ObjectiveTo examine the financial impact health information exchange (HIE) in emergency departments (EDs).Materials and MethodsWe studied all ED encounters over a 13-month period in which HIE data were accessed in all major emergency departments Memphis, Tennessee. HIE access encounter records were matched with similar encounter records without HIE access. Outcomes studied were ED-originated hospital admissions, admissions for observation, laboratory testing, head CT, body CT, ankle radiographs, chest radiographs, and echocardiograms. Our estimates employed generalized estimating equations for logistic regression models adjusted for admission type, length of stay, and Charlson co-morbidity index. Marginal probabilities were used to calculate changes in outcome variables and their financial consequences.ResultsHIE data were accessed in approximately 6.8% of ED visits across 12 EDs studied. In 11 EDs directly accessing HIE data only through a secure Web browser, access was associated with a decrease in hospital admissions (adjusted odds ratio (OR)=0.27; p<0001). In a 12th ED relying more on print summaries, HIE access was associated with a decrease in hospital admissions (OR=0.48; p<0001) and statistically significant decreases in head CT use, body CT use, and laboratory test ordering.DiscussionApplied only to the study population, HIE access was associated with an annual cost savings of $1.9 million. Net of annual operating costs, HIE access reduced overall costs by $1.07 million. Hospital admission reductions accounted for 97.6% of total cost reductions.ConclusionAccess to additional clinical data through HIE in emergency department settings is associated with net societal saving.

By modeling patient flow, rather than operational summary variables, our simulation forecasts several measures of near-future ED crowding, with various degrees of good performance.

Background Frequently, prescribers fail to account for changing kidney function when prescribing medications. We evaluated the use of a computerized provider order entry intervention to improve medication management during acute kidney injury (AKI). Study Design Quality improvement report with time series analyses. Setting & Participants 1598 adult inpatients with a minimum 0.5 mg/dl increase in serum creatinine over 48 hours following an order for at least one of 122 nephrotoxic or renally cleared medications. Quality Improvement Plan Passive, non-interactive warnings about increasing serum creatinine appeared within the computerized provider order entry interface and on printed rounding reports. For contraindicated or high toxicity medications that should be avoided or adjusted, an interruptive alert within the system asked providers to modify or discontinue the targeted orders, mark the current dosing as correct and to remain unchanged, or defer the alert to reappear in the next session. Outcomes & Measurements Intervention effect on drug modification or discontinuation, time to modification or discontinuation, provider interactions with alerts. Results The modification or discontinuation rate per 100 events for medications included in the interruptive alert within 24 hours of increasing creatinine improved from 35.2 pre-intervention to 52.6 post-intervention (p<0.001); orders were modified or discontinued more quickly (p<0.001). During the post-intervention period, providers initially deferred 78.1% of interruptive alerts, although 54% of these were eventually modified or discontinued prior to patient death, discharge, or transfer. The response to passive alerts about medications requiring review did not significantly change when compared to baseline. Limitations Single tertiary care academic medical center; provider actions were not independently adjudicated for appropriateness. Conclusions A computerized provider order entry-based alerting system to support medication management following AKI significantly increased the rate and timeliness of modification or discontinuation of targeted medications.

As health care organizations dramatically increase investment in information technology (IT) and the scope of their IT projects, implementation failures become critical events. Implementation failures cause stress on clinical units, increase risk to patients, and result in massive costs that are often not recoverable. At an estimated 28% success rate, the current level of investment defies management logic. This paper asserts that there are "chasms" in IT implementations that represent risky stages in the process. Contributors to the chasms are classified into four categories: design, management, organization, and assessment. The American College of Medical Informatics symposium participants recommend bold action to better understand problems and challenges in implementation and to improve the ability of organizations to bridge these implementation chasms. The bold action includes the creation of a Team Science for Implementation strategy that allows for participation from multiple institutions to address the long standing and costly implementation issues. The outcomes of this endeavor will include a new focus on interdisciplinary research and an inter-organizational knowledge base of strategies and methods to optimize implementations and subsequent achievement of organizational objectives.

Purpose Computerized clinical decision support systems (CDSSs) for intensive insulin therapy (IIT) are increasingly common. However, recent studies question IIT’s safety and mortality benefit. Researchers have identified factors influencing IIT performance, but little is known about how workflow affects computer-based IIT. We used ethnographic methods to evaluate IIT CDSS with respect to other clinical information systems and care processes. Methods We conducted direct observation of and unstructured interviews with nurses using IIT CDSS in the surgical and trauma intensive care units at an academic medical center. We observed 49 hours of intensive care unit workflow including 49 instances of nurses using IIT CDSS embedded in a provider order entry system. Observations focused on the interaction of people, process, and technology. By analyzing qualitative field note data through an inductive approach, we identified barriers and facilitators to IIT CDSS use. Results Barriers included (1) workload tradeoffs between computer system use and direct patient care, especially related to electronic nursing documentation, (2) lack of IIT CDSS protocol reminders, (3) inaccurate user interface design assumptions, and (4) potential for error in operating medical devices. Facilitators included (1) nurse trust in IIT CDSS combined with clinical judgment, (2) nurse resilience, and (3) paper serving as an intermediary between patient bedside and IIT CDSS. Conclusion This analysis revealed sociotechnical interactions affecting IIT CDSS that previous studies have not addressed. These issues may influence protocol performance at other institutions. Findings have implications for IIT CDSS user interface design and alerts, and may contribute to nascent general CDSS theory.