Clinical Knowledge Management Research Articles

Clinical knowledge management at the point of care

Clinical knowledge management at the point of care

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

ObjectiveExamine 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...

Use of UpToDate and outcomes in US hospitals

Computerized clinical knowledge mana-gement systems hold enormous potential for improving quality and efficiency. However, their impact on clinical practice is not well known. To examine the impact of UpToDate on outcomes of care. Retrospective study. National sample of US inpatient hospitals. Fee-for-service Medicare beneficiaries. Adoption of UpToDate in US hospitals. Risk-adjusted lengths of stay, mortality rates, and quality performance. We found that patients admitted to hospitals using UpToDate had shorter lengths of stay than patients admitted to non-UpToDate hospitals overall (5.6 days vs 5.7 days; P < 0.001) and among 6 prespecified conditions (range, -0.1 to -0.3 days; P < 0.001 for each). Further, patients admitted to UpToDate hospitals had lower risk-adjusted mortality rate for 3 of the 6 conditions (range, -0.1% to -0.6% mortality reduction; P < 0.05). Finally, hospitals with UpToDate had better quality performance for every condition on the Hospital Quality Alliance metrics. In subgroup analyses, we found that it was the smaller hospitals and the non-teaching hospitals where the benefits of the UpToDate seemed most pronounced, compared to the larger, teaching institutions where the benefits of UpToDate seemed small or nonexistent. We found a very small but consistent association between use of UpToDate and reduced length of stay, lower risk-adjusted mortality rates, and better quality performance, at least in the smaller, non-teaching institutions. These findings may suggest that computerized tools such as UpToDate could be helpful in improving care.

Comparison of clinical knowledge management capabilities of commercially-available and leading internally-developed electronic health records

BackgroundWe have carried out an extensive qualitative research program focused on the barriers and facilitators to successful adoption and use of various features of advanced, state-of-the-art electronic health records (EHRs) within large, academic, teaching facilities with long-standing EHR research and development programs. We have recently begun investigating smaller, community hospitals and out-patient clinics that rely on commercially-available EHRs. We sought to assess whether the current generation of commercially-available EHRs are capable of providing the clinical knowledge management features, functions, tools, and techniques required to deliver and maintain the clinical decision support (CDS) interventions required to support the recently defined "meaningful use" criteria.MethodsWe developed and fielded a 17-question survey to representatives from nine commercially available EHR vendors and four leading internally developed EHRs. The first part of the survey asked basic questions about the vendor's EHR. The second part asked specifically about the CDS-related system tools and capabilities that each vendor provides. The final section asked about clinical content.ResultsAll of the vendors and institutions have multiple modules capable of providing clinical decision support interventions to clinicians. The majority of the systems were capable of performing almost all of the key knowledge management functions we identified.ConclusionIf these well-designed commercially-available systems are coupled with the other key socio-technical concepts required for safe and effective EHR implementation and use, and organizations have access to implementable clinical knowledge, we expect that the transformation of the healthcare enterprise that so many have predicted, is achievable using commercially-available, state-of-the-art EHRs.

Information Systems and Healthcare XXXIV: Clinical Knowledge Management Systems—Literature Review and Research Issues for Information Systems

Knowledge Management (KM) has emerged as a possible solution to many of the challenges facing U.S. and international healthcare systems. These challenges include concerns regarding the safety and quality of patient care, critical inefficiency, disparate technologies and information standards, rapidly rising costs and clinical information overload. In this paper, we focus on clinical knowledge management systems (CKMS) research. The objectives of the paper are to evaluate the current state of knowledge management systems diffusion in the clinical setting, assess the present status and focus of CKMS research efforts, and identify research gaps and opportunities for future work across the medical informatics and information systems disciplines. The study analyzes the literature along two dimensions: (1) the knowledge management processes of creation, capture, transfer, and application, and (2) the clinical processes of diagnosis, treatment, monitoring and prognosis. The study reveals that the vast majority of CKMS research has been conducted by the medical and health informatics communities. Information systems (IS) researchers have played a limited role in past CKMS research. Overall, the results indicate that there is considerable potential for IS researchers to contribute their expertise to the improvement of clinical process through technology-based KM approaches.

The state of the art in clinical knowledge management: An inventory of tools and techniques

Purpose To explore the need for, and use of, high-quality, collaborative, clinical knowledge management (CKM) tools and techniques to manage clinical decision support (CDS) content. Methods In order to better understand the current state of the art in CKM, we developed a survey of potential CKM tools and techniques. We conducted an exploratory study by querying a convenience sample of respondents about their use of specific practices in CKM. Results The following tools and techniques should be priorities in organizations interested in developing successful computer-based provider order entry (CPOE) and CDS implementations: (1) a multidisciplinary team responsible for creating and maintaining the clinical content; (2) an external organizational repository of clinical content with web-based viewer that allows anyone in the organization to review it; (3) an online, collaborative, interactive, Internet-based tool to facilitate content development; (4) an enterprise-wide tool to maintain the controlled clinical terminology concepts. Even organizations that have been successfully using computer-based provider order entry with advanced clinical decision support features for well over 15 years are not using all of the CKM tools or practices that we identified. Conclusions If we are to further stimulate progress in the area of clinical decision support, we must continue to develop and refine our understanding and use of advanced CKM capabilities.

Managing clinical knowledge among hospital nurses

Knowledge Management (KM) tools and processes, while established in many industries, are relatively new to healthcare. Healthcare organisations resemble virtual organisations that build flexible and dynamic care networks of multiple medical providers and professionals to address a patient's needs. This research studies the major factors impacting clinical KM strategy and processes in the floor nursing function in a large metropolitan area hospital. Empirical data has been collected and analysed to understand what infrastructure enablers and process capabilities are important contributors to KM effectiveness in floor nursing. The results indicate that technology can play a pivotal role in KM initiatives among nurses, provided it supports the processes involved with knowledge acquisition and application in solving new problems. The findings have implications for the selection, deployment and management of Information Technology (IT) to enable clinical KM.

Knowledge representation issues in ontology-based clinical Knowledge Management systems

Clinical Knowledge-Management (KM) represents a specific category of KM that requires specific support. Clinical knowledge mixes formal scientific knowledge with a person-culture in which the expertise of clinicians is key. In KM life-cycles, this entails that the required processes associated to clinical knowledge diverge from other kind of activities. Further, the technological support required for clinical knowledge assets is multi-perspective. This paper deals with those differences from the viewpoint of formal ontology. An epistemological account of such knowledge is provided. Then, problems of claim evaluation and representation are approached from it, resulting in a realistic set of design guidelines for clinical KM prepared for ontology-based systems.

Doctors' consultations with children and their parents: a model of competencies, outcomes and confounding influences

The clinical consultation is an important aspect of the doctor's role. However, there is a particular shortage of methods for assessing its quality, and its complexity makes it a considerable assessment challenge. What are the key components of consultations involving children? (1) A content analysis of relevant published and unpublished literature. (2) A nominal group consensus exercise with experienced paediatricians. The content analysis and consensus exercise suggested similar lists of doctor's characteristics, tasks and outcomes as being important components of the consultation. Doctor's characteristics include: clinical judgement, clinical knowledge, physical examination, information gathering, clinical questioning, information giving, patient-centredness, parent-centredness, interpersonal skills, and consultation management. Important tasks include: organisation and efficiency, rapport, information gathering, getting the family perspective, examination and procedures, evaluation, medically appropriate plans, family appropriate plans, enhancing understanding and recall, achieving consensus, sharing responsibility, family knows how to get further help and liaison with other relevant health-care professionals. Important outcomes include: family satisfaction, family perceptions, compliance, health, health-related problems and doctor's satisfaction. The studies reviewed in the literature also provided a catalogue of factors that have been shown to influence the doctor-patient interaction that could potentially confound the assessment of a doctor's performance. These include the doctor's: age, gender, training, speciality, income, social class and politics; the patient's: age, gender, health, prognosis, social class, education, health beliefs and preferences about control and risk. The length of the acquaintance between doctor and patient, and the workload and case-mix in the clinic also affect the interaction. In several studies it is clear that particular combinations of doctor-type and patient-type have especially good or bad interactions. CONCLUSIONS AND FURTHER WORK: These components are synthesised in a single model of the doctor-patient interaction to guide the development and evaluation of assessment instruments aimed at consultations involving children.

Guest Editorial Introduction to the Special Issue on Advances in Clinical and Health-Care Knowledge Management

Clinical and health-care knowledge management (KM) as a discipline has attracted increasing worldwide attention in recent years. The approach encompasses a plethora of interrelated themes including aspects of clinical informatics, clinical governance, artificial intelligence, privacy and security, data mining, genomic mining, information management, and organizational behavior. This paper introduces key manuscripts which detail health-care and clinical KM cases and applications.

Clinical Knowledge Management Using Computerized Patient Record Systems: Is the Current Infrastructure Adequate?

The proliferation of technology in health care, spurred by environmental factors encouraging the adoption of computerized patient records (CPRs), has led to a widely held perception of fully computerized patient information systems as the industry norm. To test the validity of this assumption, using data from a national survey of certified health information managers, we examined the CPR technology adoption rates reported by health information managers, assessing variation across practice settings, regions, and organizational types. Results show that significant nonadoption, and regional variation, exists in the implementation of CPRs. Overall, nonuniform diffusion of computerized health information technology was found, despite national mandates that promote and at times require uniform adoption. A significantly greater number of hospital-based patient records were computerized, compared to clinics and other practice settings. Managers were frequently found to maintain duplicate CPRs and paper-based patient record systems, even after the initial implementation period. Nonuniform regional CPR adoption and redundant paper-based systems were found to be a common practice in medical systems, due in part to cultural factors, mistrust of computerized data, and lack of technology training and knowledge.

Patients, Power and Responsibility: The First Principles of Consumer-Driven Reform

Care pathways are being developed throughout the health service to improve the quality and effectiveness of care. Are they being developed efficiently and making the most of the latest clinical computing systems? This is the first practical guide on how Information Technology and systems methods can support the development implementation and maintenance of e-Pathways. Case studies throughout highlight team approaches to facilitation clinical knowledge management process analysis and redesign and computerisation - providing insights into how e-Pathways can be used to support high quality patient care. The information is presented in an easy-to-read style and requires no prior knowledge of IT systems. Doctors nurses and managers throughout primary and secondary care as well as healthcare information technology specialists and suppliers will find this to be essential reading. An accompanying CD-ROM includes supplementary information providing useful website links and additional material on specific topic areas.

Towards knowledge-based systems in clinical practice:: Development of an integrated clinical information and knowledge management support system

Given that clinicians presented with identical clinical information will act in different ways, there is a need to introduce into routine clinical practice methods and tools to support the scientific homogeneity and accountability of healthcare decisions and actions. The benefits expected from such action include an overall reduction in cost, improved quality of care, patient and public opinion satisfaction. Computer-based medical data processing has yielded methods and tools for managing the task away from the hospital management level and closer to the desired disease and patient management level. To this end, advanced applications of information and disease process modelling technologies have already demonstrated an ability to significantly augment clinical decision making as a by-product. The wide-spread acceptance of evidence-based medicine as the basis of cost-conscious and concurrently quality-wise accountable clinical practice suffices as evidence supporting this claim. Electronic libraries are one-step towards an online status of this key health-care delivery quality control environment. Nonetheless, to date, the underlying information and knowledge management technologies have failed to be integrated into any form of pragmatic or marketable online and real-time clinical decision making tool. One of the main obstacles that needs to be overcome is the development of systems that treat both information and knowledge as clinical objects with same modelling requirements. This paper describes the development of such a system in the form of an intelligent clinical information management system: a system which at the most fundamental level of clinical decision support facilitates both the organised acquisition of clinical information and knowledge and provides a test-bed for the development and evaluation of knowledge-based decision support functions.

An Electronic Study Form to Support Collaborating Agents in the Management of Clinical Knowledge

When dealing with biological organisms, one has to take into account some peculiarities which significantly affect the representation of knowledge about them. These are complemented by the limitations in the representation of propositional knowledge, i.e. the majority of clinical knowledge, by artificial agents. Thus, the opportunities to automate the management of clinical knowledge are widely restricted to closed contexts and to procedural knowledge. Therefore, in dynamic and complex real-world settings such as health care provision to HIV-infected patients human and artificial agents must collaborate in order to optimize the time/quality antinomy of services provided. If applied to the implementation level, the overall requirement ensues that the language used to model clinical contexts should be both human- and machine-interpretable. The eXtensible Markup Language (XML), which is used to develop an electronic study form, is evaluated against this requirement, and its contribution to collaboration of human and artificial agents in the management of clinical knowledge is analyzed.

Exchanging clinical knowledge via Internet

The need for effective and efficient exchange of clinical knowledge is increasing. Paper based methods for managing clinical knowledge are not meeting the demand for knowledge and this has undoubtedly contributed to the widely reported failures of clinical guidelines. Internet affords both opportunities and dangers for clinical knowledge. Systems such as Wax have demonstrated the importance of intuitive structure in the management of knowledge. We report on a new initiative for the global management of clinical knowledge.

Reliability and validity of the objective structured clinical examination in paediatrics

The assessment of clinical competence has traditionally been carried out through standard evaluations such as multiple choice question and bedside oral examinations. The attributes which constitute clinical competence are multidimensional, and we have modified the objective structured clinical examination (OSCE) to measure these various competencies. We have evaluated the validity and reliability of the OSCE in a paediatric clinical clerkship. We divided the examination into the four components of competence (clinical skills, problem-solving, knowledge, and patient management) and evaluated the performance of 77 fourth-year medical students. The skill and content domains of the OSCE were carefully defined, agreed upon, sampled and reproduced. This qualitative evaluation of the examination was both adequate and appropriate. We achieved both acceptable interstation and intertask reliability. When correlated with concurrent methods of evaluation we found the OSCE to be an accurate measure of paediatric knowledge and patient management skills. The OSCE did not correlate, however, with traditional measures of clinical skills including history-taking and physical examination. Our OSCE, as outlined, offers an objective means of identifying weaknesses and strengths in specific areas of clinical competence and is therefore an important addition to the traditional tools of evaluation.