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1.  Clinical decision support: progress and opportunities 
In 2005, the American Medical Informatics Association undertook a set of activities relating to clinical decision support (CDS), with support from the office of the national coordinator and the Agency for Healthcare Research and Quality. They culminated in the release of the roadmap for national action on CDS in 2006. This article assesses progress toward the short-term goals within the roadmap, and recommends activities to continue to improve CDS adoption throughout the United States. The report finds that considerable progress has been made in the past four years, although significant work remains. Healthcare quality organizations are increasingly recognizing the role of health information technology in improving care, multi-site CDS demonstration projects are under way, and there are growing incentives for adoption. Specific recommendations include: (1) designating a national entity to coordinate CDS work and collaboration; (2) developing approaches to monitor and track CDS adoption and use; (3) defining and funding a CDS research agenda; and (4) updating the CDS ‘critical path’.
PMCID: PMC2995690  PMID: 20819850
Participating in self-assessment activities may stimulate improvement in practice behaviors. However, it is unclear how best to support the development of self-assessment skills, particularly in the health care domain. Exploration of population-based data is one method to enable health care providers to identify deficiencies in overall practice behavior that can motivate quality improvement initiatives. At the University of Virginia, we are developing a decision support tool to integrate and present population-based patient data to health care providers related to both clinical outcomes and non-clinical measures (e.g., demographic information). By enabling users to separate their direct impact on clinical outcomes from other factors out of their control, we may enhance the self-assessment process.
PMCID: PMC3161497  PMID: 21874123
3.  Development of a Web-based Resident Profiling Tool to Support Training in Practice-based Learning and Improvement 
Multiple factors are driving residency programs to explicitly address practice-based learning and improvement (PBLI), yet few information systems exist to facilitate such training. We developed, implemented, and evaluated a Web-based tool that provides Internal Medicine residents at the University of Virginia Health System with population-based reports about their ambulatory clinical experiences. Residents use Systems and Practice Analysis for Resident Competencies (SPARC) to identify potential areas for practice improvement. Thirty-three (65%) of 51 residents completed a survey assessing SPARC’s usefulness, with 94% agreeing that it was a useful educational tool. Twenty-six residents (51%) completed a before–after study indicating increased agreement (5-point Likert scale, with 5=strongly agree) with statements regarding confidence in ability to access population-based data about chronic disease management (mean [SD] 2.5 [1.2] vs. 4.5 [0.5], p < .001, sign test) and information comparing their practice style to that of their peers (2.2 [1.2] vs. 4.6 [0.5], p < .001).
PMCID: PMC2359524  PMID: 18373150
practice-based learning and improvement; medical education; databases; quality improvement; information technology
4.  Updated Review of Blood Culture Contamination 
Clinical Microbiology Reviews  2006;19(4):788-802.
Blood culture contamination represents an ongoing source of frustration for clinicians and microbiologists alike. Ambiguous culture results often lead to diagnostic uncertainty in clinical management and are associated with increased health care costs due to unnecessary treatment and testing. A variety of strategies have been investigated and employed to decrease contamination rates. In addition, numerous approaches to increase our ability to distinguish between clinically significant bacteremia and contamination have been explored. In recent years, there has been an increase in the application of computer-based tools to support infection control activities as well as provide clinical decision support related to the management of infectious diseases. Finally, new approaches for estimating bacteremia risk which have the potential to decrease unnecessary blood culture utilization have been developed and evaluated. In this review, we provide an overview of blood culture contamination and describe the potential utility of a variety of approaches to improve both detection and prevention. While it is clear that progress is being made, fundamental challenges remain.
PMCID: PMC1592696  PMID: 17041144
5.  Impact of a Web-based Diagnosis Reminder System on Errors of Diagnosis 
A large number of medical errors can be attributed to errors in diagnosis. A diagnosis reminder system such as Isabel may lessen the risk of diagnostic error by providing a checklist of possible diagnoses. For this project, resident physicians used Isabel to work through a set of six simulated patient cases. The system had a positive effect on the mean diagnostic quality score and the number of clinically important diagnoses included in the differential.
PMCID: PMC1839669  PMID: 17238463
7.  Comorbid disease and the effect of race and ethnicity on in-hospital mortality from aspiration pneumonia. 
BACKGROUND: Racial and ethnic disparities in mortality have been demonstrated in several diseases. African Americans are hospitalized at a significantly higher rate than whites for aspiration pneumonia; however, no studies have investigated racial and ethnic disparities in mortality in this population. OBJECTIVE: To assess the independent effect of race and ethnicity on in-hospital mortality among aspiration pneumonia discharges while comprehensively controlling for comorbid diseases, and to assess whether the prevalence and effects of comorbid illness differed across racial and ethnic categories. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 41,581 patients admitted to California hospitals for aspiration pneumonia from 1996 through 1998, using principal and secondary diagnoses present on admission. MEASUREMENT: The primary outcome measure was in-hospital mortality. RESULTS: The adjusted odds of in-hospital death for African-American compared with white discharges [odds ratio (OR)=1.01; 95% confidence interval (CI), 0.91-1.11] was not significantly different. The odds of death for Asian compared with white discharges was significantly lower (OR=0.83; 95% CI, 0.75-0.91). Hispanics had a significantly lower odds of death (OR=0.90; 95% CI, 0.82-0.988) compared to non-Hispanics. Comorbid diseases were more prevalent among African Americans and Asians than whites, and among Hispanics compared to non-Hispanics. Differences in effects of comorbid disease on mortality risk by race and ethnicity were not statistically significant. CONCLUSION: Asians have a lower risk of death, and the risk of death for African Americans is not significantly different from whites in this analysis of aspiration pneumonia discharges. Hispanics have a lower risk of death than non-Hispanics. While there are differences in prevalence of comorbid disease by racial and ethnic category, the effects of comorbid disease on mortality risk do not differ meaningfully by race or ethnicity.
PMCID: PMC2568617  PMID: 15586650
8.  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.
PMCID: PMC150372  PMID: 12595408
9.  Improving Quality Measurement using Multiple Data Sources 
We calculated a sample of AHRQ Quality and Patient Safety Indicators for UVa hospitalized patients over a 3 year period using diagnoses and procedure codes from two different billing systems. Significant differences in results were observed suggesting that quality indicators calculated from hospital billing sources alone may be understated.
PMCID: PMC1480352  PMID: 14728504
10.  Mapping From a Clinical Data Warehouse to the HL7 Reference Information Model 
Large-scale data integration efforts to support clinical and biologic research are greatly facilitated by the adoption of standards for the representation and exchange of data. As part of a larger project to design the necessary architecture for multi-institutional sharing of disparate biomedical data, we explored the potential of the HL7 Reference Information Model (RIM) for representing the data stored in a local academic clinical data warehouse. A necessary first step in information exchange with such a warehouse is the development and utilization of tools for transforming between local data schemas and standards-based conceptual data models. We describe our initial efforts at mapping clinical concepts from a relational data warehouse to the HL7 RIM.
PMCID: PMC1480241  PMID: 14728426
11.  Introducing an academic data warehouse into the undergraduate medical curriculum. 
There is increasing interest in integrating population health and informatics topics into the undergraduate medical curriculum, yet little consensus exists on the most effective approach to accomplish this. We introduced the use of an academic data warehouse of encrypted patient information into an existing 2nd year medical school course. Exercises were developed requiring students to retrieve and interpret information regarding local disease prevalence, practice patterns, and patient characteristics. These exercises were integrated into existing weekly problem sets in a multiple-choice format. Faculty and student perceptions were assessed with surveys, and augmented with interviews of student volunteers, and database usage statistics. Our results indicate widespread agreement among both students and faculty that population-based medicine warrants inclusion in undergraduate medical education. The majority of the students felt the exercises complemented the clinical cases around which they were structured. There was less agreement, however, that the exercises were valuable, with several students suggesting a more open-ended, discussion-oriented approach. It was clear that faculty perceptions had a significant impact on student reactions.
PMCID: PMC2244483  PMID: 12463869
14.  The Resident Assessment Performance System (RAPS): User-centered Design for a Web-based Tool 
The aim of the Resident Assessment Performance System (RAPS) project is to develop a web-based tool that would use routinely collected clinical data to evaluate a residents experience and performance. To ensure the tools usefulness and before any actual programming is done, it is essential to have an understanding of the stakeholders' needs and desires. Thus, our initial effort was a needs analysis, structured around specific individuals and themes. The results were combined with pilot data to develop draft screens that were reviewed by residents and educators to illustrate how resident profiling might improve the quality of resident training.
PMCID: PMC2243552
15.  Use of a Clinical Data Warehouse to Supplement Undergraduate Medical Education 
In order to introduce medical students to the increasingly important concepts of population-based medicine and information management, we recently modified the curriculum of a first-year medical student course to include the use of a clinical data warehouse to supplement more traditional information resources. Students were asked to use a World-Wide-Web-based database of encrypted patient information to answer questions about different clinical topics, including alcoholism, heart failure, and reactive airways disease. Topics were chosen to correlate with lectures and instruction of physical exam techniques.
PMCID: PMC2243365

Results 1-17 (17)