Literature DB >> 34957491

Indication alerts to improve problem list documentation.

Anne Grauer1, Jerard Kneifati-Hayek1, Brian Reuland1, Jo R Applebaum2, Jason S Adelman1,2, Robert A Green1,2, Jeanette Lisak-Phillips1, David Liebovitz3, Thomas F Byrd3, Preeti Kansal3, Cheryl Wilkes3, Suzanne Falck4, Connie Larson5, John Shilka5, Elizabeth VanDril5, Gordon D Schiff6, William L Galanter4,5,7, Bruce L Lambert8.   

Abstract

BACKGROUND: Problem lists represent an integral component of high-quality care. However, they are often inaccurate and incomplete. We studied the effects of alerts integrated into the inpatient and outpatient computerized provider order entry systems to assist in adding problems to the problem list when ordering medications that lacked a corresponding indication.
METHODS: We analyzed medication orders from 2 healthcare systems that used an innovative indication alert. We collected data at site 1 between December 2018 and January 2020, and at site 2 between May and June 2021. We reviewed random samples of 100 charts from each site that had problems added in response to the alert. Outcomes were: (1) alert yield, the proportion of triggered alerts that led to a problem added and (2) problem accuracy, the proportion of problems placed that were accurate by chart review.
RESULTS: Alerts were triggered 131 134, and 6178 times at sites 1 and 2, respectively, resulting in a yield of 109 055 (83.2%) and 2874 (46.5%), P< .001. Orders were abandoned, for example, not completed, in 11.1% and 9.6% of orders, respectively, P<.001. Of the 100 sample problems, reviewers deemed 88% ± 3% and 91% ± 3% to be accurate, respectively, P = .65, with a mean of 90% ± 2%.
CONCLUSIONS: Indication alerts triggered by medication orders initiated in the absence of a justifying diagnosis were useful for populating problem lists, with yields of 83.2% and 46.5% at 2 healthcare systems. Problems were placed with a reasonable level of accuracy, with 90% ± 2% of problems deemed accurate based on chart review.
© The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Entities:  

Keywords:  clinical; decision support systems; indication-based prescribing; medical records; problem list; problem-oriented

Mesh:

Year:  2022        PMID: 34957491      PMCID: PMC9006708          DOI: 10.1093/jamia/ocab285

Source DB:  PubMed          Journal:  J Am Med Inform Assoc        ISSN: 1067-5027            Impact factor:   4.497


  14 in total

1.  Enhancing pharmacosurveillance with systematic collection of treatment indication in electronic prescribing: a validation study in Canada.

Authors:  Tewodros Eguale; Nancy Winslade; James A Hanley; David L Buckeridge; Robyn Tamblyn
Journal:  Drug Saf       Date:  2010-07-01       Impact factor: 5.606

2.  A trial of indication based prescribing of antihypertensive medications during computerized order entry to improve problem list documentation.

Authors:  Suzanne Falck; Sruthi Adimadhyam; David O Meltzer; Surrey M Walton; William L Galanter
Journal:  Int J Med Inform       Date:  2013-08-08       Impact factor: 4.046

3.  Using electronic medical records to determine the diagnosis of clinical depression.

Authors:  Nhi-Ha T Trinh; Soo Jeong Youn; Jessica Sousa; Susan Regan; C Andres Bedoya; Trina E Chang; Maurizio Fava; Albert Yeung
Journal:  Int J Med Inform       Date:  2011-04-22       Impact factor: 4.046

4.  A trial of inpatient indication based prescribing during computerized order entry with medications commonly used off-label.

Authors:  S M Walton; W L Galanter; H Rosencranz; D Meltzer; R S Stafford; F Tiryaki; D Sarne
Journal:  Appl Clin Inform       Date:  2011-03-09       Impact factor: 2.342

5.  Impact of problem-based charting on the utilization and accuracy of the electronic problem list.

Authors:  Ron C Li; Trit Garg; Tony Cun; Lisa Shieh; Gomathi Krishnan; Daniel Fang; Jonathan H Chen
Journal:  J Am Med Inform Assoc       Date:  2018-05-01       Impact factor: 4.497

6.  Clinical implications of an accurate problem list on heart failure treatment.

Authors:  Daniel M Hartung; Jacquelyn Hunt; Joseph Siemienczuk; Heather Miller; Daniel R Touchette
Journal:  J Gen Intern Med       Date:  2005-02       Impact factor: 5.128

7.  Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE).

Authors:  William Galanter; Suzanne Falck; Matthew Burns; Marci Laragh; Bruce L Lambert
Journal:  J Am Med Inform Assoc       Date:  2013-02-09       Impact factor: 4.497

8.  Problem list completeness in electronic health records: A multi-site study and assessment of success factors.

Authors:  Adam Wright; Allison B McCoy; Thu-Trang T Hickman; Daniel St Hilaire; Damian Borbolla; Watson A Bowes; William G Dixon; David A Dorr; Michael Krall; Sameer Malholtra; David W Bates; Dean F Sittig
Journal:  Int J Med Inform       Date:  2015-07-17       Impact factor: 4.046

9.  Improving completeness of electronic problem lists through clinical decision support: a randomized, controlled trial.

Authors:  Adam Wright; Justine Pang; Joshua C Feblowitz; Francine L Maloney; Allison R Wilcox; Karen Sax McLoughlin; Harley Ramelson; Louise Schneider; David W Bates
Journal:  J Am Med Inform Assoc       Date:  2012-01-03       Impact factor: 4.497

10.  Characterizing outpatient problem list completeness and duplications in the electronic health record.

Authors:  Edward Chia-Heng Wang; Adam Wright
Journal:  J Am Med Inform Assoc       Date:  2020-08-01       Impact factor: 4.497

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