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Nurse Order Entry – an alternative to CPOE? March 1, 2010

Posted by Hans in : research , add a comment

Getting physicians to enter their own orders on computerized systems has and continues to be a challenge to those in the health informatics field. Computerized physician order entry (CPOE) is often used as a measure of success. Given how the health care systems in North America are structured, getting physicians on-board and using information systems is required. Physicians hold the power in our system. I’m not saying this is a bad thing – it’s just a reality.

A recent paper published in the Journal of Medical Internet Research (JMIR) titled “Physician order entry or nurse order entry? Comparison of two implementation strategies for a computerized order entry system aimed at reducing dosing medication errors” presents some new information on the issue.

In this article, the authors compared physician only entry with a nurse and physician entry process to reduce medication errors on a neonatal ward. Basically, what the study found was that use of a clinical decision support system by both physicians alone or physicians with nurses entering the orders reduced medication errors. While there is an added step in the process when the nurse enters the order, this may be an acceptable trade-off if it can decrease physician data entry work while increasing overall use of electronic tools.

Two things struck me as I read this article. First, given that physicians are the most expensive and precious resource in the system, why are the efforts aimed at increasing the workload in terms of data entry? Shouldn’t the system, from an efficiency and optimization perspective, be looking at means of maximizing the physician’s time toward the things we need them to do, namely making decisions around diagnosis and treatment? If I remember my theory of constraints properly, then health systems should be doing everything possible to maximize each physician’s time such that it is spent on decision making rather than information gathering, data entry, or other process related work. If that is the case, then I suspect that our hospitals and offices should be re-organized to achieve this operational efficiency. One possible solution could be to have physicians sitting at a terminal whereby the physician holds each interaction via video-conferencing of some sort. Other health professionals can be the “arms and legs” and have everything queued up and ready for the technology mediated interaction. Hey, I don’t know about you, but that’s starting to sound like telemedicine, doesn’t it?

The second thing that struck me was that if physicians are resistant to CPOE, are they making themselves vulnerable to becoming displaced in the system in the long-term? An argument could be made that nurses are also highly qualified resources in the system which are being under-utilized and therefore more opportunities should be afforded to maximize their time and training. With the relative reluctance (general stereotype) of physicians to embrace CPOE, could nurses be the health professional who does the providing of care? As we begin to codify and standardize medical practice and decision making, then physicians start to lose their power in the system. To me, this reminds me of some of the examples in Christensen’s books on disruptive innovation. Innovations allow those with less training and skill to do more while the most highly skilled focus on those truly unique cases which involve high levels of uncertainty and complexity.

Getting back to the article, I found the article to be interesting in providing some data on the viability of using nurses as an intermediary towards CPOE. There are some methodological issues with the study, but the overall conclusions seem to be valid and reasonable. I wonder if a nurse order entry alternative could work within a North American context.

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Health Affairs issue on “E-Health in the Developing World” February 23, 2010

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The current issue of Health Affairs (February 2010, Vol. 29, No. 2) is focused on ehealth with a tag-line of “E-Health in the Developing World”.

I just stumbled onto this issue so I haven’t had a chance to read it yet. There are a number of articles grouped into some interesting categories including:

I’m looking forward to reading some of the accounts from this issue. Based on my understanding of Christensen’s theories on disruptive innovation, developing nations can be the place where new ideas can be established. Relatively simple innovations have an opportunity to meet the needs of users who have much less demanding needs and as such, the opportunity for rapid innovation can take place. In developed areas like Canada, the US, or Europe, innovations are challenged to meet the high demands of users who are accustomed to a level of sophistication and polish. The result is that innovations often don’t have a chance to develop and find a place within the market.

I will be keeping track of developments from the developing word as that is where the cheaper, simpler innovations are likely to emerge. In North America, governments have already committed billions to creating large systems which can share information across the country and meet the exacting demands of multiple users (e.g., physicians, nurses, allied health, researchers) and for different needs. On top of these two demands, innovations must also satisfy stringent regulatory burdens which adds additional complexity (and cost).

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eHealth in the peer-reviewed literature… February 3, 2010

Posted by Hans in : news, research , 1 comment so far

Much to my surprise, two leading health care journals have articles on ehealth.

The first is JAMA (vol 303, no 5, pp 391-470; February 3, 2010), which rarely publishes on the topic of ehealth.

The second is a special theme issue on global ehealth (Feb 2010, vol 29, no 2). The Health Affairs blog has a good description of the articles.

Looks like there’s an increasing interest by those in the research communities on the issues of ehealth. I haven’t had a chance to read all of the articles just yet, but it some of the titles look interesting.

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A voice against irrational exuberance in ehealth January 23, 2008

Posted by Hans in : academics, analysis, opinion, research , 1 comment so far

For those interested in a somewhat contrarian viewpoint about ehealth, I suggest you check out Scot Silverstein.  I just recently came across his site documenting some "common examples of health care IT difficulties".  You can also listen to his interview available via the Government Health IT site – an excellent site.

In his interview, Dr. Silverstein raises some very important points:

My interest in Dr. Silverstein’s work is in our common view on technology:  that there’s great potential to make positive changes, but that success isn’t a certainty – what is commonly referred to as "technological determinism".  I’ve written as far back as 2004 about technological determinism and ehealth, namely to be skeptical about the absolute certainty that the IT professionals have about ehealth (e.g., my post about IBM building computer models to solve health care’s woes).  I think it’s important to have a balanced view on being hopeful of the possibilities, but also being realistic about the challenges (some final thoughts from a 2005 ehealth conference).

I hope to do some more reading on his website to see what other nuggets I can glean from his work.

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Guide to program evaluation January 20, 2008

Posted by Hans in : research, resources , 10comments

Here’s a link to a free resource on program evaluation titled, Basic Guide to Program Evaluation.  The guide seems like a great resource for those who need help in getting started.  With some great summaries and tables comparing the pros/cons of different methods and designs, this guide seems like a great, free resource.

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The “Google generation” and some implications for ehealth January 18, 2008

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The findings of a recent report on how the "Google generation" uses technology and searched for information has some potential implications for ehealth (view the full report [35 slides] or read a summary article via ars technica).  In this case, the Google generation was defined as those kids born since 1993.

Kids seem to be familiar and comfortable using technology (i.e., what people would call ‘technologically savvy’).  However, this competence in using technology doesn’t translate into their ability to find information.  Assumptions about youngsters improving their search skills by experimentation and use alone would seem to be false.  What else was interesting was that kids prefer interactive activities (duh!), but they weren’t so picky about visual over text.  Visual was preferred to text, but it wasn’t a huge difference.

For those of us interested in ehealth, I think there are some important things we need to consider.  For example, my supervisor, Alex Jadad, often likes to challenge people by saying that we need to build a system that our kids will use because they are technologically savvy.  They may be more comfortable with information and communication technologies, but we can’t assume they’ll be "experts".  Some things to consider:

What seems clear is that we need to be careful about the assumptions we make about people using technology.  Young people may have a head start in terms of comfort and familiarity, but they aren’t "automagically" experts of finding information.  In fact, according to this study, their comfort and familiarity may lead to a shallow understanding of technology.  Something to think about.

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Online Evaluation Resource Library January 12, 2008

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Here’s an interesting resource for those interested in evaluation, titled the "Online Evaluation Resource Library" (OERL).  The goal of the OERL is to:

the continuous improvement of evaluations used to monitor and judge projects’ effectiveness. OERL provides a rich collection of evaluation best practices, guidelines for their applications to projects, and a forum for stimulating ongoing dialogue in the evaluation community. OERL is designed to support applications of sound evaluation methodologies to projects, not to replace a full course of study for those going into the evaluation field.

I did a quick search for resources regarding ehealth and related topics but didn’t find anything.  Maybe it’s an opportunity.  Nevertheless, for those interested in getting started on evaluations of health related IT projects, OERL might be a good resource for ideas.

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JMIR a top health services and informatics journal June 23, 2007

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For those interested in publishing their work, you should consider the Journal of Medical Internet Research (JMIR). JMIR is now the #2 medical informatics journal based on the ISI/SCI impact factor ratings, with a rating of 2.9. The “impact factor rating” is a statistical measure of how frequently articles from a specific journal are referenced by other articles. The thinking is that “better” articles will be referenced more frequently. You can read more about this announcement here.

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Could ehealth raise public awareness of clinical conditions? June 13, 2007

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I came accross an interesting article published in BMC Medicine titled “Do citizens have minimum medical knowledge? A survey”. The authors found a “consistent and dramatic lack of knowledge in the general public about the typical signs and risk factors of relevant clinical conditions”. What surprised me was that this finding seemed to apply to those with and without medical backgrounds. Okay, granted the study was conducted in Switzerland and the authors only investigated a few conditions (COPD/heart disease and HIV/AIDS), but I think that this finding could probably be replicated. Here are two examples from my family’s recent history:

A few years back, our family didn’t realize that our grandmother had a stroke. She complained of a headache and that she “wasn’t feeling well” and had trouble seeing. We noticed that she slept a bit more than usual, but figured it was because she was a) older (almost 90 years), b) wasn’t feeling well on the account of a flu or cold (it was in the winter), and c) her cataracts was getting worse. One day, she got out of bed and walked into a wall and fell because her left side felt weak. She wasn’t feeling well and so we took her to see our family physician. After some tests were run, he said that she experienced a minor stroke but that there was nothing we could do now. He said that if we had brought her in sooner, we could have done something to help her.

Looking back, our entire family felt quite guilty. We could have helped her more, but didn’t. But, was there anything that we could have done? I mean, her symptoms were so generic and could describe a flue or cold. She seemed okay – just a bit tired. We didn’t notice anything until she actually fell, as she was quite independent until then. Our physician said that in the elderly a prolonged “headache” was a warning signal since our grandmother had high-blood pressure. How come no-one told us that?

The second example is with my father. He’s usually up quite early, but one day he woke up late and seemed somewhat disoriented. He was up late the night before. That morning, he seemed to have trouble articulating words. I only noticed because he was supposed to drive me to the commuter train. He didn’t seem in any shape to drive so my sister ended-up driving me. I mentioned this to my supervisor (Alex Jadad – a physician) and he said that I should take my dad to the hospital immediately. Apparently, his symptoms suggested something called TIA or “Transient Ischemic Attack” – it’s like a temporary stroke. Again, there’s no way I would have even considered his condition serious.

Anyway, I’m wondering if greater and more widespread use of the Internet for health purposes could increase awareness of symptoms of clinical conditions. I’m involved in the health care system and am well educated and yet had no clue what to look for. If educated medical folks like paramedics have difficulty, what chance to non-medical folk have?

There are probably two things that need to be done: better education of medical conditions and better use of technology.

What if mobile phone developers or even telecommunications companies provided some services that really could be helpful? For example, could some sort of software be developed where the primary user inputs some basic data (age, sex, existing conditions) and then ever so often, you get a text message asking you a few questions about your health or some health promotion note? I know this is somewhat “pie-in-the-sky” thinking, but we should see how we can use commonly available tools to really help people. Maybe it could be targetted – like having patients who have heart disease get these messages reminding them about warning signs or to monitor certain physiological measures. It’s a thought.

I would probably argue that the greatest challenge, with or without technology, will be to get the attention of regular people (like me) to know when something is potentially dangerous or not. We probably won’t get there until we start wearing bio-medical devices like a “shirt”. Even then we probably couldn’t monitor everything.

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Patients want more performance information available online. Where do we go from here? June 12, 2007

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Came across an interesting little blurb reporting on a survey. In the the survey conducted in the UK, nearly 80% of patients want “more information on how their NHS hospital performs available on the internet”. Nothing too shocking, right?

My first thought was to question whether or not this matters. From my personal experience working in the health care system, I’ve heard that some patients don’t really want to know. They may want to know if their providers are doing a great job (i.e., excellent or above average), but if access to physicians or services is very limited, patients (at least anecdotally) don’t want to know – care, however “below average” it may be, is still better than no care at all. As I continued to read the report, I thought this finding was particularly interesting:

Of those surveyed, 38% said they would use it to challenge or seek reassurance from their doctor, whilst only a minority (around 16%) would use it to choose or change their provider

Aha – just as I thought. People just want to know they aren’t receiving sub-standard care.

Just some other thoughts that I have about making comparative performance data available to the public:

  • There needs to be some better efforts in helping the public understand and make sense of the data that’s available. In Ontario, hospital performance is reported annually (OHA/Ministry of Health Hospital Report). I helped compile some data for a hospital a few years back for the initial report and I don’t think that the actual reporting and knowledge translation has gotten much better. Leafing through some of these reports is a challenge as you are just bombarded with numbers, tables, and figures.
  • A senior executive that I used to work for once told me that comparative performance data is mostly for marketing purposes (both internal and external). If you get excellent results, you promote the heck out of it and market yourself as a leader, hopefully being rewarded with either extra funding from the government or attracting more donations to your foundation. If your results aren’t so great (or “below average”), then you use it to kick-start some new internal “improvement” program while asking for more $$. “Well, we didn’t perform as well as we could because of financial constraints and challenges…”.
  • Now, what does “below average” or “above average” really mean? I suppose from research perspective, it’s like asking for the difference between statistical significance and clinical significance. When I take a look at some figures (Example: 2006 Acute Care report), I’d be hard-pressed to tell you what the difference on some of these tables. On page 50 looking at the table reporting adverse events for community hospitals, we see that Rouge Valley Hospital (Scarborough) was identified as “above average” while Sault Area Hospital (Sault Ste. Mary) was only “average” for the rate of Nurse Sensitive Medical Adverse Events. When we look at the actual numbers, Rouge Valley is 0.3 while the Sault Area hospital is 0.4 (note, I couldn’t even find what the denominator is (I think it’s a percentage, but I can’t be sure). In the case of a below average, Ross Memorial Hospital is 2.6 which seems quite a bit off from the other two I mentioned. But in reality, what does this mean to a patient?

    • Hey, I don’t want to give the wrong impression. I think it’s great that this type of information is becoming easier to access. I think it’s great that hospital executives are starting to examine performance (which I hope is a good proxy for the hard to define term “quality of care”). I think it’s great that patients and the public are starting to become more interested in the type and quality of care they are receiving. My question is “what is the next step”? Patients asked for performance data. The health system has responded. What is the response? Do we ask for more? Do we demand changes? Do we just say “thanks” and go on our way because my health provider is doing okay? Was this a make-work exercise if we don’t act on it? Where do we go from here?

    I don’t have the answers but I’m hoping that as a group, we can figure something out.

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