-11-01

    A computerized ballistic design technique for CAD/PAD is described by which a set of ballistic design parameters are determined, all of which satisfy a particular performance requirement. In addition, the program yields the remaining performance predictions, so that only a very few computer runs of the design program can quickly bring the ballistic design within the specification limits prescribed. An example is presented for a small propulsion device, such as a remover or actuator, for which the input specifications define a maximum allowable thrust and minimum end-of-stroke velocity. The resulting output automatically satisfies the input requirements, and will always yield an acceptable ballistic design.

  16. Computerized procedures system

    DOEpatents

    Lipner, Melvin H.; Mundy, Roger A.; Franusich, Michael D.

    2010-10-12

    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.

  17. Optimization of the decision-making process for the selection of therapeutics to undergo clinical testing for spinal cord injury in the North American Clinical Trials Network.

    PubMed

    Guest, James; Harrop, James S; Aarabi, Bizhan; Grossman, Robert G; Fawcett, James W; Fehlings, Michael G; Tator, Charles H

    2012-09-01

    The North American Clinical Trials Network (NACTN) includes 9 clinical centers funded by the US Department of Defense and the Christopher Reeve Paralysis Foundation. Its purpose is to accelerate clinical testing of promising therapeutics in spinal cord injury (SCI) through the development of a robust interactive infrastructure. This structure includes key committees that serve to provide longitudinal guidance to the Network. These committees include the Executive, Data Management, and Neurological Outcome Assessments Committees, and the Therapeutic Selection Committee (TSC), which is the subject of this manuscript. The NACTN brings unique elements to the SCI field. The Network's stability is not restricted to a single clinical trial. Network members have diverse expertise and include experts in clinical care, clinical trial design and methodology, pharmacology, preclinical and clinical research, and advanced rehabilitation techniques. Frequent systematic communication is assigned a high value, as is democratic process, fairness and efficiency of decision making, and resource allocation. This article focuses on how decision making occurs within the TSC to rank alternative therapeutics according to 2 main variables: quality of the preclinical data set, and fit with the Network's aims and capabilities. This selection process is important because if the Network's resources are committed to a therapeutic, alternatives cannot be pursued. A proposed methodology includes a multicriteria decision analysis that uses a Multi-Attribute Global Inference of Quality matrix to quantify the process. To rank therapeutics, the TSC uses a series of consensus steps designed to reduce individual and group bias and limit subjectivity. Given the difficulties encountered by industry in completing clinical trials in SCI, stable collaborative not-for-profit consortia, such as the NACTN, may be essential to clinical progress in SCI. The evolution of the NACTN also offers substantial

  18. icuARM-An ICU Clinical Decision Support System Using Association Rule Mining

    PubMed Central

    Chanani, Nikhil; Venugopalan, Janani; Maher, Kevin; Wang, May Dongmei

    2013-01-01

    The rapid development of biomedical monitoring technologies has enabled modern intensive care units (ICUs) to gather vast amounts of multimodal measurement data about their patients. However, processing large volumes of complex data in real-time has become a big challenge. Together with ICU physicians, we have designed and developed an ICU clinical decision support system icuARM based on associate rule mining (ARM), and a publicly available research database MIMIC-II (Multi-parameter Intelligent Monitoring in Intensive Care II) that contains more than 40,000 ICU records for 30,000+patients. icuARM is constructed with multiple association rules and an easy-to-use graphical user interface (GUI) for care providers to perform real-time data and information mining in the ICU setting. To validate icuARM, we have investigated the associations between patients' conditions such as comorbidities, demographics, and medications and their ICU outcomes such as ICU length of stay. Coagulopathy surfaced as the most dangerous co-morbidity that leads to the highest possibility (54.1%) of prolonged ICU stay. In addition, women who are older than 50 years have the highest possibility (38.8%) of prolonged ICU stay. For clinical conditions treatable with multiple drugs, icuARM suggests that medication choice can be optimized based on patient-specific characteristics. Overall, icuARM can provide valuable insights for ICU physicians to tailor a patient's treatment based on his or her clinical status in real time. PMID:27170860

  19. Longitudinal feasibility of MINDSET: a clinic decision aid for epilepsy self-management.

    PubMed

    Begley, Charles; Shegog, Ross; Harding, Angelique; Goldsmith, Corey; Hope, Omotola; Newmark, Michael

    2015-03-01

    The purpose of this paper is to report on the development and feasibility of the longitudinal version of MINDSET, a clinical tool to assist patients and health-care providers in epilepsy self-management. A previous study described the feasibility of using MINDSET to identify and prioritize self-management issues during a clinic visit. This paper describes the development of the longitudinal version of MINDSET and feasibility test over multiple visits with a printed action plan for goal setting and the capacity for monitoring changes in self-management. Feasibility was assessed based on 1) postvisit patient and provider interviews addressing ease of use and usefulness, patient/provider communication, and shared decision-making and 2) the capacity of the tool to monitor epilepsy characteristics and self-management over time. Results indicate MINDSET feasibility for 1) identifying and facilitating discussion of self-management issues during clinic visits, 2) providing a printable list of prioritized issues and tailored self-management goals, and 3) tracking changes in epilepsy characteristics and self-management over time. PMID:25705825

  20. icuARM-An ICU Clinical Decision Support System Using Association Rule Mining.

    PubMed

    Cheng, Chih-Wen; Chanani, Nikhil; Venugopalan, Janani; Maher, Kevin; Wang, May Dongmei

    2013-01-01

    The rapid development of biomedical monitoring technologies has enabled modern intensive care units (ICUs) to gather vast amounts of multimodal measurement data about their patients. However, processing large volumes of complex data in real-time has become a big challenge. Together with ICU physicians, we have designed and developed an ICU clinical decision support system icuARM based on associate rule mining (ARM), and a publicly available research database MIMIC-II (Multi-parameter Intelligent Monitoring in Intensive Care II) that contains more than 40,000 ICU records for 30,000+patients. icuARM is constructed with multiple association rules and an easy-to-use graphical user interface (GUI) for care providers to perform real-time data and information mining in the ICU setting. To validate icuARM, we have investigated the associations between patients' conditions such as comorbidities, demographics, and medications and their ICU outcomes such as ICU length of stay. Coagulopathy surfaced as the most dangerous co-morbidity that leads to the highest possibility (54.1%) of prolonged ICU stay. In addition, women who are older than 50 years have the highest possibility (38.8%) of prolonged ICU stay. For clinical conditions treatable with multiple drugs, icuARM suggests that medication choice can be optimized based on patient-specific characteristics. Overall, icuARM can provide valuable insights for ICU physicians to tailor a patient's treatment based on his or her clinical status in real time. PMID:27170860

  1. Using clinical decision support as a means of implementing a universal postpartum depression screening program.

    PubMed

    Loudon, Holly; Nentin, Farida; Silverman, Michael E

    2016-06-01

    A major barrier to the diagnosis of postpartum depression (PPD) includes symptom detection. The lack of awareness and understanding of PPD among new mothers, the variability in clinical presentation, and the various diagnostic strategies can increase this further. The purpose of this study was to test the feasibility of adding clinical decision support (CDS) to the electronic health record (EHR) as a means of implementing a universal standardized PPD screening program within a large, at high risk, population. All women returning to the Mount Sinai Hospital OB/GYN Ambulatory Practice for postpartum care between 2010 and 2013 were presented with the Edinburgh Postnatal Depression Scale (EPDS) in response to a CDS "hard stop" built into the EHR. Of the 2102 women who presented for postpartum care, 2092 women (99.5 %) were screened for PPD in response to a CDS hard stop module. Screens were missing on ten records (0.5 %) secondary to refusal, language barrier, or lack of clarity in the EHR. Technology is becoming increasingly important in addressing the challenges faced by health care providers. While the identification of PPD has become the recent focus of public health concerns secondary to the significant social burden, numerous barriers to screening still exist within the clinical setting. The utility of adding CDS in the form of a hard stop, requiring clinicians to enter a standardized PPD mood assessment score to the patient EHR, offers a sufficient way to address a primary barrier to PPD symptom identification at the practitioner level. PMID:26669601

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

    PubMed

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

    2012-08-01

    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

  3. A Preliminary Instructional Model for a Computerized Training System.

    ERIC Educational Resources Information Center

    Kimberlin, D. A.

    A preliminary instructional model suitable for lesson preparation for a Computerized Training System is described. Topics discussed include general course architecture, general course structure, and the training decision process. Guidelines for the design of the model are presented and information is provided on the adaptation of the model to…

  4. Guidelines for the Development of Computerized Student Information Systems.

    ERIC Educational Resources Information Center

    Armes, Nancy, Ed.; And Others

    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…

  5. Constraining Item Exposure in Computerized Adaptive Testing with Shadow Tests

    ERIC Educational Resources Information Center

    van der Linden, Wim J.; Veldkamp, Bernard P.

    2004-01-01

    Item-exposure control in computerized adaptive testing is implemented by imposing item-ineligibility constraints on the assembly process of the shadow tests. The method resembles Sympson and Hetter's (1985) method of item-exposure control in that the decisions to impose the constraints are probabilistic. The method does not, however, require…

  6. Item Selection Criteria with Practical Constraints for Computerized Classification Testing

    ERIC Educational Resources Information Center

    Lin, Chuan-Ju

    2011-01-01

    This study compares four item selection criteria for a two-category computerized classification testing: (1) Fisher information (FI), (2) Kullback-Leibler information (KLI), (3) weighted log-odds ratio (WLOR), and (4) mutual information (MI), with respect to the efficiency and accuracy of classification decision using the sequential probability…

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

    ERIC Educational Resources Information Center

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

    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…

  8. Autonomy, religion and clinical decisions: findings from a national physician survey

    PubMed Central

    Lawrence, R E; Curlin, F A

    2010-01-01

    Background Patient autonomy has been promoted as the most important principle to guide difficult clinical decisions. To examine whether practising physicians indeed value patient autonomy above other considerations, physicians were asked to weight patient autonomy against three other criteria that often influence doctors’ decisions. Associations between physicians’ religious characteristics and their weighting of the criteria were also examined. Methods Mailed survey in 2007 of a stratified random sample of 1000 US primary care physicians, selected from the American Medical Association masterfile. Physicians were asked how much weight should be given to the following: (1) the patient’s expressed wishes and values, (2) the physician’s own judgment about what is in the patient’s best interest, (3) standards and recommendations from professional medical bodies and (4) moral guidelines from religious traditions. Results Response rate 51% (446/879). Half of physicians (55%) gave the patient’s expressed wishes and values “the highest possible weight”. In comparative analysis, 40% gave patient wishes more weight than the other three factors, and 13% ranked patient wishes behind some other factor. Religious doctors tended to give less weight to the patient’s expressed wishes. For example, 47% of doctors with high intrinsic religious motivation gave patient wishes the “highest possible weight”, versus 67% of those with low (OR 0.5; 95% CI 0.3 to 0.8). Conclusions Doctors believe patient wishes and values are important, but other considerations are often equally or more important. This suggests that patient autonomy does not guide physicians’ decisions as much as is often recommended in the ethics literature. PMID:19332575

  9. Antecedents of ethical decision-making: intercollegiate sporting environments as clinical education and practice settings.

    PubMed

    Caswell, Shane V; Ambegaonkar, Jatin P; Caswell, Amanda M; Gould, Trenton E

    2009-01-01

    Unique among allied health care professions, athletic training is predominately practiced amid competitive intercollegiate sports. Competitive sporting environments have been suggested to adversely impact morality, ethical decision-making (EDM), and behavior. The purposes of this study were to (1) investigate the effect of institutional National Collegiate Athletic Association (NCAA) participation level on preferred ethical ideologies and EDM, (2) determine the relationship between professional status (athletic training student [ATS] or certified athletic trainer [ATC]) and ethical ideology preferences and EDM, and (3) examine whether preferred ethical ideology is related to differences in EDM. A nationally representative sample of 610 ATSs and ATCs from 30 athletic training education programs, stratified by NCAA division level, participated in the study. All participants completed a demographic survey, the Ethics Position Questionnaire, and the Dilemmas in Athletic Training Questionnaire. No significant relationships were noted between NCAA participation level and respondents' ethical ideology preferences. However, ATSs and ATCs demonstrated significant preferences for specific ethical ideologies, with students adopting the subjectivist ideology more than expected and the exceptionist ideology less than expected and ATCs adopting the exceptionist ideology more than expected and the situationist ideology less than expected. In contrast to some previous research, our results suggest that competitive sporting environments do not affect ATSs' and ATCs' ethical ideology and EDM abilities at the collegiate level. These findings serve as a baseline for future research examining the ethical ideologies and ethical decision-making levels of athletic training practitioners and other allied health professionals across clinical settings. PMID:19361022

  10. A secure communication using cascade chaotic computing systems on clinical decision support.

    PubMed

    Koksal, Ahmet Sertol; Er, Orhan; Evirgen, Hayrettin; Yumusak, Nejat

    2016-06-01

    Clinical decision support systems (C-DSS) provide supportive tools to the expert for the determination of the disease. Today, many of the support systems, which have been developed for a better and more accurate diagnosis, have reached a dynamic structure due to artificial intelligence techniques. However, in cases when important diagnosis studies should be performed in secret, a secure communication system is required. In this study, secure communication of a DSS is examined through a developed double layer chaotic communication system. The developed communication system consists of four main parts: random number generator, cascade chaotic calculation layer, PCM, and logical mixer layers. Thanks to this system, important patient data created by DSS will be conveyed to the center through a secure communication line. PMID:25992507

  11. An Investigation of Factors Influencing Nurses' Clinical Decision-Making Skills.

    PubMed

    Wu, Min; Yang, Jinqiu; Liu, Lingying; Ye, Benlan

    2016-08-01

    This study aims to investigate the influencing factors on nurses' clinical decision-making (CDM) skills. A cross-sectional nonexperimental research design was conducted in the medical, surgical, and emergency departments of two university hospitals, between May and June 2014. We used a quantile regression method to identify the influencing factors across different quantiles of the CDM skills distribution and compared the results with the corresponding ordinary least squares (OLS) estimates. Our findings revealed that nurses were best at the skills of managing oneself. Educational level, experience, and the total structural empowerment had significant positive impacts on nurses' CDM skills, while the nurse-patient relationship, patient care and interaction, formal empowerment, and information empowerment were negatively correlated with nurses' CDM skills. These variables explained no more than 30% of the variance in nurses' CDM skills and mainly explained the lower quantiles of nurses' CDM skills distribution. PMID:26906246

  12. Statistics for critical clinical decision making based on readings of pairs of implanted sensors.

    PubMed

    Schmidtke, D W; Pishko, M V; Quinn, C P; Heller, A

    1996-09-01

    Low error rates are essential if lives of patients are to depend on readings of implanted sensors, such as glucose sensors in insulin-dependent diabetic patients. To verify the operation and to calibrate on demand an implanted sensor, it is necessary that calibration through a single, independent measurement involving withdrawal of only one sample of blood and its independent analysis be feasible. Such a one-point calibration must be accurate. Borrowing from nuclear reactor safety assurance, where a likelihood ratio test is applied to readings of pairs of pressure sensors for shutdown/no shutdown decisions, we apply a similar test to sensor pairs implanted in rats. We show, for five sets of glucose sensor pairs, calibrated in vivo by withdrawal of a single sample of blood, that application of the likelihood ratio test increases the fraction of the clinically correct readings from 92.4% for their averaged readings to 98.8%. PMID:8794921

  13. Recurrent Neural Networks in Computer-Based Clinical Decision Support for Laryngopathies: An Experimental Study

    PubMed Central

    Szkoła, Jarosław; Pancerz, Krzysztof; Warchoł, Jan

    2011-01-01

    The main goal of this paper is to give the basis for creating a computer-based clinical decision support (CDS) system for laryngopathies. One of approaches which can be used in the proposed CDS is based on the speech signal analysis using recurrent neural networks (RNNs). RNNs can be used for pattern recognition in time series data due to their ability of memorizing some information from the past. The Elman networks (ENs) are a classical representative of RNNs. To improve learning ability of ENs, we may modify and combine them with another kind of RNNs, namely, with the Jordan networks. The modified Elman-Jordan networks (EJNs) manifest a faster and more exact achievement of the target pattern. Validation experiments were carried out on speech signals of patients from the control group and with two kinds of laryngopathies. PMID:22007195

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

    PubMed

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

    2014-12-01

    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

  15. Computerized Placement Tests: Background Readings.

    ERIC Educational Resources Information Center

    College Entrance Examination Board, Princeton, NJ.

    This document is a compilation of background readings for the user of Computerized Placement Tests (CPTs) developed by the College Board for student placement purposes. CPTs are computerized adaptive tests that test the individual abilities and backgrounds of examinees. CPTs are part of the ACCUPLACER student information management system. The…

  16. Computerized Numerical Control Curriculum Guide.

    ERIC Educational Resources Information Center

    Reneau, Fred; And Others

    This guide is intended for use in a course in programming and operating a computerized numerical control system. Addressed in the course are various aspects of programming and planning, setting up, and operating machines with computerized numerical control, including selecting manual or computer-assigned programs and matching them with…

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

    NASA Astrophysics Data System (ADS)

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

    2008-01-01

    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%.

  18. Comparison of Decision-Assist and Clinical Judgment of Experts for Prediction of Lifesaving Interventions.

    PubMed

    Mackenzie, Colin F; Gao, Cheng; Hu, Peter F; Anazodo, Amechi; Chen, Hegang; Dinardo, Theresa; Imle, P Cristina; Hartsky, Lauren; Stephens, Christopher; Menaker, Jay; Fouche, Yvette; Murdock, Karen; Galvagno, Samuel; Alcorta, Richard; Shackelford, Stacy

    2015-03-01

    Early recognition of hemorrhage during the initial resuscitation of injured patients is associated with improved survival in both civilian and military casualties. We tested a transfusion and lifesaving intervention (LSI) prediction algorithm in comparison with clinical judgment of expert trauma care providers. We collected 15 min of pulse oximeter photopletysmograph waveforms and extracted features to predict LSIs. We compared this with clinical judgment of LSIs by individual categories of prehospital providers, nurses, and physicians and a combined judgment of all three providers using the Area Under Receiver Operating Curve (AUROC). We obtained clinical judgment of need for LSI from 405 expert clinicians in135 trauma patients. The pulse oximeter algorithm predicted transfusion within 6 h (AUROC, 0.92; P < 0.003) more accurately than either physicians or prehospital providers and as accurately as nurses (AUROC, 0.76; P = 0.07). For prediction of surgical procedures, the algorithm was as accurate as the three categories of clinicians. For prediction of fluid bolus, the diagnostic algorithm (AUROC, 0.9) was significantly more accurate than prehospital providers (AUROC, 0.62; P = 0.02) and nurses (AUROC, 0.57; P = 0.04) and as accurate as physicians (AUROC, 0.71; P = 0.06). Prediction of intubation by the algorithm (AUROC, 0.92) was as accurate as each of the three categories of clinicians. The algorithm was more accurate (P < 0.03) for blood and fluid prediction than the combined clinical judgment of all three providers but no different from the clinicians in the prediction of surgery (P = 0.7) or intubation (P = 0.8). Automated analysis of 15 min of pulse oximeter waveforms predicts the need for LSIs during initial trauma resuscitation as accurately as judgment of expert trauma clinicians. For prediction of emergency transfusion and fluid bolus, pulse oximetry features were more accurate than these experts. Such automated decision support could assist

  19. Characterizing the Access of Clinical Decision Support Offered by Immunization Information System in Minnesota

    PubMed Central

    Rajamani, Sripriya; Bieringer, Aaron; Muscoplat, Miriam

    2015-01-01

    Background: Healthy People 2020 aims to improve population health by increasing immunization rates to decrease vaccine-preventable infectious diseases. Amongst the many strategies, role of immunization information systems (IIS) are recognized by studies and taskforce reports. IIS are unique in their offering of clinical decision support for immunizations (CDSi) which are utilized by healthcare providers. Federal initiatives such as Meaningful Use (MU) and Affordable Care Act (ACA) aim to improve immunization rates through use of technology and expanding access to immunization services respectively. MU, the Electronic Health Record (EHR) incentive program includes use of IIS CDSi functionality as part of Stage 3. It is essential to understand access and use patterns of IIS CDSi, so as to utilize it better to improve immunization services. Objectives: To understand the utilization of clinical decision support for immunizations (CDSi) offered by immunization information system in Minnesota and to analyze the variability of its use across providers and EHR implementations. Methods: IIS in Minnesota (Minnesota Immunization Information Connection: MIIC) offers CDSi that is accessed through EHRs and branded as Alternate Access (AA). Data from MIIC and technical documents were reviewed to create details on organizations which implemented AA functionality. Data on EHR adoption in clinics and local health departments was obtained from Minnesota eHealth assessment reports. Data on access were tracked from January 2015 through mid-October 2015 through weekly specialized reports to track the queries by organization, volume and day of the week. Data were analyzed, findings were synthesized and reviewed with subject matter experts. Results: Currently 25 healthcare systems/organizations which represent 599 individual provider sites have implemented the AA functionality. Analysis of their EHR platform pointed to two EHRs (Epic and PH-Doc) as dominant products in Minnesota for

  20. Clinical evaluation of a high-resolution new peripheral quantitative computerized tomography (pQCT) scanner for the bone densitometry at the lower limbs

    NASA Astrophysics Data System (ADS)

    Braun, M. J.; Meta, M. D.; Schneider, P.; Reiners, Chr

    1998-08-01

    Precision, long-term stability, linearity and accuracy of the x-ray peripheral quantitative computerized tomographic (pQCT) bone scanner XCT 3000 (Norland-Stratec Medical Sys.) were evaluated using the European Forearm Phantom (EFP). In vivo measurements were assessed using a standardized procedure at the distal femur and the distal tibia. In the patient-scan mode, the spatial resolution of the system was lp/mm as measured at the 10% level of the modulation transfer function (MTF). The contrast-detail diagram (CDD) yielded a minimal difference in attenuation coefficient (AC) of 0.07 at an object size of 0.5 mm. The effective dose for humans was calculated to be less than 1.5 Sv per scan. Short-term precision in vivo was expressed as root mean square standard deviation of paired measurements of 20 healthy volunteers (%). At the distal femur total volumetric density (ToD) and total cross-sectional area (ToA) were found to be less sensitive to positioning errors than at the distal tibia. Structural parameters like the polar cross-sectional moment of inertia or the polar cross-sectional moment of resistance showed a good short-term precision at the distal femur ( and 1.4%). The relation between the two skeletal sites with respect to or showed a high

  1. Patient involvement in decision-making: a cross-sectional study in a Malaysian primary care clinic

    PubMed Central

    Ambigapathy, Ranjini; Ng, Chirk Jenn

    2016-01-01

    Objective Shared decision-making has been advocated as a useful model for patient management. In developing Asian countries such as Malaysia, there is a common belief that patients prefer a passive role in clinical consultation. As such, the objective of this study was to determine Malaysian patients’ role preference in decision-making and the associated factors. Design A cross-sectional study. Setting Study was conducted at an urban primary care clinic in Malaysia in 2012. Participants Patients aged >21 years were chosen using systematic random sampling. Methods Consenting patients answered a self-administered questionnaire, which included demographic data and their preferred and actual role before and after consultation. Doctors were asked to determine patients’ role preference. The Control Preference Scale was used to assess patients’ role preference. Primary outcome Prevalence of patients’ preferred role in decision-making. Secondary outcomes (1) Actual role played by the patient in decision-making. (2) Sociodemographic factors associated with patients’ preferred role in decision-making. (3) Doctors’ perception of patients’ involvement in decision-making. Results The response rate was 95.1% (470/494). Shared decision-making was preferred by 51.9% of patients, followed by passive (26.3%) and active (21.8%) roles in decision-making. Higher household income was significantly associated with autonomous role preference (p=0.018). Doctors’ perception did not concur with patients’ preferred role. Among patients whom doctors perceived to prefer a passive role, 73.5% preferred an autonomous role (p=0.900, κ=0.006). Conclusions The majority of patients attending the primary care clinic preferred and played an autonomous role in decision-making. Doctors underestimated patients’ preference to play an autonomous role. PMID:26729393

  2. Computerized Dental Injection Fear Treatment

    PubMed Central

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

    2013-01-01

    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

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

    PubMed Central

    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

    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

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

    PubMed Central

    2012-01-01

    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

  5. Privacy-Preserving Patient-Centric Clinical Decision Support System on Naïve Bayesian Classification.

    PubMed

    Liu, Ximeng; Lu, Rongxing; Ma, Jianfeng; Chen, Le; Qin, Baodong

    2016-03-01

    Clinical decision support system, which uses advanced data mining techniques to help clinician make proper decisions, has received considerable attention recently. The advantages of clinical decision support system include not only improving diagnosis accuracy but also reducing diagnosis time. Specifically, with large amounts of clinical data generated everyday, naïve Bayesian classification can be utilized to excavate valuable information to improve a clinical decision support system. Although the clinical decision support system is quite promising, the flourish of the system still faces many challenges including information security and privacy concerns. In this paper, we propose a new privacy-preserving patient-centric clinical decision support system, which helps clinician complementary to diagnose the risk of patients' disease in a privacy-preserving way. In the proposed system, the past patients' historical data are stored in cloud and can be used to train the naïve Bayesian classifier without leaking any individual patient medical data, and then the trained classifier can be applied to compute the disease risk for new coming patients and also allow these patients to retrieve the top- k disease names according to their own preferences. Specifically, to protect the privacy of past patients' historical data, a new cryptographic tool called additive homomorphic proxy aggregation scheme is designed. Moreover, to leverage the leakage of naïve Bayesian classifier, we introduce a privacy-preserving top- k disease names retrieval protocol in our system. Detailed privacy analysis ensures that patient's information is private and will not be leaked out during the disease diagnosis phase. In addition, performance evaluation via extensive simulations also demonstrates that our system can efficiently calculate patient's disease risk with high accuracy in a privacy-preserving way. PMID:26960216

  6. Clinical Performance and Management Outcomes with the DecisionDx-UM Gene Expression Profile Test in a Prospective Multicenter Study

    PubMed Central

    Plasseraud, Kristen Meldi; Tsai, Tony; Shildkrot, Yevgeniy; Middlebrook, Brooke; Maetzold, Derek; Wilkinson, Jeff; Stone, John; Johnson, Clare; Oelschlager, Kristen; Aaberg, Thomas M.

    2016-01-01

    Uveal melanoma management is challenging due to its metastatic propensity. DecisionDx-UM is a prospectively validated molecular test that interrogates primary tumor biology to provide objective information about metastatic potential that can be used in determining appropriate patient care. To evaluate the continued clinical validity and utility of DecisionDx-UM, beginning March 2010, 70 patients were enrolled in a prospective, multicenter, IRB-approved study to document patient management differences and clinical outcomes associated with low-risk Class 1 and high-risk Class 2 results indicated by DecisionDx-UM testing. Thirty-seven patients in the prospective study were Class 1 and 33 were Class 2. Class 1 patients had 100% 3-year metastasis-free survival compared to 63% for Class 2 (log rank test p = 0.003) with 27.3 median follow-up months in this interim analysis. Class 2 patients received significantly higher-intensity monitoring and more oncology/clinical trial referrals compared to Class 1 patients (Fisher's exact test p = 2.1 × 10−13 and p = 0.04, resp.). The results of this study provide additional, prospective evidence in an independent cohort of patients that Class 1 and Class 2 patients are managed according to the differential metastatic risk indicated by DecisionDx-UM. The trial is registered with Clinical Application of DecisionDx-UM Gene Expression Assay Results (NCT02376920). PMID:27446211

  7. Clinical Performance and Management Outcomes with the DecisionDx-UM Gene Expression Profile Test in a Prospective Multicenter Study.

    PubMed

    Plasseraud, Kristen Meldi; Cook, Robert W; Tsai, Tony; Shildkrot, Yevgeniy; Middlebrook, Brooke; Maetzold, Derek; Wilkinson, Jeff; Stone, John; Johnson, Clare; Oelschlager, Kristen; Aaberg, Thomas M

    2016-01-01

    Uveal melanoma management is challenging due to its metastatic propensity. DecisionDx-UM is a prospectively validated molecular test that interrogates primary tumor biology to provide objective information about metastatic potential that can be used in determining appropriate patient care. To evaluate the continued clinical validity and utility of DecisionDx-UM, beginning March 2010, 70 patients were enrolled in a prospective, multicenter, IRB-approved study to document patient management differences and clinical outcomes associated with low-risk Class 1 and high-risk Class 2 results indicated by DecisionDx-UM testing. Thirty-seven patients in the prospective study were Class 1 and 33 were Class 2. Class 1 patients had 100% 3-year metastasis-free survival compared to 63% for Class 2 (log rank test p = 0.003) with 27.3 median follow-up months in this interim analysis. Class 2 patients received significantly higher-intensity monitoring and more oncology/clinical trial referrals compared to Class 1 patients (Fisher's exact test p = 2.1 × 10(-13) and p = 0.04, resp.). The results of this study provide additional, prospective evidence in an independent cohort of patients that Class 1 and Class 2 patients are managed according to the differential metastatic risk indicated by DecisionDx-UM. The trial is registered with Clinical Application of DecisionDx-UM Gene Expression Assay Results (NCT02376920). PMID:27446211

  8. Computerized patient identification for the EMBRACA clinical trial using real-time data from the PRAEGNANT network for metastatic breast cancer patients.

    PubMed

    Hein, Alexander; Gass, Paul; Walter, Christina Barbara; Taran, Florin-Andrei; Hartkopf, Andreas; Overkamp, Friedrich; Kolberg, Hans-Christian; Hadji, Peyman; Tesch, Hans; Ettl, Johannes; Wuerstlein, Rachel; Lounsbury, Debra; Lux, Michael P; Lüftner, Diana; Wallwiener, Markus; Müller, Volkmar; Belleville, Erik; Janni, Wolfgang; Fehm, Tanja N; Wallwiener, Diethelm; Ganslandt, Thomas; Ruebner, Matthias; Beckmann, Matthias W; Schneeweiss, Andreas; Fasching, Peter A; Brucker, Sara Y

    2016-07-01

    As breast cancer is a diverse disease, clinical trials are becoming increasingly diversified and are consequently being conducted in very small subgroups of patients, making study recruitment increasingly difficult. The aim of this study was to assess the use of data from a remote data entry system that serves a large national registry for metastatic breast cancer. The PRAEGNANT network is a real-time registry with an integrated biomaterials bank that was designed as a scientific study and as a means of identifying patients who are eligible for clinical trials, based on clinical and molecular information. Here, we report on the automated use of the clinical data documented to identify patients for a clinical trial (EMBRACA) for patients with metastatic breast cancer. The patients' charts were assessed by two independent physicians involved in the clinical trial and also by a computer program that tested patients for eligibility using a structured query language script. In all, 326 patients from two study sites in the PRAEGNANT network were included in the analysis. Using expert assessment, 120 of the 326 patients (37 %) appeared to be eligible for inclusion in the EMBRACA study; with the computer algorithm assessment, a total of 129 appeared to be eligible. The sensitivity of the computer algorithm was 0.87 and its specificity was 0.88. Using computer-based identification of patients for clinical trials appears feasible. With the instrument's high specificity, its application in a large cohort of patients appears to be feasible, and the workload for reassessing the patients is limited. PMID:27283834

  9. Selection of diagnostic tests for clinical decision making and translation to a problem oriented medical record.

    PubMed

    Realdi, Giuseppe; Previato, Lorenzo; Vitturi, Nicola

    2008-07-01

    The leading function of the physician is the clinical reasoning, which involves appropriate investigation of the problems of the patient, formulation of a diagnostic suspect based on the patient's symptoms and signs, gathering of additional relevant information, to select necessary tests and administration of the most suitable therapy. The problems of the patient are expressed by symptoms or signs or abnormal test results, requested for a variety of reasons. The entire scientific, as well as diagnostic approach, is based on three steps: to stumble in a problem; to try a solution through a hypothesis; to disprove or to prove the hypothesis by a process of criticism. Clinicians use the information obtained from the history and physical examination to estimate initial (or pre-test) probability and then use the results from tests and other diagnostic procedures to modify this probability until the post-test probability is such that the suspected diagnosis is either confirmed or ruled out. When the pre-test probability of disease is high, tests characterized by high specificity will be preferred, in order to confirm the diagnostic suspect. When the pre-test probability of disease is low, a test with high sensitivity is advisable to exclude the hypothetical disease. The above mentioned process of decision making has been transferred to a problem oriented medical record that is currently employed in our Clinic. PMID:18420030

  10. Clinical Decision Support for the Classification of Diabetic Retinopathy: A Comparison of Manual and Automated Results.

    PubMed

    Mitsch, Christoph; Fehre, Karsten; Prager, Sonja; Scholda, Christoph; Kriechbaum, Katharina; Wrba, Thomas; Schmidt-Erfurth, Ursula

    2016-01-01

    The management of diabetic retinopathy, a frequent ophthalmological manifestation of diabetes mellitus, consists of regular examinations and a standardized, manual classification of disease severity, which is used to recommend re-examination intervals. To evaluate the feasibility and safety of implementing automated, guideline-based diabetic retinopathy (DR) grading into clinical routine by applying established clinical decision support (CDS) technology. We compared manual with automated classification that was generated using medical documentation and an Arden server with a specific medical logic module. Of 7169 included eyes, 47% (n=3373) showed inter-method classification agreement, specifically 29.4% in mild DR, 38.3% in moderate DR, 27.6% in severe DR, and 65.7% in proliferative DR. We demonstrate that the implementation of a CDS system for automated disease severity classification in diabetic retinopathy is feasible but also that, due to the highly individual nature of medical documentation, certain important criteria for the used electronic health record system need to be met in order to achieve reliable results. PMID:27139380

  11. A framework for genomic biomarker actionability and its use in clinical decision making

    PubMed Central

    Janku, Filip; Garrido-Laguna, Ignacio; Munoz, Javier; Schwab, Richard; Subbiah, Vivek; Rodon, Jordi; Kurzrock, Razelle

    2014-01-01

    The increasing scope and availability of genetic testing options for patients suffering from cancer has raised questions about how to use results of molecular diagnostics to inform patient care. For some biomarkers (e.g. BRAF mutations in melanoma), standards exist that outline treatments for individuals harboring aberrations in the biomarker; however for the vast majority of genomic abnormalities, few guidelines exist. Clinical decision making and the therapeutic approach for a patient with a given cancer characterized by aberrations in different genes may be aided by the use of a biomarker actionability framework that provides levels of evidence regarding whether and how a molecular abnormality can be considered a therapeutically relevant biomarker. A gene may be considered theoretically actionable if it has a basis of actionability, such that clinically available drugs can target a gene product that drives the cancer or is differentially expressed in tumor versus normal elements. Herein, we discuss a possible framework for developing guidelines for actionability, as they relate to genomically-based cancer therapeutics. PMID:25593991

  12. [Adequacy of clinical interventions in patients with advanced and complex disease. Proposal of a decision making algorithm].

    PubMed

    Ameneiros-Lago, E; Carballada-Rico, C; Garrido-Sanjuán, J A; García Martínez, A

    2015-01-01

    Decision making in the patient with chronic advanced disease is especially complex. Health professionals are obliged to prevent avoidable suffering and not to add any more damage to that of the disease itself. The adequacy of the clinical interventions consists of only offering those diagnostic and therapeutic procedures appropriate to the clinical situation of the patient and to perform only those allowed by the patient or representative. In this article, the use of an algorithm is proposed that should serve to help health professionals in this decision making process. PMID:25666087

  13. Computerized training management system

    DOEpatents

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

    1998-08-04

    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.

  14. Computerized training management system

    DOEpatents

    Rice, Harold B.; McNair, Robert C.; White, Kenneth; Maugeri, Terry

    1998-08-04

    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.

  15. Computerized Measuring Microscope

    NASA Astrophysics Data System (ADS)

    Schoonmaker, Thomas D.

    1980-05-01

    In the manufacturing of printed circuit boards, microscopic analysis is an essential process control activity. An inspector microscopically analyzes board samples to deter-mine board lot quality and process conditions. Prior to computerizing, this sustained measurement-taking involved the tedious process of recording raw data, converting microscope filar readings, calculating averages, logging information in a job notebook, and completing detailed final lab reports. It is evident from this brief task description that this time-consuming repetitious data recording routine was an added burden to the already fatiguing visual inspection method and therefore was a prime candidate for automatic data capture and printout. Secondly, the creation of a permanent and easily accessible data base would improve process feedback and provide for a system with quick identification of any suspect boards if further assembly/testing exhibited board-related failures. This paper describes the evolution and implementation of a computer-aided microscopic inspection operation.

  16. Computerizing natural history collections.

    PubMed

    Sunderland, Mary E

    2013-09-01

    Computers are ubiquitous in the life sciences and are associated with many of the practical and conceptual changes that characterize biology's twentieth-century transformation. Yet comparatively little has been written about how scientists use computers. Despite this relative lack of scholarly attention, the claim that computers revolutionized the life sciences by making the impossible possible is widespread, and relatively unchallenged. How did the introduction of computers into research programs shape scientific practice? The Museum of Vertebrate Zoology (MVZ) at the University of California, Berkeley provides a tractable way into this under-examined question because it is possible to follow the computerization of data in the context of long-term research programs. PMID:23664113

  17. Comparison of residents’ approaches to clinical decisions before and after the implementation of Evidence Based Medicine course

    PubMed Central

    KARIMIAN, ZAHRA; KOJURI, JAVAD; SAGHEB, MOHAMMAD MAHDI; MAHBOUDI, ALI; SABER, MAHBOOBEH; AMINI, MITRA; DEHGHANI, MOHAMMAD REZA

    2014-01-01

    Introduction: It has been found that the decision-making process in medicine is affected, to a large extent, by one’s experience, individual mentality, previous models, and common habitual approaches, in addition to scientific principles. Evidence-based medicine is an approach attempting to reinforce scientific, systematic and critical thinking in physicians and provide the ground for optimal decision making. In this connection, the purpose of the present study is to find out to what extent the education of evidence based medicine affects clinical decision making. Methods: The present quasi-experimental study was carried out on 110 clinical residents, who started their education in September, 2012 and finally 62 residents filled out the questionnaires. The instrument used was a researcher-made questionnaire containing items on four decision-making approaches. The questionnaire was used both as a pre-test and a post-test to assess the residents’ viewpoints on decision making approaches. The validity of the questionnaire was determined using medical education and clinical professionals’ viewpoints, and the reliability was calculated through Chronbach alpha; it was found to be 0.93. The results were analyzed by paired t-test using SPSS, version 14. Results: The results demonstrated that evidence-based medicine workshop significantly affected the residents’ decision-making approaches (p<0.001). The pre-test showed that principles-based, reference-based and routine model-based approaches were more preferred before the program (p<0.001). However, after the implementation of the program, the dominant approaches used by the residents in their decision making were evidence-based ones.  Conclusion: To develop the evidence-based approach, it is necessary for educational programs to continue steadily and goal-orientedly. In addition, the equipment infrastructure such as the Internet, access to data bases, scientific data, and clinical guides should develop more in the

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

    PubMed Central

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

    2012-01-01

    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

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

    NASA Astrophysics Data System (ADS)

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

    2014-10-01

    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

  20. Formative assessment and design of a complex clinical decision support tool for pulmonary embolism.

    PubMed

    Khan, Sundas; McCullagh, Lauren; Press, Anne; Kharche, Manish; Schachter, Andy; Pardo, Salvatore; McGinn, Thomas

    2016-02-01

    Electronic health record (EHR)-based clinical decision support (CDS) tools are rolled out with the urgency to meet federal requirements without time for usability testing and refinement of the user interface. As part of a larger project to design, develop and integrate a pulmonary embolism CDS tool for emergency physicians, we conducted a formative assessment to determine providers' level of interest and input on designs and content. This was a study to conduct a formative assessment of emergency medicine (EM) physicians that included focus groups and key informant interviews. The focus of this study was twofold, to determine the general attitude towards CDS tool integration and the ideal integration point into the clinical workflow. To accomplish this, we first approached EM physicians in a focus group, then, during key informant interviews, we presented workflow designs and gave a scenario to help the providers visualise how the CDS tool works. Participants were asked questions regarding the trigger location, trigger words, integration into their workflow, perceived utility and heuristic of the tool. Results from the participants' survey responses to trigger location, perceived utility and efficiency, indicated that the providers felt the tool would be more of a hindrance than an aid. However, some providers commented that they had not had exposure to CDS tools but had used online calculators, and thought the tools would be helpful at the point-of-care if integrated into the EHR. Furthermore, there was a preference for an order entry wireframe. This study highlights several factors to consider when designing CDS tools: (1) formative assessment of EHR functionality and clinical environment workflow, (2) focus groups and key informative interviews to incorporate providers' perceptions of CDS and workflow integration and/or (3) the demonstration of proposed workflows through wireframes to help providers visualise design concepts. PMID:26718820

  1. Clinical benefits of a multivariable prediction model for bladder cancer: a decision analytic approach

    PubMed Central

    Vickers, Andrew J; Cronin, Angel M; Kattan, Michael W; Gonen, Mithat; Scardino, Peter T; Milowsky, Matthew I.; Dalbagni, Guido; Bochner, Bernard H.

    2009-01-01

    Background Multivariable prediction models have been shown to predict cancer outcomes more accurately than cancer stage. The effects on clinical management are unclear. We aimed to determine whether a published multivariable prediction model for bladder cancer (“bladder nomogram”) improves medical decision making, using referral for adjuvant chemotherapy as a model. Methods We analyzed data from an international cohort study of 4462 patients undergoing cystectomy without chemotherapy 1969 – 2004. The number of patients eligible for chemotherapy was determined using pathologic stage criteria (lymph node positive or stage pT3 or pT4), and for three cut-offs on the bladder nomogram (10%, 25% and 70% risk of recurrence with surgery alone). The number of recurrences was calculated by applying a relative risk reduction to eligible patients' baseline risk. Clinical net benefit was then calculated by combining recurrences and treatments, weighting the latter by a factor related to drug tolerability. Results A nomogram cut-off outperformed pathologic stage for chemotherapy for every scenario of drug effectiveness and tolerability. For a drug with a relative risk of 0.80, where clinicians would treat no more than 20 patients to prevent one recurrence, use of the nomogram was equivalent to a strategy that resulted in 60 fewer chemotherapy treatments per 1000 patients without any increase in recurrence rates. Conclusions Referring cystectomy patients to adjuvant chemotherapy on the basis of a multivariable model is likely to lead to better patient outcomes than the use of pathological stage. Further research is warranted to evaluate the clinical effects of multivariable prediction models. PMID:19823979

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

    PubMed Central

    Welch, Brandon M.; Kawamoto, Kensaku

    2013-01-01

    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. PMID:25411643

  3. Types of Unintended Consequences Related to Computerized Provider Order Entry

    PubMed Central

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

    2006-01-01

    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

  4. Education in the Workplace for the Physician: Clinical Management States as an Organizing Framework.

    ERIC Educational Resources Information Center

    Greenes, Robert A.

    2000-01-01

    Trends in health information technology include (1) improved access to patient care information; (2) methods for patient-doctor interaction and decision making; (3) computerized practice guidelines; and (4) the concept of patients being in clinical management states (CMS). Problem-specific environments and CMS-related resources should be the focus…

  5. Depression and Anxiety During Pregnancy: Evaluating the Literature in Support of Clinical Risk-Benefit Decision-Making.

    PubMed

    Dalke, Katharine Baratz; Wenzel, Amy; Kim, Deborah R

    2016-06-01

    Depression and anxiety during pregnancy are common, and patients and providers are faced with complex decisions regarding various treatment modalities. A structured discussion of the risks and benefits of options with the patient and her support team is recommended to facilitate the decision-making process. This clinically focused review, with emphasis on the last 3 years of published study data, evaluates the major risk categories of medication treatments, namely pregnancy loss, physical malformations, growth impairment, behavioral teratogenicity, and neonatal toxicity. Nonpharmacological treatment options, including neuromodulation and psychotherapy, are also briefly reviewed. Specific recommendations, drawn from the literature and the authors' clinical experience, are also offered to help guide the clinician in decision-making. PMID:27091646

  6. Shared Decision Making Does Not Influence Physicians against Clinical Practice Guidelines

    PubMed Central

    Guerrier, Mireille; Légaré, France; Turcotte, Stéphane; Labrecque, Michel; Rivest, Louis-Paul

    2013-01-01

    Background While shared decision making (SDM) and adherence to clinical practice guidelines (CPGs) are important, some believe they are incompatible. This study explored the mutual influence between physicians’ intention to engage in SDM and their intention to follow CPGs. Methods Embedded within a clustered randomized trial to assess the impact of training physicians in SDM about using antibiotics to treat acute respiratory tract infections, this study evaluated physicians’ intentions to both engage in SDM and follow CPGs. A self-administered questionnaire based on the theory of planned behavior evaluated both behavioral intentions and their respective determinants (attitude, subjective norm and perceived behavioral control) at study entry and exit. We used path analysis to explore the relationships between the intentions. We conducted statistical analyses using the maximum likelihood method and the variance-covariance matrix. Goodness of fit indices encompassed the chi-square statistic, the comparative fit index and the root mean square error of approximation. Results We analyzed 244 responses at entry and 236 at exit. In the control group, at entry we observed that physicians’ intention to engage in SDM (r = 0, t = 0.03) did not affect their intention to follow CPGs; however, their intention to follow CPGs (r = −0.31 t = −2.82) did negatively influence their intention to engage in SDM. At exit, neither behavioral intention influenced the other. In the experimental group, at entry neither behavioral intention influenced the other; at exit, the intention to engage in SDM still did not influence the intention to use CPGs, although the intention to follow CPGs (r = −0.15 t = −2.02) slightly negatively influenced the intention to engage in SDM, but this was not clinically significant. Conclusion Physicians’ intention to engage in SDM does not affect their intention to adopt CPGs even after SDM training. Physicians’ intention

  7. An Automated System for Generating Situation-Specific Decision Support in Clinical Order Entry from Local Empirical Data

    ERIC Educational Resources Information Center

    Klann, Jeffrey G.

    2011-01-01

    Clinical Decision Support is one of the only aspects of health information technology that has demonstrated decreased costs and increased quality in healthcare delivery, yet it is extremely expensive and time-consuming to create, maintain, and localize. Consequently, a majority of health care systems do not utilize it, and even when it is…

  8. An Exploration of the Relationship between Clinical Decision-Making Ability and Educational Preparation among New Graduate Nurses

    ERIC Educational Resources Information Center

    Blount, Kamilah V.

    2013-01-01

    This study examined the impact of accelerated nursing direct entry master's programs on the development of clinical decision-making skills of new graduate nurses that completed the Performance Based Development System (PBDS) assessment during the study period of 2008-2012 at a healthcare organization. Healthcare today is practiced in a…

  9. Discussing End-of-Life Decisions in a Clinical Ethics Committee: An Interview Study of Norwegian Doctors' Experience.

    PubMed

    Bahus, Marianne K; Førde, Reidun

    2016-09-01

    With disagreement, doubts, or ambiguous grounds in end-of-life decisions, doctors are advised to involve a clinical ethics committee (CEC). However, little has been published on doctors' experiences with discussing an end-of-life decision in a CEC. As part of the quality assurance of this work, we wanted to find out if clinicians have benefited from discussing end-of-life decisions in CECs and why. We will disseminate some Norwegian doctors' experiences when discussing end-of-life decisions in CECs, based on semi-structured interviews with fifteen Norwegian physicians who had brought an end-of-life decision case to a CEC. Almost half of the cases involved conflicts with the patients' relatives. In a majority of the cases, there was uncertainty about what would be the ethically preferable solution. Reasons for referring the case to the CEC were to get broader illumination of the case, to get perspective from people outside the team, to get advice, or to get moral backing on a decision already made. A great majority of the clinicians reported an overall positive experience with the CECs' discussions. In cases where there was conflict, the clinicians reported less satisfaction with the CECs' discussions. The study shows that most doctors who have used a CEC in an end-of-life decision find it useful to have ethical and/or legal aspects illuminated, and to have the dilemma scrutinized from a new perspective. A systematic discussion seems to be significant to the clinicians. PMID:26922945

  10. 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

    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

    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

  11. An ontology-driven, case-based clinical decision support model for removable partial denture design.

    PubMed

    Chen, Qingxiao; Wu, Ji; Li, Shusen; Lyu, Peijun; Wang, Yong; Li, Miao

    2016-01-01

    We present the initial work toward developing a clinical decision support model for specific design of removable partial dentures (RPDs) in dentistry. We developed an ontological paradigm to represent knowledge of a patient's oral conditions and denture component parts. During the case-based reasoning process, a cosine similarity algorithm was applied to calculate similarity values between input patients and standard ontology cases. A group of designs from the most similar cases were output as the final results. To evaluate this model, the output designs of RPDs for 104 randomly selected patients were compared with those selected by professionals. An area under the curve of the receiver operating characteristic (AUC-ROC) was created by plotting true-positive rates against the false-positive rate at various threshold settings. The precision at position 5 of the retrieved cases was 0.67 and at the top of the curve it was 0.96, both of which are very high. The mean average of precision (MAP) was 0.61 and the normalized discounted cumulative gain (NDCG) was 0.74 both of which confirmed the efficient performance of our model. All the metrics demonstrated the efficiency of our model. This methodology merits further research development to match clinical applications for designing RPDs. This paper is organized as follows. After the introduction and description of the basis for the paper, the evaluation and results are presented in Section 2. Section 3 provides a discussion of the methodology and results. Section 4 describes the details of the ontology, similarity algorithm, and application. PMID:27297679

  12. An ontology-driven, case-based clinical decision support model for removable partial denture design

    PubMed Central

    Chen, Qingxiao; Wu, Ji; Li, Shusen; Lyu, Peijun; Wang, Yong; Li, Miao

    2016-01-01

    We present the initial work toward developing a clinical decision support model for specific design of removable partial dentures (RPDs) in dentistry. We developed an ontological paradigm to represent knowledge of a patient’s oral conditions and denture component parts. During the case-based reasoning process, a cosine similarity algorithm was applied to calculate similarity values between input patients and standard ontology cases. A group of designs from the most similar cases were output as the final results. To evaluate this model, the output designs of RPDs for 104 randomly selected patients were compared with those selected by professionals. An area under the curve of the receiver operating characteristic (AUC-ROC) was created by plotting true-positive rates against the false-positive rate at various threshold settings. The precision at position 5 of the retrieved cases was 0.67 and at the top of the curve it was 0.96, both of which are very high. The mean average of precision (MAP) was 0.61 and the normalized discounted cumulative gain (NDCG) was 0.74 both of which confirmed the efficient performance of our model. All the metrics demonstrated the efficiency of our model. This methodology merits further research development to match clinical applications for designing RPDs. This paper is organized as follows. After the introduction and description of the basis for the paper, the evaluation and results are presented in Section 2. Section 3 provides a discussion of the methodology and results. Section 4 describes the details of the ontology, similarity algorithm, and application. PMID:27297679

  13. Clinical Decision Support Tools for Selecting Interventions for Patients with Disabling Musculoskeletal Disorders: A Scoping Review.

    PubMed

    Gross, Douglas P; Armijo-Olivo, Susan; Shaw, William S; Williams-Whitt, Kelly; Shaw, Nicola T; Hartvigsen, Jan; Qin, Ziling; Ha, Christine; Woodhouse, Linda J; Steenstra, Ivan A

    2016-09-01

    Purpose We aimed to identify and inventory clinical decision support (CDS) tools for helping front-line staff select interventions for patients with musculoskeletal (MSK) disorders. Methods We used Arksey and O'Malley's scoping review framework which progresses through five stages: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies for analysis; (4) charting the data; and (5) collating, summarizing and reporting results. We considered computer-based, and other available tools, such as algorithms, care pathways, rules and models. Since this research crosses multiple disciplines, we searched health care, computing science and business databases. Results Our search resulted in 4605 manuscripts. Titles and abstracts were screened for relevance. The reliability of the screening process was high with an average percentage of agreement of 92.3 %. Of the located articles, 123 were considered relevant. Within this literature, there were 43 CDS tools located. These were classified into 3 main areas: computer-based tools/questionnaires (n = 8, 19 %), treatment algorithms/models (n = 14, 33 %), and clinical prediction rules/classification systems (n = 21, 49 %). Each of these areas and the associated evidence are described. The state of evidentiary support for CDS tools is still preliminary and lacks external validation, head-to-head comparisons, or evidence of generalizability across different populations and settings. Conclusions CDS tools, especially those employing rapidly advancing computer technologies, are under development and of potential interest to health care providers, case management organizations and funders of care. Based on the results of this scoping review, we conclude that these tools, models and systems should be subjected to further validation before they can be recommended for large-scale implementation for managing patients with MSK disorders. PMID:26667939

  14. Computerized molecular modeling of carbohydrates

    Technology Transfer Automated Retrieval System (TEKTRAN)

    Computerized molecular modleing continues to increase in capability and applicability to carbohydrates. This chapter covers nomenclature and conformational aspects of carbohydrates, perhaps of greater use to carbohydrate-inexperienced computational chemists. Its comments on various methods and studi...

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

    SciTech Connect

    Bertelli, Luiz; Toohey, Richard E

    2009-01-01

    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.

  16. Clinical Decision Support System to Enhance Quality Control of Spirometry Using Information and Communication Technologies

    PubMed Central

    2014-01-01

    Background We recently demonstrated that quality of spirometry in primary care could markedly improve with remote offline support from specialized professionals. It is hypothesized that implementation of automatic online assessment of quality of spirometry using information and communication technologies may significantly enhance the potential for extensive deployment of a high quality spirometry program in integrated care settings. Objective The objective of the study was to elaborate and validate a Clinical Decision Support System (CDSS) for automatic online quality assessment of spirometry. Methods The CDSS was done through a three step process including: (1) identification of optimal sampling frequency; (2) iterations to build-up an initial version using the 24 standard spirometry curves recommended by the American Thoracic Society; and (3) iterations to refine the CDSS using 270 curves from 90 patients. In each of these steps the results were checked against one expert. Finally, 778 spirometry curves from 291 patients were analyzed for validation purposes. Results The CDSS generated appropriate online classification and certification in 685/778 (88.1%) of spirometry testing, with 96% sensitivity and 95% specificity. Conclusions Consequently, only 93/778 (11.9%) of spirometry testing required offline remote classification by an expert, indicating a potential positive role of the CDSS in the deployment of a high quality spirometry program in an integrated care setting. PMID:25600957

  17. A Clinical Decision Support System for Femoral Peripheral Arterial Disease Treatment

    PubMed Central

    Yurtkuran, Alkın; Tok, Mustafa

    2013-01-01

    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

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

    PubMed

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

    2014-11-01

    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

  19. Evolution of a knowledge base for a clinical decision support system encoded in the Arden Syntax.

    PubMed Central

    Jenders, R. A.; Huang, H.; Hripcsak, G.; Clayton, P. D.

    1998-01-01

    Clinical decision support systems (CDSS) are being used increasingly in medical practice. Thus, long-term maintenance of the knowledge bases (KB) of such systems becomes important. To quantify changes that occur as a KB evolves, we studied the KB at the Columbia-Presbyterian Medical Center. This KB has a total of 229 Medical Logic Modules (MLMs) encoded in the Arden Syntax. Eliminating those never used in practice, we retrospectively analyzed 156 MLMs developed over 78 months. We noted 2020 distinct versions of these MLMs that included 5528 changed statements over time. These changes occurred primarily in the logic slot (38.7% of all changes), the action slot (17.8%), in queries (15.0%) and in the data slot exclusive of queries (12.4%). We conclude that long-term maintenance of a KB for a CDSS requires significant changes over time. We discuss the implications of these results for the design of KB editors for the Arden Syntax. PMID:9929281

  20. MACVIA clinical decision algorithm in adolescents and adults with allergic rhinitis.

    PubMed

    Bousquet, Jean; Schünemann, Holger J; Hellings, Peter W; Arnavielhe, Sylvie; Bachert, Claus; Bedbrook, Anna; Bergmann, Karl-Christian; Bosnic-Anticevich, Sinthia; Brozek, Jan; Calderon, Moises; Canonica, G Walter; Casale, Thomas B; Chavannes, Niels H; Cox, Linda; Chrystyn, Henry; Cruz, Alvaro A; Dahl, Ronald; De Carlo, Giuseppe; Demoly, Pascal; Devillier, Phillipe; Dray, Gérard; Fletcher, Monica; Fokkens, Wytske J; Fonseca, Joao; Gonzalez-Diaz, Sandra N; Grouse, Lawrence; Keil, Thomas; Kuna, Piotr; Larenas-Linnemann, Désirée; Lodrup Carlsen, Karin C; Meltzer, Eli O; Mullol, Jaoquim; Muraro, Antonella; Naclerio, Robert N; Palkonen, Susanna; Papadopoulos, Nikolaos G; Passalacqua, Giovanni; Price, David; Ryan, Dermot; Samolinski, Boleslaw; Scadding, Glenis K; Sheikh, Aziz; Spertini, François; Valiulis, Arunas; Valovirta, Erkka; Walker, Samantha; Wickman, Magnus; Yorgancioglu, Arzu; Haahtela, Tari; Zuberbier, Torsten

    2016-08-01

    The selection of pharmacotherapy for patients with allergic rhinitis (AR) depends on several factors, including age, prominent symptoms, symptom severity, control of AR, patient preferences, and cost. Allergen exposure and the resulting symptoms vary, and treatment adjustment is required. Clinical decision support systems (CDSSs) might be beneficial for the assessment of disease control. CDSSs should be based on the best evidence and algorithms to aid patients and health care professionals to jointly determine treatment and its step-up or step-down strategy depending on AR control. Contre les MAladies Chroniques pour un VIeillissement Actif en Languedoc-Roussillon (MACVIA-LR [fighting chronic diseases for active and healthy ageing]), one of the reference sites of the European Innovation Partnership on Active and Healthy Ageing, has initiated an allergy sentinel network (the MACVIA-ARIA Sentinel Network). A CDSS is currently being developed to optimize AR control. An algorithm developed by consensus is presented in this article. This algorithm should be confirmed by appropriate trials. PMID:27260321

  1. Computerized international geothermal information systems

    SciTech Connect

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

    1980-03-01

    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.

  2. Impact of MammaPrint on Clinical Decision-Making in South African Patients with Early-Stage Breast Cancer.

    PubMed

    Pohl, Heinrich; Kotze, Maritha J; Grant, Kathleen A; van der Merwe, Lize; Pienaar, Fredrieka M; Apffelstaedt, Justus P; Myburgh, Ettienne J

    2016-07-01

    The aim of the study was to evaluate the impact of MammaPrint on treatment decision-making in patients with breast cancer. Clinicopathologic information of all breast cancer patients referred for MammaPrint testing in South Africa was collected from 2007 until 2014. A total of 107 patients (109 tumors) with estrogen receptor/progesterone receptor positive and human epidermal growth factor receptor-2 negative tumors were selected with tumors ≥10 mm, or when 1-3 nodes were involved without extra-nodal extension. None of the clinical indicators correlated significantly with the MammaPrint risk classification, which changed the decision for adjuvant chemotherapy in 52% of patients. Of 60 patients who were clinically high risk, 62% had a low-risk MammaPrint result and of the 47 clinically low -risk patients 40% had a high-risk MammaPrint result. This study indicates that MammaPrint could reduce the need for adjuvant chemotherapy by 17% using the selection criteria stipulated. The significant impact on treatment decisions confirmed the clinical utility of MammaPrint independent of standard clinicopathologic risk factors as supported by long-term clinical outcome studies. PMID:27079770

  3. Emerging medical informatics with case-based reasoning for aiding clinical decision in multi-agent system.

    PubMed

    Shen, Ying; Colloc, Joël; Jacquet-Andrieu, Armelle; Lei, Kai

    2015-08-01

    This research aims to depict the methodological steps and tools about the combined operation of case-based reasoning (CBR) and multi-agent system (MAS) to expose the ontological application in the field of clinical decision support. The multi-agent architecture works for the consideration of the whole cycle of clinical decision-making adaptable to many medical aspects such as the diagnosis, prognosis, treatment, therapeutic monitoring of gastric cancer. In the multi-agent architecture, the ontological agent type employs the domain knowledge to ease the extraction of similar clinical cases and provide treatment suggestions to patients and physicians. Ontological agent is used for the extension of domain hierarchy and the interpretation of input requests. Case-based reasoning memorizes and restores experience data for solving similar problems, with the help of matching approach and defined interfaces of ontologies. A typical case is developed to illustrate the implementation of the knowledge acquisition and restitution of medical experts. PMID:26133480

  4. Modeling the Innovation-Decision Process: Dissemination and Adoption of a Motivational Interviewing Preparatory Procedure In Addiction Outpatient Clinics.

    PubMed

    Walitzer, Kimberly S; Dermen, Kurt H; Barrick, Christopher; Shyhalla, Kathleen

    2015-10-01

    Widespread adoption of empirically-supported treatment innovations has the potential to improve effectiveness of treatment received by individuals with substance use disorders. However, the process of disseminating such innovations has been complex, slow, and difficult. We empirically describe the dissemination and adoption of a treatment innovation--an alcohol-treatment preparatory therapeutic procedure based on motivational interviewing (MI)--in the context of Rogers' (2003) five stages of innovation-decision process (knowledge, persuasion, decision, implementation and confirmation). To this end, 145 randomly-chosen outpatient addiction treatment clinics in New York State received an onsite visit from a project trainer delivering one of three randomly-assigned dissemination intensities: a 15-minute, a half-day or a full-day presentation. Across these clinics, 141 primary administrators and 837 clinicians completed questionnaires assessing aspects of five innovation-decision stages. At each clinic, questionnaire administration occurred immediately pre- and post-dissemination, as well as 1 and 6 months after dissemination. Consistent with Rogers' theory, earlier stages of the innovation-decision process predicted later stages. As hypothesized, dissemination intensity predicted clinicians' post-dissemination knowledge. Clinician baseline characteristics (including gender, pre-dissemination knowledge regarding the MI preparatory technique, education, case load, beliefs regarding the nature of alcohol problems, and beliefs and behavior with regard to therapeutic style) predicted knowledge and persuasion stage variables. One baseline clinic characteristic (i.e., clinic mean beliefs and behavior regarding an MI-consistent therapeutic style) predicted implementation stage variables. Findings suggest that dissemination strategies should accommodate clinician and clinic characteristics. PMID:25934460

  5. Cost-Effectiveness of Clinical Decision Support System in Improving Maternal Health Care in Ghana

    PubMed Central

    Dalaba, Maxwell Ayindenaba; Akweongo, Patricia; Aborigo, Raymond Akawire; Saronga, Happiness Pius; Williams, John; Blank, Antje; Kaltschmidt, Jens; Sauerborn, Rainer; Loukanova, Svetla

    2015-01-01

    Objective This paper investigated the cost-effectiveness of a computer-assisted Clinical Decision Support System (CDSS) in the identification of maternal complications in Ghana. Methods A cost-effectiveness analysis was performed in a before- and after-intervention study. Analysis was conducted from the provider’s perspective. The intervention area was the Kassena- Nankana district where computer-assisted CDSS was used by midwives in maternal care in six selected health centres. Six selected health centers in the Builsa district served as the non-intervention group, where the normal Ghana Health Service activities were being carried out. Results Computer-assisted CDSS increased the detection of pregnancy complications during antenatal care (ANC) in the intervention health centres (before-intervention= 9 /1,000 ANC attendance; after-intervention= 12/1,000 ANC attendance; P-value=0.010). In the intervention health centres, there was a decrease in the number of complications during labour by 1.1%, though the difference was not statistically significant (before-intervention =107/1,000 labour clients; after-intervention= 96/1,000 labour clients; P-value=0.305). Also, at the intervention health centres, the average cost per pregnancy complication detected during ANC (cost –effectiveness ratio) decreased from US$17,017.58 (before-intervention) to US$15,207.5 (after-intervention). Incremental cost –effectiveness ratio (ICER) was estimated at US$1,142. Considering only additional costs (cost of computer-assisted CDSS), cost per pregnancy complication detected was US$285. Conclusions Computer –assisted CDSS has the potential to identify complications during pregnancy and marginal reduction in labour complications. Implementing computer-assisted CDSS is more costly but more effective in the detection of pregnancy complications compared to routine maternal care, hence making the decision to implement CDSS very complex. Policy makers should however be guided by whether

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

    PubMed Central

    Légaré, France; Moher, David; Elwyn, Glyn; LeBlanc, Annie; Gravel, Karine

    2007-01-01

    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, Current Contents, Dissertation Abstracts and Sociological Abstracts were searched for original studies in English or French. Reference lists from retrieved studies were also consulted. Studies were included if they reported a self-administered instrument evaluating physicians' perceptions of the decision-making process within specific clinical encounters, contained sufficient description to permit critical appraisal and presented quantitative results based on administering the instrument. Two individuals independently assessed the eligibility of the instruments and abstracted information on their conceptual underpinnings, main evaluation domain, development, format, reliability, validity and responsiveness. They also assessed the quality of the studies that reported on the development of the instruments with a modified version of STARD. Results Out of 3431 records identified and screened for evaluation, 26 potentially relevant instruments were assessed; 11 met the inclusion criteria. Five instruments were published before 1995. Among those published after 1995, five offered a corresponding patient version. Overall, the main evaluation domains were: satisfaction with the clinical encounter (n = 2), mutual understanding between health professional and patient (n = 2), mental workload (n = 1), frustration with the clinical encounter (n = 1), nurse-physician collaboration (n = 1), perceptions of communication competence (n = 2), degree of comfort with a decision (n = 1) and information on medication (n = 1). For most instruments (n = 10), some

  7. Enabling Cross-Platform Clinical Decision Support through Web-Based Decision Support in Commercial Electronic Health Record Systems: Proposal and Evaluation of Initial Prototype Implementations

    PubMed Central

    Zhang, Mingyuan; Velasco, Ferdinand T.; Musser, R. Clayton; Kawamoto, Kensaku

    2013-01-01

    Enabling clinical decision support (CDS) across multiple electronic health record (EHR) systems has been a desired but largely unattained aim of clinical informatics, especially in commercial EHR systems. A potential opportunity for enabling such scalable CDS is to leverage vendor-supported, Web-based CDS development platforms along with vendor-supported application programming interfaces (APIs). Here, we propose a potential staged approach for enabling such scalable CDS, starting with the use of custom EHR APIs and moving towards standardized EHR APIs to facilitate interoperability. We analyzed three commercial EHR systems for their capabilities to support the proposed approach, and we implemented prototypes in all three systems. Based on these analyses and prototype implementations, we conclude that the approach proposed is feasible, already supported by several major commercial EHR vendors, and potentially capable of enabling cross-platform CDS at scale. PMID:24551426

  8. Enabling cross-platform clinical decision support through Web-based decision support in commercial electronic health record systems: proposal and evaluation of initial prototype implementations.

    PubMed

    Zhang, Mingyuan; Velasco, Ferdinand T; Musser, R Clayton; Kawamoto, Kensaku

    2013-01-01

    Enabling clinical decision support (CDS) across multiple electronic health record (EHR) systems has been a desired but largely unattained aim of clinical informatics, especially in commercial EHR systems. A potential opportunity for enabling such scalable CDS is to leverage vendor-supported, Web-based CDS development platforms along with vendor-supported application programming interfaces (APIs). Here, we propose a potential staged approach for enabling such scalable CDS, starting with the use of custom EHR APIs and moving towards standardized EHR APIs to facilitate interoperability. We analyzed three commercial EHR systems for their capabilities to support the proposed approach, and we implemented prototypes in all three systems. Based on these analyses and prototype implementations, we conclude that the approach proposed is feasible, already supported by several major commercial EHR vendors, and potentially capable of enabling cross-platform CDS at scale. PMID:24551426

  9. Cognitive Workload of Computerized Nursing Process in Intensive Care Units.

    PubMed

    Dal Sasso, Grace Marcon; Barra, Daniela Couto Carvalho

    2015-08-01

    The aim of this work was to measure the cognitive workload to complete printed nursing process versus computerized nursing process from International Classification Practice of Nursing in intensive care units. It is a quantitative, before-and-after quasi-experimental design, with a sample of 30 participants. Workload was assessed using National Aeronautics and Space Administration Task-Load Index. Six cognitive categories were measured. The "temporal demand" was the largest contributor to the cognitive workload, and the role of the nursing process in the "performance" category has excelled that of computerized nursing process. It was concluded that computerized nursing process contributes to lower cognitive workload of nurses for being a support system for decision making based on the International Classification Practice of Nursing. The computerized nursing process as a logical structure of the data, information, diagnoses, interventions and results become a reliable option for health improvement of healthcare, because it can enhance nurse safe decision making, with the intent to reduce damage and adverse events to patients in intensive care. PMID:26061562

  10. Computerizing Your Program.

    ERIC Educational Resources Information Center

    Curtis, Rick

    This paper summarizes information about using computer hardware and software to aid in making purchase decisions that are based on user needs. The two major options in hardware are IBM-compatible machines and the Apple Macintosh line. The three basic software applications include word processing, database management, and spreadsheet applications.…

  11. Influence of the sFlt-1/PlGF Ratio on Clinical Decision-Making in Women with Suspected Preeclampsia

    PubMed Central

    Klein, Evelyn; Schlembach, Dietmar; Ramoni, Angela; Langer, Elena; Bahlmann, Franz; Grill, Sabine; Schaffenrath, Helene; van der Does, Reinhard; Messinger, Diethelm; Verhagen-Kamerbeek, Wilma D. J.; Reim, Manfred; Hund, Martin; Stepan, Holger

    2016-01-01

    Objective To evaluate the influence of the soluble fms-like tyrosine kinase 1/placental growth factor ratio in physicians’ decision making in pregnant women with signs and symptoms of preeclampsia in routine clinical practice. Methods A multicenter, prospective, open, non-interventional study enrolled pregnant women presenting with preeclampsia signs and symptoms in several European perinatal care centers. Before the soluble fms-like tyrosine kinase 1/placental growth factor ratio result was known, physicians documented intended clinical procedures using an iPad® application (data locked/time stamped). After the result was available, clinical decisions were confirmed or revised and documented. An independent adjudication committee evaluated the appropriateness of decisions based on maternal/fetal outcomes. Clinician decision making with regard to hospitalization was the primary outcome. Results In 16.9% of mothers (20/118) the hospitalization decision was changed after knowledge of the ratio. In 13 women (11.0%), the initial decision to hospitalize was changed to no hospitalization. In seven women (5.9%) the revised decision was hospitalization. All revised decisions were considered appropriate by the panel of adjudicators (McNemar test; p < 0.0001). Conclusions The use of the soluble fms-like tyrosine kinase 1/placental growth factor test influenced clinical decision making towards appropriate hospitalization in a considerable proportion of women with suspected preeclampsia. This is the first study to demonstrate the impact of angiogenic biomarkers on decision making in a routine clinical practice. PMID:27243815

  12. Clinical Trial Decision Making in Pediatric Sickle Cell Disease: A Qualitative Study of Perceived Benefits and Barriers to Participation.

    PubMed

    Patterson, Chavis A; Chavez, Veronica; Mondestin, Valerie; Deatrick, Janet; Li, Yimei; Barakat, Lamia P

    2015-08-01

    Clinical trial research forms the foundation for advancing treatments; yet, children with sickle cell disease (SCD) are currently underrepresented. This qualitative study examines decision-making processes of youth with SCD and their caregivers regarding enrollment in clinical trial research. A subsample of participants from a study of clinical trial decision making among youth with health disparity conditions, 23 caregivers and 29 children/teens/young adults with SCD (age, 10 to 29 y), indicated whether or not they would participate in hypothetical medical and psychosocial clinical trials and prioritized barriers and benefits to participation via card sort and semistructured interviews. Audio recordings were transcribed and coded for themes. Participants reported that concerns of potential harm most affected their decision. Secondary factors were potential benefit, manageable study demands, and trust in the medical staff. Caregivers weighed potential harm more heavily than their children. Young children were more likely to endorse potential benefit. Overall, participants stated they would be willing to participate in research if the potential benefit outweighs potential harm and unmanageable study demands. To optimize recruitment, results suggest addressing potential harm first while highlighting potential benefits, creating manageable study demands, and endorsing the future benefits of research to the sickle cell community. PMID:25072368

  13. A 2014 Medical Informatics Perspective on Clinical Decision Support Systems: Do We Hit The Ceiling of Effectiveness?

    PubMed Central

    Lamy, J.-B.

    2014-01-01

    Summary Objective To summarize recent research and propose a selection of best papers published in 2013 in the field of computer-based decision support in health care. Method Two literature reviews were performed by the two section editors from bibliographic databases with a focus on clinical decision support systems (CDSSs) and computer provider order entry in order to select a list of candidate best papers to be peer-reviewed by external reviewers. Results The full review process highlighted three papers, illustrating current trends in the domain of clinical decision support. The first trend is the development of theoretical approaches for CDSSs, and is exemplified by a paper proposing the integration of family histories and pedigrees in a CDSS. The second trend is illustrated by well-designed CDSSs, showing good theoretical performances and acceptance, while failing to show a clinical impact. An example is given with a paper reporting on scorecards aiming to reduce adverse drug events. The third trend is represented by research works that try to understand the limits of CDSS use, for instance by analyzing interactions between general practitioners, patients, and a CDSS. Conclusions CDSSs can achieve good theoretical results in terms of sensibility and specificity, as well as a good acceptance, but evaluations often fail to demonstrate a clinical impact. Future research is needed to better understand the causes of this observation and imagine new effective solutions for CDSS implementation. PMID:25123737

  14. Transforming User Needs into Functional Requirements for an Antibiotic Clinical Decision Support System

    PubMed Central

    Bright, T.J.

    2013-01-01

    Summary Background Many informatics studies use content analysis to generate functional requirements for system development. Explication of this translational process from qualitative data to functional requirements can strengthen the understanding and scientific rigor when applying content analysis in informatics studies. Objective To describe a user-centered approach transforming emergent themes derived from focus group data into functional requirements for informatics solutions and to illustrate these methods to the development of an antibiotic clinical decision support system (CDS). Methods The approach consisted of five steps: 1) identify unmet therapeutic planning information needs via Focus Group Study-I, 2) develop a coding framework of therapeutic planning themes to refine the domain scope to antibiotic therapeutic planning, 3) identify functional requirements of an antibiotic CDS system via Focus Group Study-II, 4) discover informatics solutions and functional requirements from coded data, and 5) determine the types of information needed to support the antibiotic CDS system and link with the identified informatics solutions and functional requirements. Results The coding framework for Focus Group Study-I revealed unmet therapeutic planning needs. Twelve subthemes emerged and were clustered into four themes; analysis indicated a need for an antibiotic CDS intervention. Focus Group Study-II included five types of information needs. Comments from the Barrier/Challenge to information access and Function/Feature themes produced three informatics solutions and 13 functional requirements of an antibiotic CDS system. Comments from the Patient, Institution, and Domain themes generated required data elements for each informatics solution. Conclusion This study presents one example explicating content analysis of focus group data and the analysis process to functional requirements from narrative data. Illustration of this 5-step method was used to develop an

  15. The ethics of forgoing life-sustaining treatment: theoretical considerations and clinical decision making.

    PubMed

    Welie, Jos Vm; Ten Have, Henk Amj

    2014-01-01

    Withholding or withdrawing a life-sustaining treatment tends to be very challenging for health care providers, patients, and their family members alike. When a patient's life seems to be nearing its end, it is generally felt that the morally best approach is to try a new intervention, continue all treatments, attempt an experimental course of action, in short, do something. In contrast to this common practice, the authors argue that in most instances, the morally safer route is actually to forgo life-sustaining treatments, particularly when their likelihood to effectuate a truly beneficial outcome has become small relative to the odds of harming the patient. The ethical analysis proceeds in three stages. First, the difference between neglectful omission and passive acquiescence is explained. Next, the two necessary conditions for any medical treatment, i.e., that it is medically indicated and that consent is obtained, are applied to life-sustaining interventions. Finally, the difference between withholding and withdrawing a life-sustaining treatment is discussed. In the second part of the paper the authors show how these theoretical-ethical considerations can guide clinical-ethical decision making. A case vignette is presented about a patient who cannot be weaned off the ventilator post-surgery. The ethical analysis of this case proceeds through three stages. First, it is shown that and why withdrawal of the ventilator in this case does not equate assistance in suicide or euthanasia. Next, the question is raised whether continued ventilation can be justified medically, or has become futile. Finally, the need for the health care team to obtain consent for the continuation of the ventilation is discussed. PMID:24618004

  16. Radiation Treatment in Older Patients: A Framework for Clinical Decision Making

    PubMed Central

    Smith, Grace L.; Smith, Benjamin D.

    2014-01-01

    In older patients, radiation treatment plays a vital role in curative and palliative cancer therapy. Radiation treatment recommendations should be informed by a comprehensive, personalized risk-benefit assessment that evaluates treatment efficacy and toxicity. We review several clinical factors that distinctly affect efficacy and toxicity of radiation treatment in older patients. First, locoregional tumor behavior may be more indolent in older patients for some disease sites but more aggressive for other sites. Assessment of expected locoregional relapse risk informs the magnitude and timeframe of expected radiation treatment benefits. Second, assessment of the competing cancer versus noncancer mortality and morbidity risks contextualizes cancer treatment priorities holistically within patients' entire spectrum and time course of health needs. Third, assessment of functional reserve helps predict patients' acute treatment tolerance, differentiating those patients who are unlikely to benefit from treatment or who are at high risk for treatment complications. Potential radiation treatment options include immediate curative treatment, delayed curative treatment, and no treatment, with additional consideration given to altered radiation target, dose, or sequencing with chemotherapy and/or surgery. Finally, when cure is not feasible, palliative radiation therapy remains valuable for managing symptoms and achieving meaningful quality-of-life improvements. Our proposed decision-making framework integrates these factors to help radiation oncologists formulate strategic treatment recommendations within a multidisciplinary context. Future research is still needed to identify how advanced technologies can be judiciously applied in curative and palliative settings to enhance risk-benefit profiles of radiation treatment in older patients and more accurately quantify treatment efficacy in this group. PMID:25071132

  17. Effort-Based Decision-Making Paradigms for Clinical Trials in Schizophrenia: Part 2—External Validity and Correlates.

    PubMed

    Horan, William P; Reddy, L Felice; Barch, Deanna M; Buchanan, Robert W; Dunayevich, Eduardo; Gold, James M; Marder, Steven R; Wynn, Jonathan K; Young, Jared W; Green, Michael F

    2015-09-01

    Effort-based decision making has strong conceptual links to the motivational disturbances that define a key subdomain of negative symptoms. However, the extent to which effort-based decision-making performance relates to negative symptoms, and other clinical and functionally important variables has yet to be systematically investigated. In 94 clinically stable outpatients with schizophrenia, we examined the external validity of 5 effort-based paradigms, including the Effort Expenditure for Rewards, Balloon Effort, Grip Strength Effort, Deck Choice Effort, and Perceptual Effort tasks. These tasks covered 3 types of effort: physical, cognitive, and perceptual. Correlations between effort related performance and 6 classes of variables were examined, including: (1) negative symptoms, (2) clinically rated motivation and community role functioning, (3) self-reported motivational traits, (4) neurocognition, (5) other psychiatric symptoms and clinical/demographic characteristics, and (6) subjective valuation of monetary rewards. Effort paradigms showed small to medium relationships to clinical ratings of negative symptoms, motivation, and functioning, with the pattern more consistent for some measures than others. They also showed small to medium relations with neurocognitive functioning, but were generally unrelated to other psychiatric symptoms, self-reported traits, antipsychotic medications, side effects, and subjective valuation of money. There were relatively strong interrelationships among the effort measures. In conjunction with findings from a companion psychometric article, all the paradigms warrant further consideration and development, and 2 show the strongest potential for clinical trial use at this juncture. PMID:26209546

  18. Effort-Based Decision-Making Paradigms for Clinical Trials in Schizophrenia: Part 2—External Validity and Correlates

    PubMed Central

    Reddy, L. Felice; Barch, Deanna M.; Buchanan, Robert W.; Dunayevich, Eduardo; Gold, James M.; Marder, Steven R.; Wynn, Jonathan K.; Young, Jared W.; Green, Michael F.

    2015-01-01

    Effort-based decision making has strong conceptual links to the motivational disturbances that define a key subdomain of negative symptoms. However, the extent to which effort-based decision-making performance relates to negative symptoms, and other clinical and functionally important variables has yet to be systematically investigated. In 94 clinically stable outpatients with schizophrenia, we examined the external validity of 5 effort-based paradigms, including the Effort Expenditure for Rewards, Balloon Effort, Grip Strength Effort, Deck Choice Effort, and Perceptual Effort tasks. These tasks covered 3 types of effort: physical, cognitive, and perceptual. Correlations between effort related performance and 6 classes of variables were examined, including: (1) negative symptoms, (2) clinically rated motivation and community role functioning, (3) self-reported motivational traits, (4) neurocognition, (5) other psychiatric symptoms and clinical/demographic characteristics, and (6) subjective valuation of monetary rewards. Effort paradigms showed small to medium relationships to clinical ratings of negative symptoms, motivation, and functioning, with the pattern more consistent for some measures than others. They also showed small to medium relations with neurocognitive functioning, but were generally unrelated to other psychiatric symptoms, self-reported traits, antipsychotic medications, side effects, and subjective valuation of money. There were relatively strong interrelationships among the effort measures. In conjunction with findings from a companion psychometric article, all the paradigms warrant further consideration and development, and 2 show the strongest potential for clinical trial use at this juncture. PMID:26209546

  19. Computerized Profiling of Grammatical Performance and Conversational Participation.

    ERIC Educational Resources Information Center

    Long, Steven H.; Fey, Marc E.

    1988-01-01

    The paper describes ways in which the computer can assist language clinicians in performing highly informative linguistic analyses that are useful in the development and evaluation of intervention programs. Two modules from the software package, Computerized Profiling, are described and two cases illustrating clinical application of computers are…

  20. A Clinical Decision Rule to Predict Adult Patients with Traumatic Intracranial Hemorrhage Who Do Not Require Intensive Care Unit Admission

    PubMed Central

    Nishijima, Daniel K.; Shahlaie, Kiarash; Echeverri, Angela; Holmes, James F.

    2016-01-01

    Objective To derive a clinical decision rule to identify adult emergency department (ED) patients with traumatic intracranial hemorrhage (tICH) who are at low risk for requiring critical care resources during hospitalization. Methods This is a retrospective cohort study of patients (≥18 years) with tICH presenting to the ED. The need for intensive care unit (ICU) admission was defined as the presence of a critical care intervention including: intubation, neurosurgical intervention, blood product transfusion, vasopressor or inotrope administration, invasive monitoring for hemodynamic instability, emergent treatment for arrhythmia, therapeutic angiography, and cardiopulmonary resuscitation. The decision rule was derived using binary recursive partitioning. Results A total of 432 patients were identified (median age 48 years) of which 174 patients (40%) had a critical care intervention. We performed binary recursive partitioning with Classification and Regression Trees (CART) software to develop the clinical decision rule. Patients with a normal mental status (Glasgow Coma Score=15), isolated head injury, and age < 65 were considered low risk for a critical care intervention. The derived rule had a sensitivity of 98% (95% confidence interval [CI] 94–99), a specificity of 50% (95% CI 44–56), a positive predictive value of 57% (95% CI 51–62), and a negative predictive value of 97% (95% CI 93–99). The area under the curve for the decision rule was 0.74 (95% CI 0.70–0.77). Conclusions This clinical decision rule identifies low risk adult ED patients with tICH who do not need ICU admission. Further validation and refinement of these findings would allow for more appropriate ICU resource utilization. PMID:21839444

  1. Documentation of Nursing Practice Using a Computerized Medical Information System

    PubMed Central

    Romano, Carol

    1981-01-01

    This paper discusses a definition of the content of the computerized nursing data base developed by the Nursing Department for the Clinical Center Medical Information System at the National Institutes of Health in Bethesda, Maryland. The author describes the theoretical framework for the content and presents a model to describe the organization of the nursing data components in relation to the process of nursing care delivery. Nursing documentation requirements of Nurse Practice Acts, American Nurses Association Standards of Practice and the Joint Commission on Accreditation of Hospitals are also addressed as they relate to this data base. The advantages and disadvantages of such an approach to computerized documentation are discussed.

  2. Using a service oriented architecture approach to clinical decision support: performance results from two CDS Consortium demonstrations.

    PubMed

    Paterno, Marilyn D; Goldberg, Howard S; Simonaitis, Linas; Dixon, Brian E; Wright, Adam; Rocha, Beatriz H; Ramelson, Harley Z; Middleton, Blackford

    2012-01-01

    The Clinical Decision Support Consortium has completed two demonstration trials involving a web service for the execution of clinical decision support (CDS) rules in one or more electronic health record (EHR) systems. The initial trial ran in a local EHR at Partners HealthCare. A second EHR site, associated with Wishard Memorial Hospital, Indianapolis, IN, was added in the second trial. Data were gathered during each 6 month period and analyzed to assess performance, reliability, and response time in the form of means and standard deviations for all technical components of the service, including assembling and preparation of input data. The mean service call time for each period was just over 2 seconds. In this paper we report on the findings and analysis to date while describing the areas for further analysis and optimization as we continue to expand our use of a Services Oriented Architecture approach for CDS across multiple institutions. PMID:23304342

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

    PubMed Central

    Heneghan, Carl; Thompson, Matthew; Balla, Margaret

    2012-01-01

    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

  4. A computerized multichannel platelet aggregometer system.

    PubMed

    Kuzara, D; Zoltan, B J; Greathouse, S L; Jordan, C W; Kohler, C A

    1986-08-01

    Commercially available instrumentation for conducting platelet aggregation studies in clinical and research laboratories consists of one-, two-, or four-channel aggregometers used in conjunction with strip chart recorders. These instruments have limited utility in large-scale drug screening and evaluation of the mode of action of drugs or in the clinical diagnosis of platelet disorders. A new instrument, a computerized multichannel aggregometer system (CMPAS) has been developed to collect, display, and analyze platelet aggregation data. The system is comprised of a 24-channel Born-type aggregometer, interfaced to a Rockwell AIM-65 microcomputer through an analogue-to-digital converter and an Epson dot-matrix printer. Each channel is individually calibrated, and aggregation data can be collected on up to 24 different platelet-rich plasma samples simultaneously. Conversational programs written in BASIC prompt the user for the addition of agonists and inhibitors. The tracings for each channel are displayed simultaneously, and a program automatically analyzes the data to generate the following parameters: baseline optical density, maximum aggregation response, positive and negative slopes, time to peak aggregation, and percentage response. Computerized multichannel aggregometer system data outputs are comparable to data generated by a standard Chronolog aggregometer unit. The advantages of the system include multichannel capability, simultaneous display of all channels allowing relative comparisons between control and experimental groups, and time savings and improved efficiency in conducting and analyzing aggregation experiments. PMID:3755779

  5. Modern management of childhood diabetes: a role for computerized devices?

    PubMed

    Chiarelli, F; Di Ricco, L; Catino, M; Sabatino, G; Verrotti, A

    1998-08-01

    Technology is increasingly relevant in everyday life and it can be very interesting to apply it also in the field of diabetes as it can be one way of ensuring better care. In the Diabetes Control and Complications Trial, the intensively treated patients were seen fortnightly in hospital and contacted even more frequently by telephone during the day as well as at night. For these reasons, health reforms are undergoing a radical change in an attempt to reduce the spiraling costs of health care provision. Therefore, it can be useful to use information technology (IT) in diabetes care. The European Federation for Medical Informatics recently established some Special Issues to advance IT initiatives that may be able to address the problem of adjusting the insulin dose and controlling blood glucose (BG) levels, as well as assisting in the provision of modern-day diabetes care. The Special Issues can be classified under the following headings: databases, algorithms, decision support, models and education. It can be useful to develop a prototype computer system that can be applied to different areas of clinical diabetes care; computerized out-patients' clinical databases that store patients' clinical and biochemical data; statistical and graphical analysis programs that help the clinician; dietary analysis programs which examine food composition and dietary exchanges and help devise meal plans; hand-held insulin dosage adjustment computers that advise patients on a day-by-day or even meal-by-meal basis; expert systems and question and answer programs for patients' education, and finally games for children. These systems have the potential to be useful tools in many aspects of diabetes care but their utilization by the vast majority of the health care community has been extremely limited. Nonetheless, computers cannot substitute for the pediatric diabetes team, which remains the major determinant for better care of diabetes in children and adolescents. PMID:9745768

  6. The doctor-patient relationship as a toolkit for uncertain clinical decisions.

    PubMed

    Diamond-Brown, Lauren

    2016-06-01

    Medical uncertainty is a well-recognized problem in healthcare, yet how doctors make decisions in the face of uncertainty remains to be understood. This article draws on interdisciplinary literature on uncertainty and physician decision-making to examine a specific physician response to uncertainty: using the doctor-patient relationship as a toolkit. Additionally, I ask what happens to this process when the doctor-patient relationship becomes fragmented. I answer these questions by examining obstetrician-gynecologists' narratives regarding how they make decisions when faced with uncertainty in childbirth. Between 2013 and 2014, I performed 21 semi-structured interviews with obstetricians in the United States. Obstetricians were selected to maximize variation in relevant physician, hospital, and practice characteristics. I began with grounded theory and moved to analytical coding of themes in relation to relevant literature. My analysis renders it evident that some physicians use the doctor-patient relationship as a toolkit for dealing with uncertainty. I analyze how this process varies for physicians in different models of care by comparing doctors' experiences in models with continuous versus fragmented doctor-patient relationships. My key findings are that obstetricians in both models appealed to the ideal of patient-centered decision-making to cope with uncertain decisions, but in practice physicians in fragmented care faced a number of challenges to using the doctor-patient relationship as a toolkit for decision-making. These challenges led to additional uncertainties and in some cases to poor outcomes for doctors and/or patients; they also raised concerns about the reproduction of inequality. Thus organization of care delivery mitigates the efficacy of doctors' use of the doctor-patient relationship toolkit for uncertain decisions. These findings have implications for theorizing about decision-making under conditions of medical uncertainty, for understanding

  7. Mentoring in the Clinical Setting to Improve Student Decision-Making Competence

    ERIC Educational Resources Information Center

    Stick-Mueller, Misty; Boesch, Ron; Silverman, Steven; Carpenter, Scott; Illingworth, Robert; Countryman, James

    2010-01-01

    Introduction: The physician-intern relationship can be difficult to develop. A new chiropractic intern in a teaching clinic undergoes a major transition from classroom to clinical practice and must learn to turn classroom knowledge into clinical application. The ability to start formulating clinical techniques and apply them on a patient is…

  8. Application of a computerized environmental information system to master and sector planning

    NASA Technical Reports Server (NTRS)

    Stewart, J. C.

    1978-01-01

    A computerized composite mapping system developed as an aid in the land use decision making process is described. Emphasis is placed on consideration of the environment in urban planning. The presence of alluvium, shallow bedrock, surface water, and vegetation growth are among the environmental factors considered. An analysis of the Shady Grove Sector planning is presented as an example of the use of computerized composite mapping for long range planning.

  9. Implementation of Clinical Pharmacogenomics within a Large Health System: From Electronic Health Record Decision Support to Consultation Services.

    PubMed

    Hicks, J Kevin; Stowe, David; Willner, Marc A; Wai, Maya; Daly, Thomas; Gordon, Steven M; Lashner, Bret A; Parikh, Sumit; White, Robert; Teng, Kathryn; Moss, Timothy; Erwin, Angelika; Chalmers, Jeffrey; Eng, Charis; Knoer, Scott

    2016-08-01

    The number of clinically relevant gene-based guidelines and recommendations pertaining to drug prescribing continues to grow. Incorporating gene-drug interaction information into the drug-prescribing process can help optimize pharmacotherapy outcomes and improve patient safety. However, pharmacogenomic implementation barriers exist such as integration of pharmacogenomic results into electronic health records (EHRs), development and deployment of pharmacogenomic decision support tools to EHRs, and feasible models for establishing ambulatory pharmacogenomic clinics. We describe the development of pharmacist-managed pharmacogenomic services within a large health system. The Clinical Pharmacogenetics Implementation Consortium guidelines for HLA-B*57:01-abacavir, HLA-B*15:02-carbamazepine, and TPMT-thiopurines (i.e., azathioprine, mercaptopurine, and thioguanine) were systematically integrated into patient care. Sixty-three custom rules and alerts (20 for TPMT-thiopurines, 8 for HLA-B*57:01-abacavir, and 35 for HLA-B*15:02-anticonvulsants) were developed and deployed to the EHR for the purpose of providing point-of-care pharmacogenomic decision support. In addition, a pharmacist and physician-geneticist collaboration established a pharmacogenomics ambulatory clinic. This clinic provides genetic testing when warranted, result interpretation along with pharmacotherapy recommendations, and patient education. Our processes for developing these pharmacogenomic services and solutions for addressing implementation barriers are presented. PMID:27312955

  10. Evaluation of the reliability of computerized profile cephalometric analysis.

    PubMed

    Ferreira, José Tarcísio Lima; Telles, Carlos de Souza

    2002-01-01

    The use of computers as an auxiliary instrument for case evaluation and procedures in health sciences is not new, and their advantages are well known. A growing number of orthodontists are using computerized systems for cephalometric analysis. Thus, this study evaluated the reliability of both computerized and manual methods used for creating profile cephalograms. Fifty profile radiographs were selected from the files of the Post-Graduate Course in Orthodontics at the Dental School of the Federal University of Rio de Janeiro. The good quality of the material was the only necessary requirement for selection. Results were submitted to the interclass correlation coefficient and a reliable similarity between cephalometric data obtained through both evaluated methods was found. However, the clinical utilization of computerized cephalometric analysis is not absolutely reliable. PMID:12428597

  11. Implementing a computerized operating room management system.

    PubMed

    Choy, M

    1991-01-01

    The Queen's Medical Center implemented a computerized operating room management system in 1987 that includes surgery scheduling, intraoperative recording, and resource tracking. In addition to the important functional components, the system provides management with a better tool for decision-making. The purpose of this article is to describe this implementation. Background is provided to identify the manual system's deficiencies followed by the anticipated benefits of the computer system. The paper concentrates on Queen's implementation experiences in coding the surgical procedure information, confronting staff anxiety, managing the changing roles of the staff and providing adequate resources. Minimum requirements for a successful implementation include designating an effective project leader, assigning system responsibilities to the user, relieving all operational responsibilities from key members of the project team and providing adequate resources to support the system. PMID:1760543

  12. A COMPUTERIZED OPERATOR SUPPORT SYSTEM PROTOTYPE

    SciTech Connect

    Thomas A. Ulrich; Roger Lew; Ronald L. Boring; Ken Thomas

    2015-03-01

    A computerized operator support system (COSS) is proposed for use in nuclear power plants to assist control room operators in addressing time-critical plant upsets. A COSS is a collection of technologies to assist operators in monitoring overall plant performance and making timely, informed decisions on appropriate control actions for the projected plant condition. A prototype COSS was developed in order to demonstrate the concept and provide a test bed for further research. The prototype is based on four underlying elements consisting of a digital alarm system, computer-based procedures, piping and instrumentation diagram system representations, and a recommender module for mitigation actions. The initial version of the prototype is now operational at the Idaho National Laboratory using the Human System Simulation Laboratory.

  13. Use of conditional rule structure to automate clinical decision support: a comparison of artificial intelligence and deterministic programming techniques.

    PubMed

    Friedman, R H; Frank, A D

    1983-08-01

    A rule-based computer system was developed to perform clinical decision-making support within a medical information system, oncology practice, and clinical research. This rule-based system, which has been programmed using deterministic rules, possesses features of generalizability, modularity of structure, convenience in rule acquisition, explanability, and utility for patient care and teaching, features which have been identified as advantages of artificial intelligence (AI) rule-based systems. Formal rules are primarily represented as conditional statements; common conditions and actions are stored in system dictionaries so that they can be recalled at any time to form new decision rules. Important similarities and differences exist in the structure of this system and clinical computer systems utilizing artificial intelligence (AI) production rule techniques. The non-AI rule-based system possesses advantages in cost and ease of implementation. The degree to which significant medical decision problems can be solved by this technique remains uncertain as does whether the more complex AI methodologies will be required. PMID:6352165

  14. Randomised controlled trial of clinical decision support tools to improve learning of evidence based medicine in medical students

    PubMed Central

    Leung, Gabriel M; Johnston, Janice M; Tin, Keith Y K; Wong, Irene O L; Ho, Lai-Ming; Lam, Wendy W T; Lam, Tai-Hing

    2003-01-01

    Objective To assess the educational effectiveness on learning evidence based medicine of a handheld computer clinical decision support tool compared with a pocket card containing guidelines and a control. Design Randomised controlled trial. Setting University of Hong Kong, 2001. Participants 169 fourth year medical students. Main outcome measures Factor and individual item scores from a validated questionnaire on five key self reported measures: personal application and current use of evidence based medicine; future use of evidence based medicine; use of evidence during and after clerking patients; frequency of discussing the role of evidence during teaching rounds; and self perceived confidence in clinical decision making. Results The handheld computer improved participants' educational experience with evidence based medicine the most, with significant improvements in all outcome scores. More modest improvements were found with the pocket card, whereas the control group showed no appreciable changes in any of the key outcomes. No significant deterioration was observed in the improvements even after withdrawal of the handheld computer during an eight week washout period, suggesting at least short term sustainability of effects. Conclusions Rapid and convenient access to valid and relevant evidence on a portable computing device can improve learning in evidence based medicine, increase current and future use of evidence, and boost students' confidence in clinical decision making. PMID:14604933

  15. Design and Development of a Sharable Clinical Decision Support System Based on a Semantic Web Service Framework.

    PubMed

    Zhang, Yi-Fan; Gou, Ling; Tian, Yu; Li, Tian-Chang; Zhang, Mao; Li, Jing-Song

    2016-05-01

    Clinical decision support (CDS) systems provide clinicians and other health care stakeholders with patient-specific assessments or recommendations to aid in the clinical decision-making process. Despite their demonstrated potential for improving health care quality, the widespread availability of CDS systems has been limited mainly by the difficulty and cost of sharing CDS knowledge among heterogeneous healthcare information systems. The purpose of this study was to design and develop a sharable clinical decision support (S-CDS) system that meets this challenge. The fundamental knowledge base consists of independent and reusable knowledge modules (KMs) to meet core CDS needs, wherein each KM is semantically well defined based on the standard information model, terminologies, and representation formalisms. A semantic web service framework was developed to identify, access, and leverage these KMs across diverse CDS applications and care settings. The S-CDS system has been validated in two distinct client CDS applications. Model-level evaluation results confirmed coherent knowledge representation. Application-level evaluation results reached an overall accuracy of 98.66 % and a completeness of 96.98 %. The evaluation results demonstrated the technical feasibility and application prospect of our approach. Compared with other CDS engineering efforts, our approach facilitates system development and implementation and improves system maintainability, scalability and efficiency, which contribute to the widespread adoption of effective CDS within the healthcare domain. PMID:27002818

  16. Personalised Medicine Possible With Real-Time Integration of Genomic and Clinical Data To Inform Clinical Decision-Making.

    PubMed

    Martin-Sanchez, Fernando; Turner, Maureen; Johnstone, Alice; Heffer, Leon; Rafael, Naomi; Bakker, Tim; Thorne, Natalie; Macciocca, Ivan; Gaff, Clara

    2015-01-01

    Despite widespread use of genomic sequencing in research, there are gaps in our understanding of the performance and provision of genomic sequencing in clinical practice. The Melbourne Genomics Health Alliance (the Alliance), has been established to determine the feasibility, performance and impact of using genomic sequencing as a diagnostic tool. The Alliance has partnered with BioGrid Australia to enable the linkage of genomic sequencing, clinical treatment and outcome data for this project. This integrated dataset of genetic, clinical and patient sourced information will be used by the Alliance to evaluate the potential diagnostic value of genomic sequencing in routine clinical practice. This project will allow the Alliance to provide recommendations to facilitate the integration of genomic sequencing into clinical practice to enable personalised disease treatment. PMID:26262351

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

    PubMed Central

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

    2014-01-01

    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

  18. Future perspectives toward the early definition of a multivariate decision-support scheme employed in clinical decision making for senior citizens.

    PubMed

    Frantzidis, Christos A; Gilou, Sotiria; Billis, Antonis; Karagianni, Maria; Bratsas, Charalampos D; Bamidis, Panagiotis

    2016-03-01

    Recent neuroscientific studies focused on the identification of pathological neurophysiological patterns (emotions, geriatric depression, memory impairment and sleep disturbances) through computerised clinical decision-support systems. Almost all these research attempts employed either resting-state condition (e.g. eyes-closed) or event-related potentials extracted during a cognitive task known to be affected by the disease under consideration. This Letter reviews existing data mining techniques and aims to enhance their robustness by proposing a holistic decision framework dealing with comorbidities and early symptoms' identification, while it could be applied in realistic occasions. Multivariate features are elicited and fused in order to be compared with average activities characteristic of each neuropathology group. A proposed model of the specific cognitive function which may be based on previous findings (a priori information) and/or validated by current experimental data should be then formed. So, the proposed scheme facilitates the early identification and prevention of neurodegenerative phenomena. Neurophysiological semantic annotation is hypothesised to enhance the importance of the proposed framework in facilitating the personalised healthcare of the information society and medical informatics research community. PMID:27222732

  19. Clinical factors influencing the decision to transfuse after percutaneous native kidney biopsy

    PubMed Central

    Whittier, William L.; Sayeed, Khaleel; Korbet, Stephen M.

    2016-01-01

    bleeding time: 7.6 ± 1.8 versus 7.4 ± 2.0 versus 6.7 ± 1.8 min, P < 0.0001). When BL-T was stratified by pre-PRB Hgb, there were more transfusions in those with lower pre-PRB Hgb (24 versus 9 versus 3%, P < 0.0001). However, these patients not only had fewer hematomas (58 versus 83 versus 87%, P = 0.04) but also demonstrated a smaller ΔHgb post-PRB (1.3 ± 1.0 versus 1.8 ± 0.8 versus 3.2 ± 1.6, P < 0.0001) compared with patients with higher pre-PRB Hgb, yet still received a transfusion. Conclusions While patients with lower pre-PRB Hgb have more of the traditional risk factors for a complication after PRB, there was actually less clinically evident bleeding in these patients who were transfused. Although anemia itself has been considered to be a risk factor for a complication in the past, it more accurately represents only a predictor of receiving an erythrocyte transfusion. In the setting of the PRB, the decision for transfusion is influenced more by the severity of anemia at baseline as opposed to clinically evident bleeding. PMID:26798469

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

    PubMed Central

    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

    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

  1. Prevalence of clinically significant decisional conflict: an analysis of five studies on decision-making in primary care

    PubMed Central

    Thompson-Leduc, Philippe; Turcotte, Stéphane; Labrecque, Michel; Légaré, France

    2016-01-01

    Objectives Unresolved clinically significant decisional conflict (CSDC) in patients following a consultation with health professionals is often the result of inadequate patient involvement in decision-making and may result in poor outcomes. We sought to identify the prevalence of CSDC in studies on decision-making in primary care and to explore its risk factors. Setting We performed a secondary analysis of existing data sets from studies conducted in Primary Care Practice-Based Research Networks in Québec and Ontario, Canada. Participants Eligible studies included a patient-reported measure on the 16-item Decisional Conflict Scale (DCS) following a decision made with a healthcare professional with no study design restriction. Primary and secondary outcome measures CSDC was defined as a score ≥25/100 on the DCS. The prevalence of CSDC was stratified by sex; and patient-level logistic regression analysis was performed to explore its potential risk factors. Data sets of studies were analysed individually and qualitatively compared. Results 5 projects conducted between 2003 and 2010 were included. They covered a range of decisions: prenatal genetic screening, antibiotics for acute respiratory infections and miscellaneous. Altogether, the 5 projects gathered data from encounters with a total of 1338 primary care patients (69% female; range of age 15–83). The prevalence of CSDC in patients varied across studies and ranged from 10.3% (95% CI 7.2% to 13.4%) to 31.1% (95% CI 26.6% to 35.6%). Across the 5 studies, risk factors of CSDC included being male, living alone and being 45 or older. Conclusions Prevalence of CSDC in patients who had enrolled in studies conducted in primary care contexts was substantial and appeared to vary according to the type of decision as well as to patient characteristics such as sex, living arrangement and age. Patients presenting risk factors of CSDC should be offered tools to increase their involvement in decision-making. PMID:27354076

  2. Arkansas' Curriculum Guide. Competency Based Computerized Accounting.

    ERIC Educational Resources Information Center

    Arkansas State Dept. of Education, Little Rock. Div. of Vocational, Technical and Adult Education.

    This guide contains the essential parts of a total curriculum for a one-year secondary-level course in computerized accounting. Addressed in the individual sections of the guide are the following topics: the complete accounting cycle, computer operations for accounting, computerized accounting and general ledgers, computerized accounts payable,…

  3. Computerized Proof Techniques for Undergraduates

    ERIC Educational Resources Information Center

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

    2012-01-01

    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…

  4. California's Computerized Pupil Transportation Systems.

    ERIC Educational Resources Information Center

    Edwards, James C.

    1983-01-01

    Traces efforts to develop a statewide plan for computerized school bus fleet operation by means of questionnaires distributed to all 58 county education offices, 7 regional data processing centers, and selected private school bus contractors and school districts. Findings indicate significant potential savings for fleets of 20 or more busses. (JBM)

  5. Student Perceptions of Computerized Tests

    ERIC Educational Resources Information Center

    Pino-Silva, Juan

    2008-01-01

    The challenge to test small groups by means of microcomputers demands appropriate software design and sound test design. To comply with this demand, students' beliefs or perceptions on the advantages and disadvantages of a computerized test were tapped. Overall, self-reported advantages outnumbered disadvantages to a significant degree. This was…

  6. Computerized Cognitive Testing in the Management of Youth Sports-Related Concussion.

    PubMed

    De Marco, Anthony P; Broshek, Donna K

    2016-01-01

    Computerized neurocognitive testing has become a growing practice across medical populations, but particularly within sports medicine and the management of sports-related concussion. Although traditional neuropsychological measures are solely administered and interpreted by neuropsychologists, computerized cognitive tests are marketed to and utilized by a wide range of professionals involved in the management of sports-related concussions, many of whom lack specialized psychometric training. Although the benefits of computerized testing allow for many youth athletes to be evaluated quickly, professionals implementing their use should be aware of the potential pitfalls and the high potential for misuse. After briefly reviewing the recommended guidelines set forth by the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology, we review the benefits/limitations of computerized testing in the management of sports-related concussion and the basic psychometric properties of some of the more widely used computerized measures. Lastly, we discuss the practical application of these devices. PMID:25477270

  7. A two-stage clinical decision support system for early recognition and stratification of patients with sepsis: an observational cohort study

    PubMed Central

    Lyons, Jason J; Greene, Tracy L; Haley, James M

    2015-01-01

    Objective To examine the diagnostic accuracy of a two-stage clinical decision support system for early recognition and stratification of patients with sepsis. Design Observational cohort study employing a two-stage sepsis clinical decision support to recognise and stratify patients with sepsis. The stage one component was comprised of a cloud-based clinical decision support with 24/7 surveillance to detect patients at risk of sepsis. The cloud-based clinical decision support delivered notifications to the patients’ designated nurse, who then electronically contacted a provider. The second stage component comprised a sepsis screening and stratification form integrated into the patient electronic health record, essentially an evidence-based decision aid, used by providers to assess patients at bedside. Setting Urban, 284 acute bed community hospital in the USA; 16,000 hospitalisations annually. Participants Data on 2620 adult patients were collected retrospectively in 2014 after the clinical decision support was implemented. Main outcome measure ‘Suspected infection’ was the established gold standard to assess clinical decision support clinimetric performance. Results A sepsis alert activated on 417 (16%) of 2620 adult patients hospitalised. Applying ‘suspected infection’ as standard, the patient population characteristics showed 72% sensitivity and 73% positive predictive value. A postalert screening conducted by providers at bedside of 417 patients achieved 81% sensitivity and 94% positive predictive value. Providers documented against 89% patients with an alert activated by clinical decision support and completed 75% of bedside screening and stratification of patients with sepsis within one hour from notification. Conclusion A clinical decision support binary alarm system with cross-checking functionality improves early recognition and facilitates stratification of patients with sepsis. PMID:26688744

  8. Influence of MRI field strength on clinical decision making in knee cartilage injury – A case study

    PubMed Central

    Cashman, Glenn; Attariwala, Raj

    2014-01-01

    Objective: To increase clinicians’ awareness of the differences in image resolution and potential diagnostic accuracy between small and large-field MR Scanners. To present an example of a clinical decision making challenge in how to proceed when knee MRI and clinical findings don’t agree. Clinical Features: A 38 year old female mountain biker presented with knee pain and clinical features strongly suggestive of a torn meniscus or loose bodies. An initial MRI using a small field strength (0.18T) scanner was reported as normal. Her clinical presentation was suspicious enough that a repeat MRI on a high-field (1.5T) scanner was ordered. The second MRI included high resolution 3D volumetric imaging which revealed cartilage damage and loose bodies. Intervention and Outcome: The patient was treated with arthroscopic surgery which confirmed the presence of meniscal and chondral injury and resulted in notable improvement in the patient’s symptoms. Conclusion: Clinicians should consider scanner quality and diagnostic accuracy before discounting strongly suggestive clinical history and examination findings when MRIs are reported as normal. PMID:25550664

  9. Improving Awareness of Cancer Clinical Trials Among Hispanic Patients and Families: Audience Segmentation Decisions for a Media Intervention

    PubMed Central

    QUINN, GWENDOLYN P.; McINTYRE, JESSICA; GONZALEZ, LUIS E.; ANTONIA, TERESITA MUÑOZ; ANTOLINO, PRADO; WELLS, KRISTEN J.

    2016-01-01

    Clinical trials hold great promise for cancer treatment; yet, Hispanic cancer patients have low rates of clinical trial participation. Lack of awareness and knowledge of clinical trials and language barriers may account for low participation rates. Patient education through audiovisual materials can improve knowledge of and attitudes toward clinical trials among Hispanic populations. In this study, 36 Hispanic cancer patients/survivors and caregivers in Florida and Puerto Rico participated in focus groups to aid in developing a Spanish-language DVD and booklet intervention designed to increase knowledge about clinical trials. Focus group results showed (a) low levels of knowledge about clinical trials, (b) uncertainty about why a physician would expect a patient to make a choice about treatment, and (c) desire for family participation in decision making. Respondents expressed various preferences for aspects of the DVD such as showing extended family in the DVD and physician explanations about key terms. On the basis of these preferences, the authors developed a creative brief for a DVD. The content of the DVD was reviewed by Hispanic community leaders and key stakeholders. A final DVD was created, in Spanish, using Hispanic patients and physicians, which contained the information deemed important from the focus groups and stakeholder interviews. The DVD is complete with companion booklet and currently undergoing a randomized control trial. PMID:23639101

  10. Patient-reported Outcomes in Randomised Controlled Trials of Prostate Cancer: Methodological Quality and Impact on Clinical Decision Making

    PubMed Central

    Efficace, Fabio; Feuerstein, Michael; Fayers, Peter; Cafaro, Valentina; Eastham, James; Pusic, Andrea; Blazeby, Jane

    2014-01-01

    Context Patient-reported outcomes (PRO) data from randomised controlled trials (RCTs) are increasingly used to inform patient-centred care as well as clinical and health policy decisions. Objective The main objective of this study was to investigate the methodological quality of PRO assessment in RCTs of prostate cancer (PCa) and to estimate the likely impact of these studies on clinical decision making. Evidence acquisition A systematic literature search of studies was undertaken on main electronic databases to retrieve articles published between January 2004 and March 2012. RCTs were evaluated on a predetermined extraction form, including (1) basic trial demographics and clinical and PRO characteristics; (2) level of PRO reporting based on the recently published recommendations by the International Society for Quality of Life Research; and (3) bias, assessed using the Cochrane Risk of Bias tool. Studies were systematically analysed to evaluate their relevance for supporting clinical decision making. Evidence synthesis Sixty-five RCTs enrolling a total of 22 071 patients were evaluated, with 31 (48%) in patients with nonmetastatic disease. When a PRO difference between treatments was found, it related in most cases to symptoms only (n = 29, 58%). Although the extent of missing data was generally documented (72% of RCTs), few reported details on statistical handling of this data (18%) and reasons for dropout (35%). Improvements in key methodological aspects over time were found. Thirteen (20%) RCTs were judged as likely to be robust in informing clinical decision making. Higher-quality PRO studies were generally associated with those RCTs that had higher internal validity. Conclusions Including PRO in RCTs of PCa patients is critical for better evaluating the treatment effectiveness of new therapeutic approaches. Marked improvements in PRO quality reporting over time were found, and it is estimated that at least one-fifth of PRO RCTs have provided sufficient

  11. A web-based system for clinical decision support and knowledge maintenance for deterioration monitoring of hemato-oncological patients.

    PubMed

    Wicht, Andreas; Wetter, Thomas; Klein, Ulrike

    2013-07-01

    We introduce a web-based clinical decision support system (CDSS) and knowledge maintenance based on rules and a set covering method focusing on the problem of detecting serious comorbidities in hemato-oncological patients who are at high risk of developing serious infections and life threatening complications. We experienced that diagnostic problems which are characterized by fuzzy, uncertain knowledge and overlapping signs, still reveal some kind of patterns that can be transferred into a computer-based decision model. We applied a multi-stage evaluation process to assess the system's diagnostic performance. Depending on how system behavior was compared to presumably correct judgment of a case the correctness rate for closed cases with all data available varied between 58% and 71%, the overall rate after critical review was 84%. However, the real time behavior of our approach which data becoming available as time passes still has to be evaluated and observational studies need to be conducted. PMID:23522434

  12. Decision-tree analysis of clinical data to aid diagnostic reasoning for equine laminitis: a cross-sectional study.

    PubMed

    Wylie, C E; Shaw, D J; Verheyen, K L P; Newton, J R

    2016-04-23

    The objective of this cross-sectional study was to compare the prevalence of selected clinical signs in laminitis cases and non-laminitic but lame controls to evaluate their capability to discriminate laminitis from other causes of lameness. Participating veterinary practitioners completed a checklist of laminitis-associated clinical signs identified by literature review. Cases were defined as horses/ponies with veterinary-diagnosed, clinically apparent laminitis; controls were horses/ponies with any lameness other than laminitis. Associations were tested by logistic regression with adjusted odds ratios (ORs) and 95% confidence intervals, with veterinary practice as an a priori fixed effect. Multivariable analysis using graphical classification tree-based statistical models linked laminitis prevalence with specific combinations of clinical signs. Data were collected for 588 cases and 201 controls. Five clinical signs had a difference in prevalence of greater than +50 per cent: 'reluctance to walk' (OR 4.4), 'short, stilted gait at walk' (OR 9.4), 'difficulty turning' (OR 16.9), 'shifting weight' (OR 17.7) and 'increased digital pulse' (OR 13.2) (all P<0.001). 'Bilateral forelimb lameness' was the best discriminator; 92 per cent of animals with this clinical sign had laminitis (OR 40.5, P<0.001). If, in addition, horses/ponies had an 'increased digital pulse', 99 per cent were identified as laminitis. 'Presence of a flat/convex sole' also significantly enhanced clinical diagnosis discrimination (OR 15.5, P<0.001). This is the first epidemiological laminitis study to use decision-tree analysis, providing the first evidence base for evaluating clinical signs to differentially diagnose laminitis from other causes of lameness. Improved evaluation of the clinical signs displayed by laminitic animals examined by first-opinion practitioners will lead to equine welfare improvements. PMID:26969668

  13. Attitudes of Oncologists, Oncology Nurses, and Patients from a Women's Clinic Regarding Medical Decision Making for Older and Younger Breast Cancer Patients.

    ERIC Educational Resources Information Center

    Beisecker, Analee E.; And Others

    1994-01-01

    Administered Beisecker Locus of Authority in Decision Making: Breast Cancer survey to 67 oncologists, 94 oncology nurses, and 288 patients from women's clinic. All groups believed that physicians should have dominant role in decision making. Nurses felt that patients should have more input than patients or physicians felt they should. Physicians…

  14. Construction of a Clinical Decision Support System for Undergoing Surgery Based on Domain Ontology and Rules Reasoning

    PubMed Central

    Bau, Cho-Tsan; Huang, Chung-Yi

    2014-01-01

    Abstract Objective: To construct a clinical decision support system (CDSS) for undergoing surgery based on domain ontology and rules reasoning in the setting of hospitalized diabetic patients. Materials and Methods: The ontology was created with a modified ontology development method, including specification and conceptualization, formalization, implementation, and evaluation and maintenance. The Protégé–Web Ontology Language editor was used to implement the ontology. Embedded clinical knowledge was elicited to complement the domain ontology with formal concept analysis. The decision rules were translated into JENA format, which JENA can use to infer recommendations based on patient clinical situations. Results: The ontology includes 31 classes and 13 properties, plus 38 JENA rules that were built to generate recommendations. The evaluation studies confirmed the correctness of the ontology, acceptance of recommendations, satisfaction with the system, and usefulness of the ontology for glycemic management of diabetic patients undergoing surgery, especially for domain experts. Conclusions: The contribution of this research is to set up an evidence-based hybrid ontology and an evaluation method for CDSS. The system can help clinicians to achieve inpatient glycemic control in diabetic patients undergoing surgery while avoiding hypoglycemia. PMID:24730353

  15. A Clinical Decision Support System for Integrating Tuberculosis and HIV Care in Kenya: A Human-Centered Design Approach

    PubMed Central

    Catalani, Caricia; Green, Eric; Owiti, Philip; Keny, Aggrey; Diero, Lameck; Yeung, Ada; Israelski, Dennis; Biondich, Paul

    2014-01-01

    With the aim of integrating HIV and tuberculosis care in rural Kenya, a team of researchers, clinicians, and technologists used the human-centered design approach to facilitate design, development, and deployment processes of new patient-specific TB clinical decision support system for medical providers. In Kenya, approximately 1.6 million people are living with HIV and have a 20-times higher risk of dying of tuberculosis. Although tuberculosis prevention and treatment medication is widely available, proven to save lives, and prioritized by the World Health Organization, ensuring that it reaches the most vulnerable communities remains challenging. Human-centered design, used in the fields of industrial design and information technology for decades, is an approach to improving the effectiveness and impact of innovations that has been scarcely used in the health field. Using this approach, our team followed a 3-step process, involving mixed methods assessment to (1) understand the situation through the collection and analysis of site observation sessions and key informant interviews; (2) develop a new clinical decision support system through iterative prototyping, end-user engagement, and usability testing; and, (3) implement and evaluate the system across 24 clinics in rural West Kenya. Through the application of this approach, we found that human-centered design facilitated the process of digital innovation in a complex and resource-constrained context. PMID:25170939

  16. EULAR report on the use of ultrasonography in painful knee osteoarthritis. Part 2: Exploring decision rules for clinical utility

    PubMed Central

    Conaghan, P; D'Agostino, M; Ravaud, P; Baron, G; Le Bars, M; Grassi, W; Martin-Mola, E; Wakefield, R; Brasseur, J; So, A; Backhaus, M; Malaise, M; Burmester, G; Schmidely, N; Emery, P; Dougados, M

    2005-01-01

    Background: Synovial inflammation (as defined by hypertrophy and effusion) is common in osteoarthritis (OA) and may be important in both pain and structural progression. Objective: To determine if decision rules can be devised from clinical findings and ultrasonography (US) to allow recognition of synovial inflammation in patients with painful knee OA. Methods: A EULAR-ESCISIT cross sectional, multicentre study enrolled subjects with painful OA knee who had clinical, radiographic, and US evaluations. A classification and regression tree (CART) analysis was performed to find combinations of predictor variables that would provide high sensitivity and specificity for clinically detecting synovitis and effusion in individual subjects. A range of definitions for the two key US variables, synovitis and effusion (using different combinations of synovial thickness, depth, and appearance), were also included in exploratory analyses. Results: 600 patients with knee OA were included in the analysis. For both knee synovitis and joint effusion, the sensitivity and specificity were poor, yielding unsatisfactory likelihood ratios (75% sensitivity, 45% specificity, and positive LR of 1.36 for knee synovitis; 71.6% sensitivity, 43.2% specificity, and positive LR of 1.26 for joint effusion). The exploratory analyses did not improve the sensitivity and specificity (demonstrating positive LRs of between 1.26 and 1.57). Conclusion: Although it is possible to determine clinical and radiological predictors of OA inflammation in populations, CART analysis could not be used to devise useful clinical decision rules for an individual subject. Thus sensitive imaging techniques such as US remain the most useful tool for demonstrating synovial inflammation of the knee at the individual level. PMID:15878902

  17. Using SNOMED CT Expression Constraints to Bridge the Gap Between Clinical Decision-Support Systems and Electronic Health Records.

    PubMed

    Martínez-Salvador, Begoña; Marcos, Mar; Mañas, Alejandro; Maldonado, José Alberto; Robles, Monserrat

    2016-01-01

    Clinical decision-support systems (CDSSs) should be able to interact with the electronic health record (EHR) to obtain the patient data they require. A recent solution for the interoperability of CDSSs and EHR systems consists in the use of a mediated schema which provides a unified view of their two schemas. The use of such a mediated schema requires the definition of a mapping between this schema and the EHR one. In this paper we investigate the use of the SNOMED CT Expression Constraint Language to characterize these mappings. PMID:27577434

  18. Clinical decision-making for coronal caries management in the permanent dentition.

    PubMed

    Anusavice, K

    2001-10-01

    Optimal conservative treatment decisions to prevent, arrest, and reverse tooth demineralization caused by caries require probability estimates on caries risk and treatment outcomes. This review is focused on the use of the best scientific evidence to recommend treatment strategies for management of coronal caries in permanent teeth as a function of caries risk. Evidence suggests that assigning therapeutic regimens to individuals according to their risk levels should yield a significantly greater probability of success and better cost effectiveness than applying identical treatments to all patients independent of risk. Depending on caries risk levels, treatment decisions based on risk can minimize unnecessary surgical intervention by incorporating the best evidence to prescribe treatment regimens for the use of fluoride-releasing agents, sealants, chlorhexidine, or combinations of these products. PMID:11699991

  19. Shared Surgical Decision Making and Youth Resilience Correlates of Satisfaction With Clinical Outcomes.

    PubMed

    Kapp-Simon, Kathleen A; Edwards, Todd; Ruta, Caroline; Bellucci, Claudia Crilly; Aspirnall, Cassandra L; Strauss, Ronald P; Topolski, Tari D; Rumsey, Nichola J; Patrick, Donald L

    2015-07-01

    The aim of this study was to identify factors associated with youth satisfaction with surgical procedures performed to address oral cleft or craniofacial conditions (CFCs). It was hypothesized that youth mental health, participation in decision making, perceived consequences of living with a CFC, and coping strategies would be associated with satisfaction with past surgeries. A total of 203 youth between the ages of 11 and 18 years (mean age = 14.5, standard deviation = 2.0, 61% male participants, 78% oral cleft) completed a series of questionnaires measuring depression, self-esteem, participation in decision making, condition severity, negative and positive consequences of having a CFC, coping, and satisfaction with past surgeries. Multiple regression analysis using boot-strapping techniques found that youth participation in decision making, youth perception of positive consequences of having a CFC, and coping accounted for 32% of the variance in satisfaction with past surgeries (P < 0.001). Youth age, sex, and assessment of condition severity were not significantly associated with satisfaction with surgical outcome. Depression, self-esteem, and negative consequences of having a CFC were not associated with satisfaction with past surgeries. Youth should be actively involved in the decision for craniofacial surgery. Youth who were more satisfied with their surgical outcomes also viewed themselves as having gained from the experience of living with a CFC. They felt that having a CFC made them stronger people and they believed that they were more accepting of others and more in touch with others' feelings because of what they had been through. PMID:26114527

  20. Marfan syndrome and the evolving spectrum of heritable thoracic aortic disease: do we need genetics for clinical decisions?

    PubMed

    von Kodolitsch, Y; Rybczynski, M; Bernhardt, A; Mir, T S; Treede, H; Dodge-Khatami, A; Robinson, P N; Sheikhzadeh, S; Reichenspurner, H; Meinertz, T

    2010-02-01

    Marfan syndrome (MFS) is a disorder of the connective tissue that is inherited in an autosomal dominant fashion and that is classically caused by mutations in the gene coding for fibrillin-1, FBN1. The high mortality of untreated MFS results almost exclusively from aortic complications such as aortic dissection and rupture. However, more than half of patients with Marfan-like features do not have MFS, but have other diseases including inherited aortic aneurysms and dissections (TAAD). We elucidate the increasing spectrum of syndromes associated with Marfan-like features and discuss the clinical implications of these diseases. We performed a systematic review to tabulate all known inherited diseases and syndromes carrying a risk for thoracic aortic disease. We discuss evidence that different syndromes with different causative genes and mutations have different prognoses and profiles of cardiovascular manifestations. We conclude that future decisions for optimized management of patients with inherited TAAD require a comprehensive clinical and genetic work-up. PMID:20186673