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1.  The VA Computerized Patient Record — A First Look 
In support of its in-house DHCP Physician Order Entry/Results Reporting application, the VA is developing the first edition of a Computerized Patient Record. The system will feature a physician-oriented interface with real time, expert system-based order checking, a controlled vocabulary, a longitudinal repository of patient data, HL7 messaging support, a clinical reminder and warning system, and full integration with existing VA applications including lab, pharmacy, A/D/T, radiology, dietetics, surgery, vitals, allergy tracking, discharge summary, problem list, progress notes, consults, and online physician order entry.
PMCID: PMC2247783  PMID: 7949886
2.  PROMPT for COSTAR—A Clinical Reminder System 
The PROMPT reminder system was developed to enable physicians to write their own computerized reminders to assist them in ambulatory care. PROMPT is a public domain module for the COSTAR medical information system. Patients are enrolled in site-specific clinical protocols created by practitioners using interactive routines. Reminders of tests to be ordered or actions to be taken are printed at clinic visits and at times between visits if previously specified by the clinician. Clinical data and instructions for reminder control are fed back into the system for future use. PROMPT reminders can function even if the COSTAR records module is not used to replace paper medical records. The system is currently being evaluated in five practices.
PMCID: PMC2245618
3.  Use of reminders to increase compliance with tetanus booster vaccination. 
OBJECTIVE: To assess the effect of three computerized reminder systems on compliance with tetanus vaccination. DESIGN: Prospective randomized controlled trial. SETTING: Ottawa Civic Hospital Family Medicine Centre. PARTICIPANTS: Of 8069 patients 20 years of age or more who were not in a hospital or institution 5589 were randomly assigned, by family, to a control group, a physician reminder group, a telephone reminder group or a letter reminder group. The remaining 2480 patients were not included in the randomized portion of the study but were monitored. Results are presented for the 5242 randomized patients and the 2369 nonrandomized patients for whom there was no up-to-date record of tetanus vaccination at the start of the trial. INTERVENTIONS: For the patients in the physician reminder group the physician was reminded at an office visit to assess the patient's tetanus vaccination status and to recommend vaccination; those in the other two reminder groups received a telephone call or letter enquiring about their tetanus vaccination status and recommending a booster dose. MAIN OUTCOME MEASURE: Proportion of patients who received tetanus toxoid during the study year or who had a claim of vaccination in the previous 10 years. MAIN RESULTS: The rate of recorded tetanus vaccination in the randomized control group was 3.2%. The difference between that rate and those for the three reminder groups was 19.6% in the physician reminder group (95% confidence interval [CI] 17.1% to 22.2%, p less than 0.00001), 20.8% in the telephone reminder group (95% CI 18.3% to 23.5%, p less than 0.00001) and 27.4% in the letter reminder group (95% CI 24.8% to 30.2%, p less than 0.00001)). The letter reminders were more effective than either the telephone reminders (p = 0.00013) or the physician reminders (p less than 0.00001) in improving compliance. The cost to the practice per additional vaccination recorded was 43 for the physician reminders, $5.43 for the telephone reminders and $6.05 for the letter reminders. CONCLUSIONS: Although all three reminder systems increased the rate of recorded tetanus vaccination they fell far short of achieving complete population coverage. More intensive interventions would be required to approach that goal. However, such interventions do not appear to be justified given the rarity of tetanus.
PMCID: PMC1488617  PMID: 1544078
4.  Usability evaluation of the progress note construction set. 
OVERVIEW: The Veterans Administration (VA) Computerized Patient Record System (CPRS) is a nationally deployed software product that integrates provider order entry, progress notes, vitals, consults, discharge summaries, problem lists, medications, labs, radiology, transcribed documents, study reports, and clinical reminders. Users rapidly adopted the graphical user interface for data retrieval, but demanded options to typing for data entry. We programmed "point and click" forms that integrate with CPRS individually, but were soon overwhelmed by requests. Subsequently, we developed the Progress Note Construction Set (PNCS); a tool suite that permits subject matter experts without programming skills to create reusable "point and click" forms. In this study, we evaluate the usability of these user-constructed forms. METHODS: An untrained, non-VA subject matter expert used the PNCS to create a graphical form for "skin tear" documentation. Ten VA nurses used the skin tear form to document findings for 7 standardized clinical scenarios. Following each scenario the subjects answered usability questions about the form. RESULTS: The subject matter expert created the skin tear form in 78 minutes. Users found the form to facilitate their data entry (p 0.0265), and to be at least as fast (p 0.0029) and as easy to use as expected (p 0.0166). Average note entry time was 3.4 minutes. CONCLUSION: The PNCS allowed a non-programmer to quickly create a usable, CPRS-integrated point and click form. Users found the subject matter expert s form fast and easy to use. The tool suite is a more scaleable form creation method because capacity is no longer limited by programmer availability.
PMCID: PMC2243587  PMID: 11825158
5.  A Computerized Pneumococcal Vaccination Reminder System in the Adult Emergency Department 
Vaccine  2011;29(40):7035-7041.
Pneumococcal vaccination is an effective strategy to prevent invasive pneumococcal disease in the elderly. Emergency Department (ED) visits present an underutilized opportunity to increase vaccination rates; however, designing a sustainable vaccination program in an ED is challenging. We examined whether an information technology supported approach would provide a feasible and sustainable method to increase vaccination rates in an adult ED.
During a 1-year period we prospectively evaluated a team-oriented, workflow-embedded reminder system that integrated four different information systems. The computerized triage application screened all patients 65 years and older for pneumococcal vaccine eligibility with information from the electronic patient record. For eligible patients the computerized provider order entry system reminded clinicians to place a vaccination order, which was passed to the order tracking application. Documentation of vaccine administration was then added to the longitudinal electronic patient record. The primary outcome was the vaccine administration rate in the ED.
Multivariate logistic regression analysis was used to estimate the odds ratios and their 95% confidence intervals, representing the overall relative risks of ED workload related variables associated with vaccination rate.
Among 3,371 patients 65 years old and older screened at triage 1,309 (38.8%) were up-to-date with pneumococcal vaccination and 2,062 (61.2%) were eligible for vaccination. Of the eligible patients, 621 (30.1%) consented to receive the vaccination during their ED visit. Physicians received prompts for 428 (68.9%) patients. When prompted, physicians declined to order the vaccine in 192 (30.9%) patients, while 222 (10.8%) of eligible patients actually received the vaccine. The computerized reminder system increased vaccination rate from a baseline of 38.8% to 45.4%. Vaccination during the ED visit was associated younger age (OR: 0.972, CI: 0.953–0.991), Caucasian race (OR: 0.329, CI: 0.241–0.448), and longer ED boarding times (OR: 1.039, CI: 1.013–1.065).
The integrated informatics solution seems to be a feasible and sustainable model to increase vaccination rates in a challenging ED environment.
PMCID: PMC3168965  PMID: 21784117
Reminder Systems; Medical Informatics; Pneumococcal Vaccines; Emergency Service; Hospital
6.  An Integrated Computerized Triage System in the Emergency Department 
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 medication reconciliation application. The application includes decision support capabilities such as assessing the patient’s acuity level, age-dependent alerts for vital signs, and clinical reminders. The browser-based system utilizes the institution’s 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 >290,000 pediatric and adult patients.
PMCID: PMC2656061  PMID: 18999190
7.  Point-of-Care International Normalized Ratio (INR) Monitoring Devices for Patients on Long-term Oral Anticoagulation Therapy 
Executive Summary
Subject of the Evidence-Based Analysis
The purpose of this evidence based analysis report is to examine the safety and effectiveness of point-of-care (POC) international normalized ratio (INR) monitoring devices for patients on long-term oral anticoagulation therapy (OAT).
Clinical Need: Target Population and Condition
Long-term OAT is typically required by patients with mechanical heart valves, chronic atrial fibrillation, venous thromboembolism, myocardial infarction, stroke, and/or peripheral arterial occlusion. It is estimated that approximately 1% of the population receives anticoagulation treatment and, by applying this value to Ontario, there are an estimated 132,000 patients on OAT in the province, a figure that is expected to increase with the aging population.
Patients on OAT are regularly monitored and their medications adjusted to ensure that their INR scores remain in the therapeutic range. This can be challenging due to the narrow therapeutic window of warfarin and variation in individual responses. Optimal INR scores depend on the underlying indication for treatment and patient level characteristics, but for most patients the therapeutic range is an INR score of between 2.0 and 3.0.
The current standard of care in Ontario for patients on long-term OAT is laboratory-based INR determination with management carried out by primary care physicians or anticoagulation clinics (ACCs). Patients also regularly visit a hospital or community-based facility to provide a venous blood samples (venipuncture) that are then sent to a laboratory for INR analysis.
Experts, however, have commented that there may be under-utilization of OAT due to patient factors, physician factors, or regional practice variations and that sub-optimal patient management may also occur. There is currently no population-based Ontario data to permit the assessment of patient care, but recent systematic reviews have estimated that less that 50% of patients receive OAT on a routine basis and that patients are in the therapeutic range only 64% of the time.
Overview of POC INR Devices
POC INR devices offer an alternative to laboratory-based testing and venipuncture, enabling INR determination from a fingerstick sample of whole blood. Independent evaluations have shown POC devices to have an acceptable level of precision. They permit INR results to be determined immediately, allowing for more rapid medication adjustments.
POC devices can be used in a variety of settings including physician offices, ACCs, long-term care facilities, pharmacies, or by the patients themselves through self-testing (PST) or self-management (PSM) techniques. With PST, patients measure their INR values and then contact their physician for instructions on dose adjustment, whereas with PSM, patients adjust the medication themselves based on pre-set algorithms. These models are not suitable for all patients and require the identification and education of suitable candidates.
Potential advantages of POC devices include improved convenience to patients, better treatment compliance and satisfaction, more frequent monitoring and fewer thromboembolic and hemorrhagic complications. Potential disadvantages of the device include the tendency to underestimate high INR values and overestimate low INR values, low thromboplastin sensitivity, inability to calculate a mean normal PT, and errors in INR determination in patients with antiphospholipid antibodies with certain instruments. Although treatment satisfaction and quality of life (QoL) may improve with POC INR monitoring, some patients may experience increased anxiety or preoccupation with their disease with these strategies.
Evidence-Based Analysis Methods
Research Questions
1. Effectiveness
Does POC INR monitoring improve clinical outcomes in various settings compared to standard laboratory-based testing?
Does POC INR monitoring impact patient satisfaction, QoL, compliance, acceptability, convenience compared to standard laboratory-based INR determination?
Settings include primary care settings with use of POC INR devices by general practitioners or nurses, ACCs, pharmacies, long-term care homes, and use by the patient either for PST or PSM.
2. Cost-effectiveness
What is the cost-effectiveness of POC INR monitoring devices in various settings compared to standard laboratory-based INR determination?
Inclusion Criteria
English-language RCTs, systematic reviews, and meta-analyses
Publication dates: 1996 to November 25, 2008
Population: patients on OAT
Intervention: anticoagulation monitoring by POC INR device in any setting including anticoagulation clinic, primary care (general practitioner or nurse), pharmacy, long-term care facility, PST, PSM or any other POC INR strategy
Minimum sample size: 50 patients Minimum follow-up period: 3 months
Comparator: usual care defined as venipuncture blood draw for an INR laboratory test and management provided by an ACC or individual practitioner
Outcomes: Hemorrhagic events, thromboembolic events, all-cause mortality, anticoagulation control as assessed by proportion of time or values in the therapeutic range, patient reported outcomes including satisfaction, QoL, compliance, acceptability, convenience
Exclusion criteria
Non-RCTs, before-after studies, quasi-experimental studies, observational studies, case reports, case series, editorials, letters, non-systematic reviews, conference proceedings, abstracts, non-English articles, duplicate publications
Studies where POC INR devices were compared to laboratory testing to assess test accuracy
Studies where the POC INR results were not used to guide patient management
Method of Review
A search of electronic databases (OVID MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library, and the International Agency for Health Technology Assessment [INAHTA] database) was undertaken to identify evidence published from January 1, 1998 to November 25, 2008. Studies meeting the inclusion criteria were selected from the search results. Reference lists of selected articles were also checked for relevant studies.
Summary of Findings
Five existing reviews and 22 articles describing 17 unique RCTs met the inclusion criteria. Three RCTs examined POC INR monitoring devices with PST strategies, 11 RCTs examined PSM strategies, one RCT included both PST and PSM strategies and two RCTs examined the use of POC INR monitoring devices by health care professionals.
Anticoagulation Control
Anticoagulation control is measured by the percentage of time INR is within the therapeutic range or by the percentage of INR values in the therapeutic range. Due to the differing methodologies and reporting structures used, it was deemed inappropriate to combine the data and estimate whether the difference between groups would be significant. Instead, the results of individual studies were weighted by the number of person-years of observation and then pooled to calculate a summary measure.
Across most studies, patients in the intervention groups tended to have a higher percentage of time and values in the therapeutic target range in comparison to control patients. When the percentage of time in the therapeutic range was pooled across studies and weighted by the number of person-years of observation, the difference between the intervention and control groups was 4.2% for PSM, 7.2% for PST and 6.1% for POC use by health care practitioners. Overall, intervention patients were in the target range 69% of the time and control patients were in the therapeutic target range 64% of the time leading to an overall difference between groups of roughly 5%.
Major Complications and Deaths
There was no statistically significant difference in the number of major hemorrhagic events between patients managed with POC INR monitoring devices and patients managed with standard laboratory testing (OR =0.74; 95% CI: 0.52- 1.04). This difference was non-significant for all POC strategies (PSM, PST, health care practitioner).
Patients managed with POC INR monitoring devices had significantly fewer thromboembolic events than usual care patients (OR =0.52; 95% CI: 0.37 - 0.74). When divided by POC strategy, PSM resulted in significantly fewer thromboembolic events than usual care (OR =0.46.; 95% CI: 0.29 - 0.72). The observed difference in thromboembolic events for PSM remained significant when the analysis was limited to major thromboembolic events (OR =0.40; 95% CI: 0.17 - 0.93), but was non-significant when the analysis was limited to minor thromboembolic events (OR =0.73; 95% CI: 0.08 - 7.01). PST and GP/Nurse strategies did not result in significant differences in thromboembolic events, however there were only a limited number of studies examining these interventions.
No statistically significant difference was observed in the number of deaths between POC intervention and usual care control groups (OR =0.67; 95% CI: 0.41 - 1.10). This difference was non-significant for all POC strategies. Only one study reported on survival with 10-year survival rate of 76.1% in the usual care control group compared to 84.5% in the PSM group (P=0.05).
Summary Results of Meta-Analyses of Major Complications and Deaths in POC INR Monitoring Studies
Patient Satisfaction and Quality of Life
Quality of life measures were reported in eight studies comparing POC INR monitoring to standard laboratory testing using a variety of measurement tools. It was thus not possible to calculate a quantitative summary measure. The majority of studies reported favourable impacts of POC INR monitoring on QoL and found better treatment satisfaction with POC monitoring. Results from a pre-analysis patient and caregiver focus group conducted in Ontario also indicated improved patient QoL with POC monitoring.
Quality of the Evidence
Studies varied with regard to patient eligibility, baseline patient characteristics, follow-up duration, and withdrawal rates. Differential drop-out rates were observed such that the POC intervention groups tended to have a larger number of patients who withdrew. There was a lack of consistency in the definitions and reporting for OAT control and definitions of adverse events. In most studies, the intervention group received more education on the use of warfarin and performed more frequent INR testing, which may have overestimated the effect of the POC intervention. Patient selection and eligibility criteria were not always fully described and it is likely that the majority of the PST/PSM trials included a highly motivated patient population. Lastly, a large number of trials were also sponsored by industry.
Despite the observed heterogeneity among studies, there was a general consensus in findings that POC INR monitoring devices have beneficial impacts on the risk of thromboembolic events, anticoagulation control and patient satisfaction and QoL (ES Table 2).
GRADE Quality of the Evidence on POC INR Monitoring Studies
CI refers to confidence interval; Interv, intervention; OR, odds ratio; RCT, randomized controlled trial.
Economic Analysis
Using a 5-year Markov model, the health and economic outcomes associated with four different anticoagulation management approaches were evaluated:
Standard care: consisting of a laboratory test with a venipuncture blood draw for an INR;
Healthcare staff testing: consisting of a test with a POC INR device in a medical clinic comprised of healthcare staff such as pharmacists, nurses, and physicians following protocol to manage OAT;
PST: patient self-testing using a POC INR device and phoning in results to an ACC or family physician; and
PSM: patient self-managing using a POC INR device and self-adjustment of OAT according to a standardized protocol. Patients may also phone in to a medical office for guidance.
The primary analytic perspective was that of the MOHLTC. Only direct medical costs were considered and the time horizon of the model was five years - the serviceable life of a POC device.
From the results of the economic analysis, it was found that POC strategies are cost-effective compared to traditional INR laboratory testing. In particular, the healthcare staff testing strategy can derive potential cost savings from the use of one device for multiple patients. The PSM strategy, however, seems to be the most cost-effective method i.e. patients are more inclined to adjust their INRs more readily (as opposed to allowing INRs to fall out of range).
Considerations for Ontario Health System
Although the use of POC devices continues to diffuse throughout Ontario, not all OAT patients are suitable or have the ability to practice PST/PSM. The use of POC is currently concentrated at the institutional setting, including hospitals, ACCs, long-term care facilities, physician offices and pharmacies, and is much less commonly used at the patient level. It is, however, estimated that 24% of OAT patients (representing approximately 32,000 patients in Ontario), would be suitable candidates for PST/PSM strategies and willing to use a POC device.
There are several barriers to the use and implementation of POC INR monitoring devices, including factors such as lack of physician familiarity with the devices, resistance to changing established laboratory-based methods, lack of an approach for identifying suitable patients and inadequate resources for effective patient education and training. Issues of cost and insufficient reimbursement strategies may also hinder implementation and effective quality assurance programs would need to be developed to ensure that INR measurements are accurate and precise.
For a select group of patients who are highly motivated and trained, PSM resulted in significantly fewer thromboembolic events compared to conventional laboratory-based INR testing. No significant differences were observed for major hemorrhages or all-cause mortality. PST and GP/Nurse use of POC strategies are just as effective as conventional laboratory-based INR testing for thromboembolic events, major hemorrhages, and all-cause mortality. POC strategies may also result in better OAT control as measured by the proportion of time INR is in the therapeutic range and there appears to be beneficial impacts on patient satisfaction and QoL. The use of POC devices should factor in patient suitability, patient education and training, health system constraints, and affordability.
anticoagulants, International Normalized Ratio, point-of-care, self-monitoring, warfarin.
PMCID: PMC3377545  PMID: 23074516
8.  Effect of an interactive voice response system on oral anticoagulant management 
Monitoring oral anticoagulants is logistically challenging for both patients and medical staff. We evaluated the effect of adding an interactive voice response system to computerized decision support for oral anticoagulant management.
We developed an interactive voice response system to communicate to patients the results of international normalized ratio testing and their dosage schedules for anticoagulation therapy. The system also reminded patients of upcoming and missed appointments for blood tests. We recruited patients whose anticoagulation control was stable after at least 3 months of warfarin therapy. We prospectively examined clinical data and outcomes for these patients for an intervention period of at least 3 months. We also collected retrospective data for each patient for the 3 months before study enrolment.
We recruited 226 patients between Nov. 23, 2006, and Aug. 1, 2007. The mean duration of the intervention period (prospective data collection) was 4.2 months. Anticoagulation control was similar for the periods during and preceding the intervention (mean time within the therapeutic range 80.3%, 95% confidence interval [CI] 77.5% to 83.1% v. 79.9%, 95% CI 77.3% to 82.6%). The interactive voice response system delivered 1211 (77.8%) of 1557 scheduled dosage messages, with no further input required from clinic staff. The most common reason for clinic staff having to deliver the remaining messages (accounting for 143 [9.2%] of all messages) was an international normalized ratio that was excessively high or low, (i.e., 0.5 or more outside the therapeutic range). When given the option, 76.6% of patients (164/214) chose to continue with the interactive voice response system for management of their anticoagulation after the study was completed. The system reduced staff workload for monitoring anticoagulation therapy by 48 min/wk, a 33% reduction from the baseline of 2.4 hours.
Interactive voice response systems have a potential role in improving the monitoring of patients taking oral anticoagulants. Further work is required to determine the generalizability and cost-effectiveness of these results.
PMCID: PMC2670905  PMID: 19398739
9.  Computerized Reminders to Improve Isolation Rates of Patients with Drug-Resistant Infections: Design and Preliminary Results 
Infections with multi-drug resistant organisms (MDROs) are a steadily increasing threat to inpatients as they move through the hospital. We constructed a computerized reminder system, integrated with existing data sources maintained by the infection control service. We tested the hypothesis that computerized reminders from a centralized infection control expert system can improve rates of barrier isolation in patients with MDROs. Immediately after institution of this reminder system, isolation of eligible ward patients increased from a baseline rate of 33% to 95% (p<0.0001). The median time to isolation decreased from 16.6 hours to 0 hours, indicating that the majority of patients post-intervention had isolation orders written prior to arrival on the ward. We conclude that a computerized reminder system can dramatically increase the clinical impact of data sources maintained by hospital Infection Control services.
PMCID: PMC1560469  PMID: 16779068
10.  Effects of automated alerts on unnecessarily repeated serology tests in a cardiovascular surgery department: a time series analysis 
Laboratory testing is frequently unnecessary, particularly repetitive testing. Among the interventions proposed to reduce unnecessary testing, Computerized Decision Support Systems (CDSS) have been shown to be effective, but their impact depends on their technical characteristics. The objective of the study was to evaluate the impact of a Serology-CDSS providing point of care reminders of previous existing serology results, embedded in a Computerized Physician Order Entry at a university teaching hospital in Paris, France.
A CDSS was implemented in the Cardiovascular Surgery department of the hospital in order to decrease inappropriate repetitions of viral serology tests (HBV).
A time series analysis was performed to assess the impact of the alert on physicians' practices. The study took place between January 2004 and December 2007. The primary outcome was the proportion of unnecessarily repeated HBs antigen tests over the periods of the study. A test was considered unnecessary when it was ordered within 90 days after a previous test for the same patient. A secondary outcome was the proportion of potentially unnecessary HBs antigen test orders cancelled after an alert display.
In the pre-intervention period, 3,480 viral serology tests were ordered, of which 538 (15.5%) were unnecessarily repeated. During the intervention period, of the 2,095 HBs antigen tests performed, 330 unnecessary repetitions (15.8%) were observed. Before the intervention, the mean proportion of unnecessarily repeated HBs antigen tests increased by 0.4% per month (absolute increase, 95% CI 0.2% to 0.6%, p < 0.001). After the intervention, a significant trend change occurred, with a monthly difference estimated at -0.4% (95% CI -0.7% to -0.1%, p = 0.02) resulting in a stable proportion of unnecessarily repeated HBs antigen tests. A total of 380 unnecessary tests were ordered among 500 alerts displayed (compliance rate 24%).
The proportion of unnecessarily repeated tests immediately dropped after CDSS implementation and remained stable, contrasting with the significant continuous increase observed before. The compliance rate confirmed the effect of the alerts. It is necessary to continue experimentation with dedicated systems in order to improve understanding of the diversity of CDSS and their impact on clinical practice.
PMCID: PMC2848138  PMID: 20298618
11.  Use of reminders for preventive procedures in family medicine. 
OBJECTIVE: To compare the effectiveness of three computerized reminder systems in the delivery of five preventive procedures in family practice. DESIGN: Prospective, randomized, controlled study. SETTING: Ottawa Civic Hospital Family Medicine Centre. PARTICIPANTS: Of 8502 patients 15 years of age or more who were not in a hospital or institution 5883 were randomly assigned, by family, to a control group, a physician reminder group (passive) or a telephone or letter reminder group (active). The remaining 2619 patients were not included in the randomized portion of the study but were monitored. INTERVENTION: During 1 year the patients in the active reminder groups received a telephone call or letter reminding them of any overdue preventive procedures; for those in the passive reminder group the physician was reminded at an office visit to provide any overdue service. OUTCOME MEASURE: Rates of completion of the preventive procedures required. MAIN RESULTS: All three reminder systems significantly improved the delivery of preventive services (p less than 0.001). The procedure completion rates were 42.0% in the letter reminder group, 42.0% in the telephone reminder group, 33.7% in the physician reminder group and 14.1% in the randomized control group. The use of a letter was more cost-effective than the telephone system, but the physician reminder system was the most cost-effective. CONCLUSION: Computerized reminder systems do improve the delivery of preventive services in family practice.
PMCID: PMC1335900  PMID: 1913409
12.  A Randomized Trial of Electronic Clinical Reminders to Improve Quality of Care for Diabetes and Coronary Artery Disease 
Objective: The aim of this study was to evaluate the impact of an integrated patient-specific electronic clinical reminder system on diabetes and coronary artery disease (CAD) care and to assess physician attitudes toward this reminder system.
Design: We enrolled 194 primary care physicians caring for 4549 patients with diabetes and 2199 patients with CAD at 20 ambulatory clinics. Clinics were randomized so that physicians received either evidence-based electronic reminders within their patients' electronic medical record or usual care. There were five reminders for diabetes care and four reminders for CAD care.
Measurements: The primary outcome was receipt of recommended care for diabetes and CAD. We created a summary outcome to assess the odds of increased compliance with overall diabetes care (based on five measures) and overall CAD care (based on four measures). We surveyed physicians to assess attitudes toward the reminder system.
Results: Baseline adherence rates to all quality measures were low. While electronic reminders increased the odds of recommended diabetes care (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.01–1.67) and CAD (OR 1.25, 95% CI 1.01–1.55), the impact of individual reminders was variable. A total of three of nine reminders effectively increased rates of recommended care for diabetes or CAD. The majority of physicians (76%) thought that reminders improved quality of care.
Conclusion: An integrated electronic reminder system resulted in variable improvement in care for diabetes and CAD. These improvements were often limited and quality gaps persist.
PMCID: PMC1174888  PMID: 15802479
13.  Associations between the concurrent use of clinical decision support and computerized provider order entry and the rates of appropriate prescribing at discharge 
Applied Clinical Informatics  2012;3(2):186-196.
Electronic health record systems used in conjunction with clinical decision support (CDS) or computerized provider order entry (CPOE) have shown potential in improving quality of care, yet less is known about the effects of combination use of CDS and CPOE on prescribing rates at discharge.
This study investigates the effectiveness of combination use of CDS and CPOE on appropriate drug prescribing rates at discharge for AMI or HF patients.
Combination use of CDS and CPOE is defined as hospitals self-reporting full implementation across all hospital units of CDS reminders, CDS guidelines, and CPOE. Appropriate prescribing rates of aspirin, ACEI/ARBs, or beta blockers are defined using quality measures from Hospital Compare. Multivariate linear regressions are used to test for differences in mean appropriate prescribing rates between hospitals reporting combination use of CDS and CPOE, compared to those reporting the singular use of one or the other, or the absence of both. Covariates include hospital size, region, and ownership status.
Approximately 10% of the sample reported full implementation of both CDS and CPOE, while 7% and 17% reported full use of only CPOE or only CDS, respectively. Hospitals reporting full use of CDS only reported between 0.2% (95% CI 0.04 – 1.0) and 1.6% (95% CI 0.6 – 2.6) higher appropriate prescribing rates compared to hospitals reporting use of neither system. Rates of prescribing by hospitals reporting full use of both CPOE and CDS did not significantly differ from the control group.
Although associations found between full implementation of CDS and appropriate prescribing rates suggest that clinical decision tools are sufficient compared to basic EHR systems in improving prescribing at discharge, the modest differences raise doubt about the clinical relevance of the findings. Future studies need to continue investigating the causal nature and clinical relevance of these associations.
PMCID: PMC3613019  PMID: 23646071
Electronic health records and systems; clinical decision support; inpatient computerized provider order entry; medication management; guidelines and protocols; quantitative methodologies
14.  Comparing the quality of oral anticoagulant management by anticoagulation clinics and by family physicians: a randomized controlled trial 
There is growing evidence that better outcomes are achieved when anticoagulation is managed by anticoagulation clinics rather than by family physicians. We carried out a randomized controlled trial to evaluate these 2 models of anticoagulant care.
We randomly allocated patients who were expected to require warfarin sodium for 3 months either to anticoagulation clinics located in 3 Canadian tertiary hospitals or to their family physician practices. We evaluated the quality of oral anticoagulant management by comparing the proportion of time that the international normalized ratio (INR) of patients receiving warfarin sodium was within the target therapeutic range ± 0.2 INR units (expanded therapeutic range) while they were managed in anticoagulation clinics as opposed to family physicians' care over 3 months. We measured the rates of thromboembolic and major hemorrhagic events and patient satisfaction in the 2 groups.
Of the 221 patients enrolled, 112 were randomly assigned to anticoagulation clinics and 109 to family physicians. The INR values of patients who were managed by anticoagulation clinics were within the expanded therapeutic range 82% of the time versus 76% of the time for those managed by family physicians (p = 0.034). High-risk INR values (defined as being < 1.5 or > 5.0) were more commonly observed in patients managed by family physicians (40%) than in patients managed by anticoagulation clinics (30%, p = 0.005). More INR measurements were performed by family physicians than by anticoagulation clinics (13 v. 11, p = 0.001). Major bleeding events (2 [2%] v. 1 [1%]), thromboembolic events (1 [1%] v. 2 [2%]) and deaths (5 [4%] v. 6 [6%]) occurred at a similar frequency in the anticoagulation clinic and family physician groups respectively. Of the 170 (77%) patients who completed the patient satisfaction questionnaire, more were satisfied when their anticoagulant management was managed through anticoagulation clinics than by their family physicians (p = 0.001).
Anticoagulation clinics provided better oral anticoagulant management than family physicians, but the differences were relatively modest.
PMCID: PMC180652  PMID: 12925422
15.  Implementation and Evaluation of a Computerized Reminder System in Ambulatory Care 
We have developed and are testing computerized reminders for providers to determine whether automated systems can improve patient care in ambulatory settings. The reminder system is based on stepwise clinical protocols, and is entirely controlled by the provider. It does not require clinic use of computerized medical records. A randomized controlled trial will assess provider compliance with protocols, detection of serious pathology, and volume of service usage. Preliminary findings suggest that providers who receive reminders to work up a low hematocrit are more likely to order appropriate diagnostic tests than those not receiving reminders. Incremental costs for implementation of a reminder system are consistent with expenses for other new computer services at the study site. Provider use of the system varies greatly.
PMCID: PMC2245305
16.  Information technology and medication safety: what is the benefit? 
Quality & safety in health care  2002;11(3):261-265.

 Medication errors occur frequently and have significant clinical and financial consequences. Several types of information technologies can be used to decrease rates of medication errors. Computerized physician order entry with decision support significantly reduces serious inpatient medication error rates in adults. Other available information technologies that may prove effective for inpatients include computerized medication administration records, robots, automated pharmacy systems, bar coding, "smart" intravenous devices, and computerized discharge prescriptions and instructions. In outpatients, computerization of prescribing and patient oriented approaches such as personalized web pages and delivery of web based information may be important. Public and private mandates for information technology interventions are growing, but further development, application, evaluation, and dissemination are required.
PMCID: PMC1743646  PMID: 12486992
17.  Countrywide Computer Alerts to Community Physicians Improve Potassium Testing in Patients Receiving Diuretics 
More than 20% of approximately 35,000 patients filling a diuretic prescription had no potassium blood test recorded within the previous year. A laboratory reporting system used throughout Israel by Maccabi Healthcare Services physicians was modified to provide physician alerts regarding potassium testing. The physicians were experienced users of a computerized medical record (CMR) that provided online laboratory test results. A nightly batch file checked pharmacy diuretic purchases against the patient's potassium blood test status. On-screen computer-generated reminders were sent to physicians of patients lacking a recent potassium test. Reminders to clinicians increased potassium testing by 9.8% (p < 0.001). Physician age and gender played a small part in predicting compliance to the alert, but specialty and practice size did not. The time delay between the date a reminder was sent and the potassium test date decreased steadily during the intervention. The success of this reminder system encourages expansion to include more drug–laboratory interactions. Furthermore, direct alerts to patients at multiple organization/patient contact points are planned.
PMCID: PMC264431  PMID: 12925546
18.  Clinical Information System Post-Adoption Evaluation at the Georges Pompidou University Hospital 
The evaluation of a clinical information system (CIS) at different stages of deployment and routine use is a key factor to improve acceptability and use by health professionals. This paper examines on an expectation-confirmation model (ITPAM) the relationships between the determinants of success of a CIS in a cross-sectional survey performed at the Georges Pompidou University Hospital (HEGP). Results for the groups of physicians and nurses that replied to the survey (n=312) suggest that health professional satisfaction (overall R2=0.60) is determined by the quality of user support (r=.21, p=<0001), ease of use (r=.19, p=<0001), confirmation of expectations (r=.15, p=.0037), usefulness (r=.12, p=.0068), and compatibility (r=.10, p=.0206). The best predictor of physician satisfaction (R2=0.71) was compatibility (r=.21, p=.0072) whereas for nurses (R2=0.52) it was user support (r=.22, p=<0001) and ease of use (r=.22, p=.0001). Confirmation of expectations had an impact on post-adoption expectation and user’s satisfaction, and confirms its importance for CIS evaluation studies.
PMCID: PMC3041336  PMID: 21347045
19.  Computerized Reminders Reduce the Use of Medications during Shortages 
Medication shortages pose serious problems in health care. This study examines the impact of a computer-based reminder in addressing a national methylprednisolone shortage. An alert was designed and implemented in a computerized order entry platform at a children's hospital. The alert informed physicians of the shortage and provided an alternative prescribing pathway. Data regarding the number and type of parenteral corticosteroid prescriptions were collected for a one-month period before and after the alert was implemented. The alert resulted in a 55% relative reduction in methylprednisolone use and an average reduction of more than three orders each day. Dexamethasone and hydrocortisone, the recommended alternative medications, increased in use by 12% and 49%, respectively. The alert resulted in a $36,552 annualized cost reduction to the institution. Similar alert applications have great potential for effectively altering physician prescribing behavior.
PMCID: PMC436075  PMID: 15064285
20.  Pharmacokinetic and pharmacodynamic variability of fluindione in octogenarians 
In the PREPA observational study, we investigated the factors influencing pharmacokinetic and pharmacodynamic variability in the response to fluindione, an oral anticoagulant drug, in a general population of octogenarians inpatients.
Measurements of fluindione concentrations and INR (International Normalised Ratio) were obtained from 131 inpatients initiating fluindione treatment. Treatment was adjusted according to routine clinical practice. The data was analysed using non-linear mixed effect models, and the parameters were estimated using MONOLIX 3.2.
The pharmacokinetics of fluindione was monocompartmental, while the evolution of INR was modelled according to a turnover model (inhibition of vitamin K recycling). Interindividual variability was very large. Clearance decreased with age and with prior administration of cordarone. Patients who underwent surgery before the study had lower IC50, leading to an increased sensitivity to fluindione.
Pharmacokinetic exposure is substantially increased in elderly patients, warranting a lower dose of fluindione.
PMCID: PMC3789273  PMID: 22472992
Aged; Aged, 80 and over; Anticoagulants; pharmacokinetics; pharmacology; Female; Humans; International Normalized Ratio; Male; Phenindione; analogs & derivatives; pharmacokinetics; pharmacology; fluindione; antivitamin K; oral anticoagulant; elderly; pharmacokinetics; pharmacodynamics; International Normalised Ratio (INR)
21.  A computer-generated reminder system improves physician compliance with diabetes preventive care guidelines. 
Computerized reminder systems have been shown to be effective in improving physician compliance with preventive services guidelines. Very little has been published about the use of computerized reminders for preventive care in diabetes. We implemented a computer-generated reminder system for diabetes care guidelines in a randomized controlled study in the outpatient clinics of 35 internal medicine residents at the University of Utah and Salt Lake Veterans Affairs Hospitals. After a six month study period, compliance with the recommended care significantly improved in both the intervention group that received patient-specific reminders about the guidelines (38.0% at baseline, 54.9% at follow-up) and the control group that received a nonspecific report (34.6% at baseline, 51.0% at follow-up). There was no significant difference between the two groups. Both clinic sites showed similar improvement over baseline levels of compliance. Residents who completed encounter forms used by the system showed a significantly greater improvement in compliance than those who did not complete encounter forms (19.7% vs. 7.6%, p = 0.006). The improvements in guideline compliance were seen in all areas of diabetes preventive care studied, and significant improvements were seen with recommended items from the medical history, physical exam, laboratory testing, referrals, and patient education. The use of encounter forms by the providers significantly improved documented compliance with the guidelines in almost all categories of preventive care. These results suggest that computerized reminder systems improve compliance with recommended care more by facilitating the documentation of clinical findings and the ordering of recommended procedures than by providing the clinician with patient-specific information about guideline compliance status. Further study is needed to understand the implications of these findings to the development of future computerized reminder systems for chronic diseases such as diabetes.
PMCID: PMC2579172  PMID: 8563365
22.  Evaluation of computer-generated reminders to improve CD4 laboratory monitoring in sub-Saharan Africa: a prospective comparative study 
Little evidence exists on effective interventions to integrate HIV-care guidelines into practices within developing countries. This study tested the hypothesis that clinical summaries with computer-generated reminders could improve clinicians' compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa.
A prospective comparative study of two randomly selected outpatient adult HIV clinics in western Kenya. Printed summaries with reminders for overdue CD4 tests were made available to clinicians in the intervention clinic but not in the control clinic.
Changes in order rates for overdue CD4 tests were compared between and within the two clinics.
The computerized reminder system identified 717 encounters (21%) with overdue CD4 tests. Analysis by study assignment (regardless of summaries being printed or not) revealed that with computer-generated reminders, CD4 order rates were significantly higher in the intervention clinic compared to the control clinic (53% vs 38%, OR=1.80, CI 1.34 to 2.42, p<0.0001). When comparison was restricted to encounters where summaries with reminders were printed, order rates in intervention clinic were even higher (63%). The intervention clinic increased CD4 ordering from 42% before reminders to 63% with reminders (50% increase, OR=2.32, CI 1.67 to 3.22, p<0.0001), compared to control clinic with only 8% increase from prestudy baseline (CI 0.83 to 1.46, p=0.51).
Evaluation was conducted at two clinics in a single institution.
Clinical summaries with computer-generated reminders significantly improved clinician compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa. This technology can have broad applicability to improve quality of HIV care in these settings.
PMCID: PMC3116261  PMID: 21252053
23.  Improving Sedative-Hypnotic Prescribing in Older Hospitalized Patients: Provider-Perceived Benefits and Barriers of a Computer-Based Reminder 
Journal of General Internal Medicine  2007;23(Suppl 1):32-36.
Older adults are commonly prescribed sedative-hypnotic (SH) medications when hospitalized, yet these drugs are associated with important adverse effects such as falls and delirium.
To identify provider-perceived benefits or barriers of a computer-based reminder regarding appropriate use of SH medications.
Qualitative study using semi-structured interviews.
Participants and setting
Thirty-six house staff physicians at a university hospital.
Information was collected regarding the experiences of prescribing an SH using a computer order entry system with a reminder intervention. Clinicians were asked about their perceptions of the reminder and what they found most and least useful about it. Responses were analyzed using grounded theory methodology.
The 36 participants (including 29 interns) had prescribed an SH medication for a hospitalized patient over age 65 years. Three themes associated with benefits of a computer reminder were identified: increasing awareness of safety, including risk of delirium, falls, and general patient safety risks; usefulness of information technology; and the value of the educational content, including geriatric pharmacology review and nonpharmacologic treatment options. Barriers included the demands of the reminder with regard to time needed to read the reminder, the role of clinician experience with regard to preserving clinical autonomy, and the information content of the reminder, including its being too basic or not relevant for a particular patient. The mean satisfaction rating for the reminder was 8.5 (±0.9 SD), with 10 indicating high satisfaction.
Improving decision support systems involves an understanding of how clinicians respond to real-time strategies encouraging better prescribing.
PMCID: PMC2150640  PMID: 18095041
point-of-care systems; medical order entry systems; sedatives and hypnotics; aged; computers
24.  Improving Sedative-Hypnotic Prescribing in Older Hospitalized Patients: Provider-Perceived Benefits and Barriers of a Computer-Based Reminder 
Journal of General Internal Medicine  2007;23(Suppl 1):32-36.
Older adults are commonly prescribed sedative-hypnotic (SH) medications when hospitalized, yet these drugs are associated with important adverse effects such as falls and delirium.
To identify provider-perceived benefits or barriers of a computer-based reminder regarding appropriate use of SH medications.
Qualitative study using semi-structured interviews.
Participants and setting
Thirty-six house staff physicians at a university hospital.
Information was collected regarding the experiences of prescribing an SH using a computer order entry system with a reminder intervention. Clinicians were asked about their perceptions of the reminder and what they found most and least useful about it. Responses were analyzed using grounded theory methodology.
The 36 participants (including 29 interns) had prescribed an SH medication for a hospitalized patient over age 65 years. Three themes associated with benefits of a computer reminder were identified: increasing awareness of safety, including risk of delirium, falls, and general patient safety risks; usefulness of information technology; and the value of the educational content, including geriatric pharmacology review and nonpharmacologic treatment options. Barriers included the demands of the reminder with regard to time needed to read the reminder, the role of clinician experience with regard to preserving clinical autonomy, and the information content of the reminder, including its being too basic or not relevant for a particular patient. The mean satisfaction rating for the reminder was 8.5 (±0.9 SD), with 10 indicating high satisfaction.
Improving decision support systems involves an understanding of how clinicians respond to real-time strategies encouraging better prescribing.
PMCID: PMC2150640  PMID: 18095041
point-of-care systems; medical order entry systems; sedatives and hypnotics; aged; computers
25.  The effect of computer-based reminders on the management of hospitalized patients with worsening renal function. 
We performed a prospective time-series study to determine whether computerized reminders to physicians about rising creatinine levels in hospitalized patients receiving nephrotoxic and renally excreted medications led to more rapid adjustment or discontinuation of those medications, and to evaluate physician acceptance of computerized reminders. Laboratory data were followed on 10,076 patients over 13,703 admissions generating 1104 events of rising creatinine levels during treatment with nephrotoxic or renally excreted medications. During the intervention period, medications were adjusted or discontinued an average of 21.1 hours sooner (p less than 0.0001) after such an event occurred when compared with the control period. This effect of the reminders was strongest for patients receiving renally excreted and mildly nephrotoxic medications. Of physicians who responded to a computerized survey, 53% said that the reminders had been helpful in the care of their patients, while 31% felt that the reminders were annoying. Seventy-three percent wished to continue receiving computerized reminders. We conclude that computerized reminders are well-accepted in our hospital and have a strong effect on physician behavior.
PMCID: PMC2247489  PMID: 1807605

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