Clinical Support Tool Research Articles

The Pharmacists Role in CPOE: A Pediatric Perspective

This continuing feature describes the clinical pharmacy support tools and services that are provided by the computerized provider order entry (CPOE) system at Vanderbilt University Medical Center (VUMC) — with an emphasis on pediatrics. The authors focus on the development and maintenance of decision support tools created specifically for use in the pediatric population.

Personal Data Assistants

This article explains how the new technology of personal data assistants can be used to enhance and augment comprehensive nursing care. Nurses are constantly challenged in their need for current, reliable, and accurate information at the point of patient care. Professional books and journals, by the very nature of their print format, have been prepared long before they can be actually used in practice. More current information is available from the World Wide Web, but it is often impractical for a nurse to access a computer during a patient encounter. Personal data assistants [PDAs] allow clinicians to access and document absolutely current information at the moment the patient is being seen. There are many general applications for PDAs that nurses might use such as keeping electronic calendars, address books, and reminder lists. In addition, however, there are even more actual healthcare applications, including patient tracking systems, access to pharmacologic databases, and a variety of clinical decision-making support tools. This article describes the wide variety of PDAs, along with the factors a nurse should consider in the decision of whether to purchase a PDA, and which type of device is best suited for which application.

Improving the effects of psychotherapy: The use of early identification of treatment and problem-solving strategies in routine practice.

Client-focused research systems have been developed to monitor and provide feedback information about clients' progress in psychotherapy as a method of enhancing outcome for those who are predicted to be treatment failures. In the current study, the authors examined whether feedback regarding client progress and the use of clinical support tools (CSTs) affected client outcome and number of sessions attended. Results showed that clients in the feedback plus CST group stayed in therapy longer and had superior outcomes. Nearly twice as many clients in the feedback plus CST group achieved clinically significant or reliable change, and fewer were classified as deteriorated by the time treatment ended.

Using NetMeeting for remote configuration of the Otto Bock C-Leg: technical considerations.

Telehealth has the potential to be a valuable tool for technical and clinical support of computer controlled prosthetic devices. This pilot study examined the use of Internet-based, desktop video conferencing for remote configuration of the Otto Bock C-Leg. Laboratory tests involved connecting two computers running Microsoft NetMeeting over a local area network (IP protocol). Over 56 Kbs(-1), DSL/Cable, and 10 Mbs(-1) LAN speeds, a prosthetist remotely configured a user's C-Leg by using Application Sharing, Live Video, and Live Audio. A similar test between sites in Ottawa and Toronto, Canada was limited by the notebook computer's 28 Kbs(-1) modem. At the 28 Kbs(-1) Internet-connection speed, NetMeeting's application sharing feature was not able to update the remote Sliders window fast enough to display peak toe loads and peak knee angles. These results support the use of NetMeeting as an accessible and cost-effective tool for remote C-Leg configuration, provided that sufficient Internet data transfer speed is available.

E-Health? Clinical information network interest and impediments in a community paediatric setting

Increased interest in implementing evidence-based medicine in paediatric practice has led to the development of a variety of electronic clinical and decision-making support tools. Electronic medical records and information resources have the potential to improve both the clinical and cost effectiveness of paediatric community practice at the point of care. Barriers to the successful implementation of clinical information Intranet resources include physician attitudes, as well as system and practitioner capabilities. To examine Ontario's community care paediatricians' electronic information resource needs and interest in accessing the proposed Central West Ontario Pediatric Information Network (CWPIN). Cross-sectional, interviewer-facilitated, structured survey. Paediatricians providing community care in the Central West Ontario Health Region. Three-quarters of regional community paediatricians responded to the survey. Of those surveyed, 98% expressed interest in gaining access to the CWPIN. Computer literacy, suggested by home computer and Internet use rates (88% and 81%, respectively), did not differ significantly by age or sex. Other factors that may affect network use, such as workplace computer use and allied personnel role assignment, differed by sex, indicating potentially greater CWPIN use among male practitioners. Physicians reported an overwhelming interest in gaining access to and using the CWPIN. Disparities in current workplace but not home-based computer use by sex indicate that workplace role allocation, rather than computer literacy, may explain sex differences in CWPIN use rates. Attitudinal and computer proficiency issues did not appear to be obstacles to implementing the clinical information Intranet resource in the region.

Disease Management: An Intermediate Step Toward Integrated and Coordinated Patient Care

The purpose of this article is to examine the evolving role of disease management in healthcare delivery and how it is adapting to meet the needs of patients in the current environment. An alternative view of disease management is contrasted to the more traditional one currently held by most in the field. Disease management is pragmatically conceived as the manageable subdomains of a quality improvement process applied to healthcare. This conception reflects the wholly inadequate information and decision support systems currently employed in healthcare. The transition from a pragmatic to a more comprehensive and integrated disease and health management approach will accompany advances in the development and adoption of medical informatics, including electronic medical records (EMRs) and handheld clinical support tools (e.g., personal digital assistants [PDAs]). As such, pragmatic disease management is an artificial construct or a halfway technology that one can expect will be replaced as real-time measurement and management of process and outcomes becomes embedded into the fabric of healthcare delivery. Given this scenario, efforts to codify or standardize disease management might not be prudent, as it would inhibit innovation. Indeed, the value of disease management will be determined in the marketplace based on its ability to enhance the effectiveness and efficiency of healthcare delivery, not by its conformance to well intentioned but fixed definitions of appropriate processes of care.

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

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

A hypermedia-based group decision support system to support collaborative medical decision-making

The systematic evolution of a hypermedia-based group decision support system (GDSS) architecture to support collaborative medical decision-making (MDM) is presented in this paper. This GDSS is for subsequent use by designers and researchers in the GDSS/medical informatics arena who can use several or parts of the presented architecture for effecting collaborative MDM. The GDSS design also supports various levels of inference-based medical support ranging from the lower diagnostic levels to the higher clinical levels. The evolution of this architecture incorporated systematic research and investigation of the basic elements of the MDM process, associated procedures, tools and the potential impact of different characteristics of medical groups. This architecture incorporates clinical reasoning and problem-solving features identified through an analysis of the schools of MDM from a GDSS perspective. Identification of inadequacies from a collaborative MDM perspective of existing GDSS research frameworks and architectures has also influenced current architecture development. The inexact nature of cognitive processes that are inherent in MDM necessitated the incorporation of “cognitive-aid structures” and the “cognitive appropriation processes” architectural components. The MEDICALWARE™ 1 1 MEDICALWARE is a trademark of Quantum Enterprises, NJ. component, integrated with a GDSS is designed to provide problem-solving support, access to clinical algorithms and procedures, expert inference support and several MDM support tools with hypermedia functionality. Hypertext templates with semantic nodes and links provide group members the ability to modify templates for accommodating expected or unexpected variations in decision-making criterion in handling a clinical case. Group members can thus ascertain whether they have followed all required procedures and algorithms, and modify diagnostic procedures if necessary. Several facets of the GDSS architecture can be prototyped and field-tested, incorporating clinical algorithms and related diagnostic support tools. The GDSS architecture presented can also be used for empirical studies in collaborative MDM.

Growth factor usage patterns and outcomes in the community setting: collection through a practice-based computerized clinical information system.

Although use of colony-stimulating factor (CSF) is widespread and guidelines for use have been disseminated, actual practice patterns of medical oncologists are unknown. The purpose of this study was to collect these data using an office-based computerized clinical information system. Data were collected on patients at 10 community-based oncology practices. Information regarding CSF use was captured at the time of prescribing through a computerized clinical support tool and stored in a data warehouse, and an analysis was carried out retrospectively. A total of 6,813 cancer regimens administered to 5,034 patients were evaluated for growth factor use. Overall, CSFs were used in 14% of regimens, with breast, lymphoma, lung, and ovarian being the most common cancers for which CSFs were used. In 49.4% of regimens, CSF was initiated during cycle 1, with an average duration of 1 week, and was used in two or three cycles per regimen. Afebrile neutropenia is rarely followed by CSF initiation. Granulocyte colony-stimulating factor (G-CSF) is associated with fewer dose adjustments, delays, and hospitalizations when compared with granulocyte-macrophage colony stimulating factor (GM-CSF). There is wide variation among oncologists in CSF use, and several substantial differences were noted between the prescribing behavior of American Society of Clinical Oncology (ASCO) survey-reported oncologists and actual clinical practice, as captured by the computerized clinical information system. Computerized clinical information systems can collect detailed information regarding practice patterns of medical oncologists. ASCO physician practice survey data do not accurately reflect actual practice patterns and must be interpreted with caution. Substantial deviations from ASCO growth factor guidelines remain, and oncologists' use of CSFs demonstrates wide variation. There may be important clinical differences between G-CSF and GM-CSF, but definitive phase III trials are needed for confirmation.

Maximising the world wide web for high quality educational and clinical support to health and medical professionals in rural areas

Attracting and retaining medical and allied health professionals to rural and remote regions is a perennial problem, world-wide. It is exacerbated by the associated problem of providing high quality, cost-effective educational and clinical support to health professionals and trainees located in such areas. The world wide web is being used as a tool to address these twin problems to provide a means of communication, interaction and educational and clinical support to geographically dispersed and isolated pools of users. An interactive electronic notice board has been developed as a clinical problems’ discussion forum to act as a venue for critical debate about clinical issues and to provide a searchable archive of information to assist in the management of clinical problems. A description of the forum will demonstrate the potential of the world wide web as a learning and a clinical support tool.