Medical Informatics for Better and Safer Health Care (continued)
AHRQ Research to Fight Bioterrorism and Improve Patient Safety
AHRQ had already begun funding research to deal with bioterrorism issues prior to September 11. It continues to fund research that investigates the effectiveness of information technology in fighting bioterrorism. In addition, AHRQ is currently funding many projects that investigate how technology can help improve patient safety.
Informatics to Help Identify Bioterrorist Attacks
Clinicians now need to be able to detect organisms such as ebola, anthrax, plague, tularemia, glanders, and smallpox when treating patients who are acutely ill, especially those who have fever.15 The organisms that cause these diseases can be spread through the air and have the ability to infect many people simultaneously.15 Diseases such as anthrax respond best to early treatment and must therefore be detected quickly.15 Research projects have focused on helping hospitals and health care systems respond to bioterrorism emergencies, improve communication among various health systems, and train health care providers.29 While most of these projects are still ongoing, some of their results are already helping clinicians and public health workers respond to bioterrorism and other disaster threats.
In order to help clinicians detect these diseases faster, AHRQ is funding continuing medical education (CME) training through the University of Alabama at Birmingham (UAB).30 Along with researchers at the Research Triangle Institute, researchers at UAB have developed online training modules for anthrax, smallpox, botulism, tularemia, viral hemorrhagic fever, and plague.30 As of April 2002, UAB had awarded 883 continuing education credits.31 The UAB CME Web site can be accessed at http://www.bioterrorism.uab.edu.
AHRQ-sponsored researchers at the University of Pittsburgh have demonstrated that early detection of infectious disease is possible using the Real-time Outbreak and Disease Surveillance (RODS) computer system.15 Several studies using data from emergency department visits, such as laboratory test results and patient demographic information, showed that the RODS computer system detected acute respiratory illnesses and influenza far more quickly than standard methods of detection.15
The RODS computer system provides descriptions of symptoms that precede the physical presentation of diseases such as botulism, encephalitis, respiratory diseases, hemorrhagic diseases, diarrheal diseases, and viruses.19 When patients begin exhibiting symptoms of one of these types of diseases more frequently than is considered normal, a notification system is engaged.19 Physicians who have public health, emergency, and infectious disease training monitor this system and report suspicious events to the public health departments.19
An AHRQ project at Children's Hospital in Boston is developing computer systems that collect and analyze emergency department data, incorporate an online diagnosis and treatment manual, and use a decision support system specifically designed to detect diseases early.19 To help clinicians identify the diseases that result from bioterrorism, the Massachusetts Institute of Technology has created a Web-based decision support tool that links patient symptoms and signs with a database of potential organisms and a treatment manual.19
Continuing its support of the Regenstrief Institute at Indiana University, AHRQ is funding a project that uses the Indianapolis Network for Patient Care to collect patient data such as lab results, clinic notes, chief complaint, diagnoses, procedures, immunizations, allergies, medications, and test results. When the system identifies cases of a reportable condition, it copies the patient information to the county and State health departments. It also sends E-mail summaries to public health officers and investigators.19
Patient Safety Programs that Use Medical Informatics
AHRQ is continuing to sponsor research promoting the use of informatics to ensure patient safety. Projects funded under the Clinical Informatics and Patient Safety (CLIPS) research program are examining how informatics can improve decisionmaking and patient safety while reducing errors and maintaining patient confidentiality.32
- Improving Primary Care Patient Safety with Handheld Decision Support Systems. Grant No. R18 HS11820. This project will examine the acceptance of, benefits of, and barriers to the use of stand-alone, handheld decision support systems (DSSs) in an ambulatory setting to improve prescribing patterns in order to prevent medication errors. It will also study the clinical impact and cost-effectiveness of point-of-care, handheld ambulatory DSSs on medical errors. A suite of decision support tools will be implemented in a number of ambulatory clinics, and the investigators will assess the extent to which potential or perceived barriers influence their use.
- Impact of Personal Digital Assistant Devices on Medication Errors. Grant No. R18 HS11808. This study will assess the impact of personal digital assistants (PDAs) on reducing medication errors in primary care office-based practices. Researchers will also measure the occurrence of potential preventable medication-related errors, assess physicians' attitudes toward the PDAs, and identify barriers perceived by physicians to PDA use in practice and successful strategies to overcome these barriers.
- Using Handheld Technology to Reduce Errors in Attention-Deficit Hyperactivity Disorder Care. Grant No. R18 HS11859. This project will use a real-time point-of-care handheld computerized decision support module called DS-ADHD to reduce medical errors in the treatment of attention-deficit/hyperactivity disorder (ADHD) in children. They will address two important types of errors that occur in the management of ADHD: failure to detect comorbid conditions and failure to respond to adverse effects of ADHD medications.
- Mining Complex Clinical Data for Patient Safety Research. Grant No. R18 HS11806. Researchers are developing an infrastructure to support automated surveillance of errors by using a natural language processor called MedLEE to code the information contained in patients' electronic medical records to detect and characterize medical errors. Using a clinical repository with 10 years of data on approximately 2 million patients, they will incorporate the system into a hospital's current events surveillance program and assess its impact on error detection.
- Informatics Tools to Reduce Warfarin Errors. Grant No. R18 HS11804. This project will create clinical informatics tools specifically designed to reduce the incidence of warfarin dosing errors in hospitalized patients who are taking this medication for the first time. Researchers will modify a program that predicts warfarin dosing requirements along with a program that identifies potential drug-drug interactions. The investigators will also evaluate the feasibility of using these informatics tools in routine hospital practice. In addition, they plan to make them widely available at no cost for public use.
- Using Prospective Minimum Data Set Data to Enhance Resident Safety. Grant No. R18 HS11869. This research project will determine whether preventable adverse outcomes for the frail elderly population in long-term care settings can be avoided by using computers to alert nursing and other staff to the likelihood that a problem such as falls, pressure ulcers, and urinary tract infections will occur. They will also identify resident-specific risk factors that are likely to cause an adverse outcome and target these risk factors for preventive interventions.
- Impact of Electronic Prescribing on Medication Errors. Grant No. R18 HS11868. This study will assess the baseline medication error rate in an urban pediatric emergency department and clinic. Researchers will also examine the effect of handheld electronic prescription writing on prescribing practices and medication error rates.
- Identifying and Reducing Errors with Surgical Simulation. Grant No. R18 HS11866. This research project will use state-of-the-art simulation tools to train otolaryngology physicians. Through the use of these simulation tools, physicians will be able to practice surgical procedures without exposing patients to the potential risk of having their surgery performed by an inexperienced surgeon. Data from the program will be collected into a central database and used for outcomes analysis. Technical errors and "near misses" will be identified, quantified, and analyzed. This information will be used to improve physician training and to monitor ongoing performance.
- Pharmacist Technology for Nursing Home Resident Safety. Grant No. R18 HS11835. This study will use the Geriatric Risk Assessment Minimum Data Set Med Guide (GRAM), a clinical tool to alert medication prescribers and nursing staff to information that can reduce the threat to patient safety associated with adverse drug events in nursing homes. The GRAM software helps evaluate the complex medication regimens of older patients, incorporates patient assessment data for monitoring medication therapy, and facilitates inclusion of recommendations in the care plan to prevent medication-related problems. Researchers will examine the extent to which the GRAM clinical tool reduces the incidence of delirium, falls, and hospitalizations due to adverse drug events and will determine the impact the GRAM software has on the efficiency, productivity, workload, and job satisfaction of pharmacists and nursing facility staff.
- Linking User Error to Lab and Field Study of Medical Informatics. Grant No. R18 HS11816. This project will explore the relationship among human, machine, and environmental factors associated with the operation of infusion devices in clinical settings. The project will identify and characterize properties of infusion devices, environmental conditions, and problems in operator cognition that promote "user error."
- HIV Treatment Error Reduction Using a Genotype Database. Grant No. R18 HS11800. This project will implement and evaluate an automated computerized decision support system. The system will integrate patient-specific HIV genotype information with corresponding medication data within an electronic medical record system to improve antiretroviral drug selection, reduce prescribing errors, prevent the development of drug resistance, and improve overall quality of care.
AHRQ-Funded Research on Medical Informatics
- Demonstrating Computer Support Impact on AIDS Patients, University of Wisconsin-Madison: This study examined the effects of CHESS (Comprehensive Health Enhancement Support System, a patient-centered, computer-based support system) on the health care costs and quality of care of HlV-infected men and women.
- Effect of Computer Feedback on Physician Test Ordering, Indiana University: This project tested the effect of patient-specific computer feedback on physicians' test-ordering practices.
- Variance in Medical Decisions: Causes and Cures, Indiana University: This study examined the effects of three informational interventions (newsletters, reports comparing an individual physician with his or her peers, and personal contact by faculty members) in terms of changes in physicians' medical decisions.
- Assessment of Technology Use Via a Computerized Ordering System, Indiana University: This study developed a microcomputer network for ordering by physicians of all tests and treatments on the inpatient medicine service.
- Computerized National Chronic Disease Databank System, Stanford University: This project established a pilot rheumatic disease computer data bank network (Arthritis, Rheumatism and Aging Medical Information System, or ARAMIS) that pooled clinical data between institutions and institutional studies, allowed rapid access to large quantities of clinical data, and provided computer consultation and clinical decision procedures based on these data.
- Assessment of Technology in Chronic Disease, Stanford University: This project utilized ARAMIS, a successful national chronic disease data bank system, to develop a systematic technology assessment program in rheumatic disease.
- Clinical Applications of an Expert System, LDS Hospital: This project developed an antibiotic consultant for the Health Evaluation through Logical Processing (HELP) hospital information system.
- Evaluation of a Computerized Infectious Disease Monitor, LDS Hospital: This study demonstrated the effectiveness of using a computerized infectious disease monitor to minimize the inappropriate use of prophylactic antibiotics, optimize the use of therapeutic antibiotics, and detect the presence of nosocomial infections.
- Hospital Computer Project, Massachusetts General Hospital: This research project developed the Computer Stored Ambulatory Record (COSTAR), a totally integrated computer-based information system that supported all the medical care, financial, and administrative needs of an ambulatory care organization.
- Computer-Based Access to Guidelines for Clinical Care, Massachusetts General Hospital: This study developed, implemented, and evaluated a computer-based system that provided physicians and nurses access to clinical guidelines of care for the purpose of learning and consultation.
- Bioterrorism: Automated Decision Support and Clinical Data Collection, Boston Children's Hospital: This project is developing a prototype database and Web site to facilitate clinician reporting of trends reflecting possible bioterrorist events.
- Using Information Technology to Improve Clinical Preparedness for Bioterrorism, MPC Corporation-University of Pittsburgh/Carnegie Mellon University: This project is developing the Real-time Outbreak and Disease Surveillance (RODS) system to provide early warning of infectious disease outbreaks possibly caused by an act of bioterrorism.
- Innovative Approaches to Training Clinicians for Bioterrorist Attacks: Online Modules, University of Alabama-Birmingham: This project has developed interactive Web-based training modules to teach health professionals how to address varied biological agents, including anthrax, smallpox, botulism, tularemia, viral hemorrhagic fever, and plague.
Medical informatics is one of many important components necessary to improve the quality of health care in the United States. Research funded by AHRQ over the past 30 years has given clinicians solutions to many problems they face in patient care. It has covered a wide range of topics, including the electronic medical record system, access to current information, clinical reminders, clinical decision support, electronic communication, patient education and self-management of chronic disease, and methods for identifying a bioterrorist attack. AHRQ remains committed to supporting research in medical informatics, including continued support of new and innovative technologies, information/knowledge management, improved communication between patients and providers, shared decisionmaking, identifying and overcoming barriers to the use of computers in health care, and new challenges posed by the threat of bioterrorism.
* 1. American Medical Informatics Association. Frequently Asked Questions. Web site: http://www.amia.org/about/faqs/f7.html. Accessed May 13, 2002.
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* 10. Evans RS, Classen DC, Pestotnik SL, et al. Improving empiric antibiotic selection using computer decision support. Arch Intern Med 1994; 154(8):878-84.
11. Pestotnik SL, Classen DC, Evans RS, et al. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med 1996; 124(10):884-90.
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* 14. Havey G. Wireless Internet medical monitoring devices. Final report. Fridley (MN): Advanced Medical Electronics Corp.; 2001. Contract No: 290-00-0028. Sponsored by the Agency for Healthcare Research and Quality.
* 15. Teich JM, Wagner MM, Mackenzie CF, et al. The informatics response in disaster, terrorism, and war. J Am Med Inform Assoc 2002; 9(2):97-104.
* 18. Tierney WM, Miller ME, Overhage M, et al. Physician inpatient order writing on microcomputer workstations. JAMA 1993; 269(3):379-83.
* 19. Lober WB, Karras BT, Wagner MM, et al. Roundtable on bioterrorism detection: information system-based surveillance. J Am Med Inform Assoc 2002; 9(2): 105-15.
* 25. Small Business Innovative Research Program, Phase 1. Request for Proposals. Agency for Healthcare Research and Quality, Rockville, MD. Web site: http://www.ahrq.gov/fund/rfp000006.htm. Current as of July 2000.
* 26. Sharma S. Web-based tool for diabetes self-care. Final report. Watertown (MA): New England Research Institutes; 2001. Contract No. 290-00-0025. Sponsored by the Agency for Healthcare Research and Quality.
* 27. Gibson P. Automatic wireless data collection from medical devices. Final report. Fridley (MN): Advanced Medical Electronics Corp., 2001. Contract No. 290-00-0029. Sponsored by the Agency for Healthcare Research and Quality.
* 29. Agency for Healthcare Research and Quality. AHRQ research relevant to bioterrorism preparedness. Rockville (MD); 2002. AHRQ Publication No. 02-P018. Current as of March 2002.
* 30. Agency for Healthcare Research and Quality. Responding to bioterrorism: AHRQ helps clinicians, health systems, and policymakers. Rockville (MD); 2001. Current as of Oct. 2001.
* 31. Terndrup T, Tresler M. Researchers, University of Alabama-Birmingham. E-mail correspondence to Barbara Kass-Bartelmes, Agency for Healthcare Research and Quality. April 10, 2002.
* 32. Agency for Healthcare Research and Quality. AHRQ issues request for applications on clinical informatics and patient safety research. Press release, Feb. 23, 2001. Rockville (MD): 2001.
For More Information
For further information on medical informatics at the Agency for Healthcare Research and Quality, please contact Eduardo Ortiz, M.D., M.P.H., at Eduardo.Ortiz@ahrq.hhs.gov or go to the Health Information Technology Web site.
AHRQ Publication Number 02-0031