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1.  Beyond information retrieval and electronic health record use: competencies in clinical informatics for medical education 
Physicians in the 21st century will increasingly interact in diverse ways with information systems, requiring competence in many aspects of clinical informatics. In recent years, many medical school curricula have added content in information retrieval (search) and basic use of the electronic health record. However, this omits the growing number of other ways that physicians are interacting with information that includes activities such as clinical decision support, quality measurement and improvement, personal health records, telemedicine, and personalized medicine. We describe a process whereby six faculty members representing different perspectives came together to define competencies in clinical informatics for a curriculum transformation process occurring at Oregon Health & Science University. From the broad competencies, we also developed specific learning objectives and milestones, an implementation schedule, and mapping to general competency domains. We present our work to encourage debate and refinement as well as facilitate evaluation in this area.
Video abstract
doi:10.2147/AMEP.S63903
PMCID: PMC4085140  PMID: 25057246
curriculum transformation; clinical decision support; patient safety; health care quality; patient engagement
2.  Comparison of Antibiograms Developed for Inpatients and Primary Care Outpatients 
To support antimicrobial stewardship, some healthcare systems have begun creating outpatient antibiograms. We developed inpatient and primary care outpatient antibiograms for a regional health maintenance organization (HMO) and academic healthcare system (AHS). Antimicrobial susceptibilities from 16,428 Enterococcus, Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa cultures from 2010 were summarized and compared. Methicillin susceptibility among S. aureus was similar in inpatients and primary care outpatients (HMO: 61.2% vs. 61.9%, p=0.951; AHS: 62.9% vs. 63.3%, p>0.999). E. coli susceptibility to trimethoprim/sulfamethoxazole was also similar (HMO: 81.8% vs. 83.6%, p=0.328; AHS: 77.2% vs. 80.9%, p=0.192), but ciprofloxacin susceptibility differed (HMO: 88.9% vs. 94.6%, p<0.001; AHS: 81.2% vs. 90.6%, p<0.001). In the HMO, ciprofloxacin-susceptible P. aeruginosa were more frequent in primary care outpatients than inpatients (91.4% vs. 79.0%, p=0.007). Comparison of cumulative susceptibilities across settings yielded no consistent patterns; therefore, outpatient primary care antibiograms may more accurately inform prudent empiric antibiotic prescribing.
doi:10.1016/j.diagmicrobio.2013.01.026
PMCID: PMC3658613  PMID: 23541690
infectious disease; bacterial resistance; pharmacy practice; ambulatory; antimicrobial stewardship
3.  Perceptions of Shared Decision Making and Decision Aids Among Rural Primary Care Clinicians 
Background
Shared Decision Making (SDM) and Decision Aids (DAs) increase patients’ involvement in healthcare decisions and enhance satisfaction with their choices. Studies of SDM and DAs have primarily occurred in academic centers and large health systems, but most primary care is delivered in smaller practices and over 20% of Americans live in rural areas where poverty, disease prevalence and limited access to care may increase the need for SDM and DAs.
Objective
To explore perceptions and practices of rural primary care clinicians regarding SDM and DAs.
Design
Cross sectional survey.
Setting and Participants
Primary care clinicians affiliated with the Oregon Rural Practice-based Research Network (ORPRN).
Results
Surveys were returned by 181 of 231 eligible participants (78%), 174 could be analyzed. Two-thirds of participants were physicians, 84% practiced family medicine, and 55% were male. Sixty five percent of respondents were unfamiliar with the term “SDM”, but following definition, 97% reported they found the approach useful for conditions with multiple treatment options. Over 90% of clinicians perceived helping patients make decisions regarding chronic pain and health behavior change as moderate/hard in difficulty. Although 69% of respondents preferred that patients play an equal role in making decisions, they estimate this happens only 35% of the time. Time was reported as the largest barrier to engaging in SDM (63%). Respondents were receptive to using DAs to facilitate SDM in printed (95%) or web-based formats (72%) and topic preference varied by clinician specialty and decision difficulty.
Conclusions
Rural clinicians recognized the value of SDM and were receptive to using DAs in multiple formats. Integration of DAs to facilitate SDM in routine patient care may require addressing practice operation and reimbursement.
doi:10.1177/0272989X11431961
PMCID: PMC3665512  PMID: 22247423
Primary Care; Translating Research Into Practice; Shared Decision Making – Decision Aid Tools; Decision Aids – Decision Aid Tools; Survey Methods – Statistical Methods
4.  Tiering Drug–Drug Interaction Alerts by Severity Increases Compliance Rates 
Objective
Few data exist measuring the effect of differentiating drug–drug interaction (DDI) alerts in computerized provider order entry systems (CPOE) by level of severity (“tiering”). We sought to determine if rates of provider compliance with DDI alerts in the inpatient setting differed when a tiered presentation was implemented.
Design
We performed a retrospective analysis of alert log data on hospitalized patients at two academic medical centers during the period from 2/1/2004 through 2/1/2005. Both inpatient CPOE systems used the same DDI checking service, but one displayed alerts differentially by severity level (tiered presentation, including hard stops for the most severe alerts) while the other did not. Participants were adult inpatients who generated a DDI alert, and providers who wrote the orders. Alerts were presented during the order entry process, providing the clinician with the opportunity to change the patient's medication orders to avoid the interaction.
Measurements
Rate of compliance to alerts at a tiered site compared to a non-tiered site.
Results
We reviewed 71,350 alerts, of which 39,474 occurred at the non-tiered site and 31,876 at the tiered site. Compliance with DDI alerts was significantly higher at the site with tiered DDI alerts compared to the non-tiered site (29% vs. 10%, p < 0.001). At the tiered site, 100% of the most severe alerts were accepted, vs. only 34% at the non-tiered site; moderately severe alerts were also more likely to be accepted at the tiered site (29% vs. 10%).
Conclusion
Tiered alerting by severity was associated with higher compliance rates of DDI alerts in the inpatient setting, and lack of tiering was associated with a high override rate of more severe alerts.
doi:10.1197/jamia.M2808
PMCID: PMC2605599  PMID: 18952941
5.  Advancing Biomedical Image Retrieval: Development and Analysis of a Test Collection 
Objective
Develop and analyze results from an image retrieval test collection.
Methods
After participating research groups obtained and assessed results from their systems in the image retrieval task of Cross-Language Evaluation Forum, we assessed the results for common themes and trends. In addition to overall performance, results were analyzed on the basis of topic categories (those most amenable to visual, textual, or mixed approaches) and run categories (those employing queries entered by automated or manual means as well as those using visual, textual, or mixed indexing and retrieval methods). We also assessed results on the different topics and compared the impact of duplicate relevance judgments.
Results
A total of 13 research groups participated. Analysis was limited to the best run submitted by each group in each run category. The best results were obtained by systems that combined visual and textual methods. There was substantial variation in performance across topics. Systems employing textual methods were more resilient to visually oriented topics than those using visual methods were to textually oriented topics. The primary performance measure of mean average precision (MAP) was not necessarily associated with other measures, including those possibly more pertinent to real users, such as precision at 10 or 30 images.
Conclusions
We developed a test collection amenable to assessing visual and textual methods for image retrieval. Future work must focus on how varying topic and run types affect retrieval performance. Users' studies also are necessary to determine the best measures for evaluating the efficacy of image retrieval systems.
doi:10.1197/jamia.M2082
PMCID: PMC1561788  PMID: 16799124
6.  Impacts of Computerized Physician Documentation in a Teaching Hospital: Perceptions of Faculty and Resident Physicians 
Objective: Computerized physician documentation (CPD) has been implemented throughout the nation's Veterans Affairs Medical Centers (VAMCs) and is likely to increasingly replace handwritten documentation in other institutions. The use of this technology may affect educational and clinical activities, yet little has been reported in this regard. The authors conducted a qualitative study to determine the perceived impacts of CPD among faculty and housestaff in a VAMC.
Design: A cross-sectional study was conducted using semistructured interviews with faculty (n = 10) and a group interview with residents (n = 10) at a VAMC teaching hospital.
Measurements: Content analysis of field notes and taped transcripts were done by two independent reviewers using a grounded theory approach. Findings were validated using member checking and peer debriefing.
Results: Four major themes were identified: (1) improved availability of documentation; (2) changes in work processes and communication; (3) alterations in document structure and content; and (4) mistakes, concerns, and decreased confidence in the data. With a few exceptions, subjects felt documentation was more available, with benefits for education and patient care. Other impacts of CPD were largely seen as detrimental to aspects of clinical practice and education, including documentation quality, workflow, professional communication, and patient care.
Conclusion: CPD is perceived to have substantial positive and negative impacts on clinical and educational activities and environments. Care should be taken when designing, implementing, and using such systems to avoid or minimize any harmful impacts. More research is needed to assess the extent of the impacts identified and to determine the best strategies to effectively deal with them.
doi:10.1197/jamia.M1525
PMCID: PMC436079  PMID: 15064287
7.  Computerized Physician Order Entry in U.S. Hospitals: Results of a 2002 Survey 
Objective: To determine the availability of inpatient computerized physician order entry in U.S. hospitals and the degree to which physicians are using it.
Design: Combined mail and telephone survey of 964 randomly selected hospitals, contrasting 2002 data and results of a survey conducted in 1997.
Measurements: Availability: computerized order entry has been installed and is available for use by physicians; inducement: the degree to which use of computers to enter orders is required of physicians; participation: the proportion of physicians at an institution who enter orders by computer; and saturation: the proportion of total orders at an institution entered by a physician using a computer.
Results: The response rate was 65%. Computerized order entry was not available to physicians at 524 (83.7%) of 626 hospitals responding, whereas 60 (9.6%) reported complete availability and 41 (6.5%) reported partial availability. Of 91 hospitals providing data about inducement/requirement to use the system, it was optional at 31 (34.1%), encouraged at 18 (19.8%), and required at 42 (46.2%). At 36 hospitals (45.6%), more than 90% of physicians on staff use the system, whereas six (7.6%) reported 51–90% participation and 37 (46.8%) reported participation by fewer than half of physicians. Saturation was bimodal, with 25 (35%) hospitals reporting that more than 90% of all orders are entered by physicians using a computer and 20 (28.2%) reporting that less than 10% of all orders are entered this way.
Conclusion: Despite increasing consensus about the desirability of computerized physician order entry (CPOE) use, these data indicate that only 9.6% of U.S. hospitals presently have CPOE completely available. In those hospitals that have CPOE, its use is frequently required. In approximately half of those hospitals, more than 90% of physicians use CPOE; in one-third of them, more than 90% of orders are entered via CPOE.
doi:10.1197/jamia.M1427
PMCID: PMC353025  PMID: 14633935
8.  Usability Testing of a Digital Pen and Paper System in Nursing Documentation 
Usability testing was used to evaluate whether a new technology, a digital pen and paper system, would be usable for hospital nurses. Twenty-one nurses in a Labor and Delivery unit were randomly assigned into two groups, and a crossover design was used to compare the digital pen and paper system to conventional pens. Data collection included observations, interviews, and a questionnaire. Results showed that nurses had a positive attitude toward the system and could foresee its potential benefits, but they found that in its current design the system had poor usability and interfered with nurses’ work practices. Usability testing provided important insight into the needs of nurses and the suitability of this technology. This study is an example of how a user-centered approach can improve our understanding of the real needs of nurses and contribute to the design of useful and usable technologies for healthcare.
PMCID: PMC1560675  PMID: 16779159
9.  A Cross-site Qualitative Study of Physician Order Entry 
Objective: To describe the perceptions of diverse professionals involved in computerized physician order entry (POE) at sites where POE has been successfully implemented and to identify differences between teaching and nonteaching hospitals.
Design: A multidisciplinary team used observation, focus groups, and interviews with clinical, administrative, and information technology staff to gather data at three sites. Field notes and transcripts were coded using an inductive approach to identify patterns and themes in the data.
Measurements: Patterns and themes concerning perceptions of POE were identified.
Results: Four high-level themes were identified: (1) organizational issues such as collaboration, pride, culture, power, politics, and control; (2) clinical and professional issues involving adaptation to local practices, preferences, and policies; (3) technical/implementation issues, including usability, time, training and support; and (4) issues related to the organization of information and knowledge, such as system rigidity and integration. Relevant differences between teaching and nonteaching hospitals include extent of collaboration, staff longevity, and organizational missions.
Conclusion: An organizational culture characterized by collaboration and trust and an ongoing process that includes active clinician engagement in adaptation of the technology were important elements in successful implementation of physician order entry at the institutions that we studied.
doi:10.1197/jamia.M770
PMCID: PMC150372  PMID: 12595408
11.  Using medication list--problem list mismatches as markers of potential error. 
The goal of this project was to specify and develop an algorithm that will check for drug and problem list mismatches in an electronic medical record (EMR). The algorithm is based on the premise that a patient's problem list and medication list should agree, and a mismatch may indicate medication error. Successful development of this algorithm could mean detection of some errors, such as medication orders entered into a wrong patient record, or drug therapy omissions, that are not otherwise detected via automated means. Additionally, mismatches may identify opportunities to improve problem list integrity. To assess the concept's feasibility, this study compared medications listed in a pharmacy information system with findings in an online nursing adult admission assessment, serving as a proxy for the problem list. Where drug and problem list mismatches were discovered, examination of the patient record confirmed the mismatch, and identified any potential causes. Evaluation of the algorithm in diabetes treatment indicates that it successfully detects both potential medication error and opportunities to improve problem list completeness. This algorithm, once fully developed and deployed, could prove a valuable way to improve the patient problem list, and could decrease the risk of medication error.
PMCID: PMC2244138  PMID: 12463796
14.  A taxonomy of generic clinical questions: classification study 
BMJ : British Medical Journal  2000;321(7258):429-432.
Objective
To develop a taxonomy of doctors' questions about patient care that could be used to help answer such questions.
Design
Use of 295 questions asked by Oregon primary care doctors to modify previously developed taxonomy of 1101 clinical questions asked by Iowa family doctors.
Setting
Primary care practices in Iowa and Oregon.
Participants
Random samples of 103 Iowa family doctors and 49 Oregon primary care doctors.
Main outcome measures
Consensus among seven investigators on a meaningful taxonomy of generic questions; interrater reliability among 11 individuals who used the taxonomy to classify a random sample of 100 questions: 50 from Iowa and 50 from Oregon.
Results
The revised taxonomy, which comprised 64 generic question types, was used to classify 1396 clinical questions. The three commonest generic types were “What is the drug of choice for condition x?” (150 questions, 11%); “What is the cause of symptom x?” (115 questions, 8%); and “What test is indicated in situation x?” (112 questions, 8%). The mean interrater reliability among 11 coders was moderate (κ=0.53, agreement 55%).
Conclusions
Clinical questions in primary care can be categorised into a limited number of generic types. A moderate degree of interrater reliability was achieved with the taxonomy developed in this study. The taxonomy may enhance our understanding of doctors' information needs and improve our ability to meet those needs.
PMCID: PMC27459  PMID: 10938054

Results 1-14 (14)