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Objective: Authors evaluated whether displaying context sensitive links to infrequently accessed educational materials and patient information via the user interface of an inpatient computerized care provider order entry (CPOE) system would affect access rates to the materials.Design: The CPOE of Vanderbilt University Hospital (VUH) included "baseline" clinical decision support advice for safety and quality. Authors augmented this with seven new primarily educational decision support features. A prospective, randomized, controlled trial compared clinicians' utilization rates for the new materials via two interfaces. Control subjects could access study-related decision support from a menu in the standard CPOE interface. Intervention subjects received active notification when study-related decision support was available through context sensitive, visibly highlighted, selectable hyperlinks.Measurements: Rates of opportunities to access and utilization of study-related decision support materials from April 1999 through March 2000 on seven VUH Internal Medicine wards.Results: During 4,466 intervention subject-days, there were 240,504 (53.9/subject-day) opportunities for study-related decision support, while during 3,397 control subject-days, there were 178,235 (52.5/subject-day) opportunities for such decision support, respectively (p = 0.11). Individual intervention subjects accessed the decision support features at least once on 3.8% of subject-days logged on (278 responses); controls accessed it at least once on 0.6% of subject-days (18 responses), with a response rate ratio adjusted for decision support frequency of 9.17 (95% confidence interval 4.6-18, p < 0.0005). On average, intervention subjects accessed study-related decision support materials once every 16 days individually and once every 1.26 days in aggregate.Conclusion: Highlighting availability of context-sensitive educational materials and patient information through visible hyperlinks significantly increased utilization rates for study-related decision support when compared to "standard" VUH CPOE methods, although absolute response rates were low. [ABSTRACT FROM AUTHOR]

Consensus is growing that a health care information and communication infrastructure is one key to fixing the crisis in the United States in health care quality, cost, and access. The National Health Information Infrastructure (NHII) is an initiative of the Department of Health and Human Services receiving bipartisan support. There are many possible courses toward its objective. Decision makers need to reflect carefully on which approaches are likely to work on a large enough scale to have the intended beneficial national impacts and which are better left to smaller projects within the boundaries of health care organizations. This report provides a primer for use by informatics professionals as they explain aspects of that dividing line to policy makers and to health care leaders and front-line providers. It then identifies short-term, intermediate, and long-term steps that might be taken by the NHII initiative. [ABSTRACT FROM AUTHOR]

Nine secondary cases of tuberculosis and 59 tuberculin skin test conversions occurred after exposure to a hospitalized patient with a large tuberculous abscess of the hip and thigh. Among 442 tuberculin-negative hospital employees, the relative risk of skin test conversion associated with recalled exposure to the patient was 14.0 (95% confidence limits, 6.8, 28.7). Four of 5 surgical suite employees who assisted with incision and debridement of the abscess had skin test conversions, as did 85% of 33 employees on a general medical floor who recalled exposure to the patient and 30% of 20 intensive care unit employees who recalled exposure. The prevalence of tuberculin reactivity in visitors and other patients on two floors also showed a strong association with exposure to the patient. A high concentration of Mycobacterium tuberculosis in the abscessed tissue, disturbance of the surface of liquid drainage from the abscess by irrigations and by the agitated behavior of the patient, and positive air pressure in the patient's room are factors that appear to have contributed to the high risk of tuberculosis transmission. [ABSTRACT FROM AUTHOR]

The rising popularity of artificial intelligence in healthcare is highlighting the problem that a computational model achieving super-human clinical performance at its training sites may perform substantially worse at new sites. In this perspective, we argue that we should typically expect this failure to transport, and we present common sources for it, divided into those under the control of the experimenter and those inherent to the clinical data-generating process. Of the inherent sources we look a little deeper into site-specific clinical practices that can affect the data distribution, and propose a potential solution intended to isolate the imprint of those practices on the data from the patterns of disease cause and effect that are the usual target of probabilistic clinical models., (© 2024. The Author(s).)

Motivation: Phecodes are widely used and easily adapted phenotypes based on International Classification of Diseases codes. The current version of phecodes (v1.2) was designed primarily to study common/complex diseases diagnosed in adults; however, there are numerous limitations in the codes and their structure., Results: Here, we present phecodeX, an expanded version of phecodes with a revised structure and 1,761 new codes. PhecodeX adds granularity to phenotypes in key disease domains that are under-represented in the current phecode structure-including infectious disease, pregnancy, congenital anomalies, and neonatology-and is a more robust representation of the medical phenome for global use in discovery research., Availability and Implementation: phecodeX is available at https://github.com/PheWAS/phecodeX., (© The Author(s) 2023. Published by Oxford University Press.)

Objective: Knowledgebases are needed to clarify correlations observed in real-world electronic health record (EHR) data. We posit design principles, present a unifying framework, and report a test of concept., Materials and Methods: We structured a knowledge framework along 3 axes: condition of interest, knowledge source, and taxonomy. In our test of concept, we used hypertension as our condition of interest, literature and VanderbiltDDx knowledgebase as sources, and phecodes as our taxonomy. In a cohort of 832 566 deidentified EHRs, we modeled blood pressure and heart rate by sex and age, classified individuals by hypertensive status, and ran a Phenome-wide Association Study (PheWAS) for hypertension. We compared the correlations from PheWAS to the associations in our knowledgebase., Results: We produced PhecodeKbHtn: a knowledgebase comprising 167 hypertension-associated diseases, 15 of which were also negatively associated with blood pressure (pos+neg). Our hypertension PheWAS included 1914 phecodes, 129 of which were in the PhecodeKbHtn. Among the PheWAS association results, phecodes that were in PhecodeKbHtn had larger effect sizes compared with those phecodes not in the knowledgebase., Discussion: Each source contributed unique and additive associations. Models of blood pressure and heart rate by age and sex were consistent with prior cohort studies. All but 4 PheWAS positive and negative correlations for phecodes in PhecodeKbHtn may be explained by knowledgebase associations, hypertensive cardiac complications, or causes of hypertension independently associated with hypotension., Conclusion: It is feasible to assemble a knowledgebase that is compatible with EHR data to aid interpretation of clinical correlation research., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Electronic Health Record (EHR) data are captured over time as patients receive care. Accordingly, variations among patients, such as when a patient presents for care during the course of a disease, introduce bias into standard longitudinal EHR data analysis methods. We, therefore, aim to provide an alignment method that reduces this bias. We structure this task as a registration problem. While limited prior research on longitudinal EHR data considered registration, we propose a robust registration method to provide better data alignment by estimating the optimum time shift at each time point. We validate the proposed method for mortality prediction. We utilize a Recurrent Neural Network (RNN), time-varying Cox regression model, and Logistic Regression (LR) for mortality prediction. Results suggest our proposed registration method enhances mortality prediction with at least a 1-2% increase in major evaluation metrics utilized., (©2023 AMIA - All rights reserved.)

Importance: Numerous prognostic models of suicide risk have been published, but few have been implemented outside of integrated managed care systems., Objective: To evaluate performance of a suicide attempt risk prediction model implemented in a vendor-supplied electronic health record to predict subsequent (1) suicidal ideation and (2) suicide attempt., Design, Setting, and Participants: This observational cohort study evaluated implementation of a suicide attempt prediction model in live clinical systems without alerting. The cohort comprised patients seen for any reason in adult inpatient, emergency department, and ambulatory surgery settings at an academic medical center in the mid-South from June 2019 to April 2020., Main Outcomes and Measures: Primary measures assessed external, prospective, and concurrent validity. Manual medical record validation of coded suicide attempts confirmed incident behaviors with intent to die. Subgroup analyses were performed based on demographic characteristics, relevant clinical context/setting, and presence or absence of universal screening. Performance was evaluated using discrimination (number needed to screen, C statistics, positive/negative predictive values) and calibration (Spiegelhalter z statistic). Recalibration was performed with logistic calibration., Results: The system generated 115 905 predictions for 77 973 patients (42 490 [54%] men, 35 404 [45%] women, 60 586 [78%] White, 12 620 [16%] Black). Numbers needed to screen in highest risk quantiles were 23 and 271 for suicidal ideation and attempt, respectively. Performance was maintained across demographic subgroups. Numbers needed to screen for suicide attempt by sex were 256 for men and 323 for women; and by race: 373, 176, and 407 for White, Black, and non-White/non-Black patients, respectively. Model C statistics were, across the health system: 0.836 (95% CI, 0.836-0.837); adult hospital: 0.77 (95% CI, 0.77-0.772); emergency department: 0.778 (95% CI, 0.777-0.778); psychiatry inpatient settings: 0.634 (95% CI, 0.633-0.636). Predictions were initially miscalibrated (Spiegelhalter z = -3.1; P = .001) with improvement after recalibration (Spiegelhalter z = 1.1; P = .26)., Conclusions and Relevance: In this study, this real-time predictive model of suicide attempt risk showed reasonable numbers needed to screen in nonpsychiatric specialty settings in a large clinical system. Assuming that research-valid models will translate without performing this type of analysis risks inaccuracy in clinical practice, misclassification of risk, wasted effort, and missed opportunity to correct and prevent such problems. The next step is careful pairing with low-cost, low-harm preventive strategies in a pragmatic trial of effectiveness in preventing future suicidality.

Academic health centers (AHCs) are the nation's primary resource for healthcare discovery, innovation, and training. US healthcare revenue growth has declined sharply since 2009, and is forecast to remain well below historic levels for the foreseeable future. As the cost of education and research at nearly all AHCs is heavily subsidized through large transfers from clinical care margins, our institutions face a mounting crisis. Choices centering on how to increase the cost-effectiveness of the AHC enterprise require unprecedented levels of alignment to preserve an environment that nurtures creativity. Management processes require governance models that clarify decision rights while harnessing the talents and the intellectual capital of a large, diverse enterprise to nimbly address unfamiliar organizational challenges. This paper describes key leadership tactics aimed at propelling AHCs along this journey - one that requires from all leaders a commitment to resilience, optimism, and willingness to embrace change., Competing Interests: Potential Conflicts of Interest: None disclosed.

Consistent collection and use of social and behavioral determinants of health can improve clinical care, prevention and general health, patient satisfaction, research, and public health. A recent Institute of Medicine committee defined a panel of 11 domains and 12 measures to be included in electronic health records. Incorporating the panel into practice creates a number of informatics research opportunities as well as challenges. The informatics issues revolve around standardization, efficient collection and review, decision support, and support for research. The informatics community can aid the effort by simultaneously optimizing the collection of the selected measures while also partnering with social science researchers to develop and validate new sources of information about social and behavioral determinants of health., (© The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different factors when writing clinical notes, such as narrative expressivity, amenability to the existing workflow, and usability. The authors explore the tension between expressivity and structured clinical documentation, review methods for obtaining reusable data from clinical notes, and recommend that healthcare providers be able to choose how to document patient care based on workflow and note content needs. When reusable data are needed from notes, providers can use structured documentation or rely on post-hoc text processing to produce structured data, as appropriate.

A closed-loop control process assures that a system performs within control limits by direct feedback of the system's output to change the system's inputs. We developed methods for the closed-loop control of system-based practice, using ventilator management as a model or test bed. The control system has three components: 1) an explicit end-to-end plan; 2) a record of what is done as it is done; and 3) an instant display of the status of each patient against the plan for that patient. The status display provides process control by showing the clinical team where corrections are needed while the team still has the time needed to act prospectively. We are extending these methods to the management of chronic disease. Their extension requires engagement of the patient as a member of the team, a coordinated plan across the care continuum, informatics algorithms to stratify individual patients according to co-morbidities and their current level of control, and a means of detecting the presence or absence of a reaction to each action taken by the team.

Clinical notes summarize interactions that occur between patients and healthcare providers. With adoption of electronic health record (EHR) and computer-based documentation (CBD) systems, there is a growing emphasis on structuring clinical notes to support reusing data for subsequent tasks. However, clinical documentation remains one of the most challenging areas for EHR system development and adoption. The current manuscript describes the Vanderbilt experience with implementing clinical documentation with an EHR system. Based on their experience rolling out an EHR system that supports multiple methods for clinical documentation, the authors recommend that documentation method selection be made on the basis of clinical workflow, note content standards and usability considerations, rather than on a theoretical need for structured data.

A closed loop control process assures that a system performs within control limits. In closed loop control, the system's output feeds back directly to change the system's inputs. We describe an approach to planning and monitoring care that uses closed loop control to assure the desired performance using examples from Vanderbilt University Medical Center's ventilator management initiative. The approach has three components: an explicit end-to-end plan; a record of what is done as it is done; and an instant display of the status of each patient against their plan. The status display provides process control by showing the clinical team where correction is needed while they have time to act prospectively. Plans, displays and performance evolve together iteratively until the desired performance is achieved.

A cluster of tuberculosis cases in a rural community in Arkansas persisted from 1991 to 1999. The cluster had 13 members, 11 linked epidemiologically. Old records identified 24 additional patients for 40 linked cases during a 54-year period. Residents of this neighborhood represent a population at high risk who should be considered for tuberculin testing and treatment for latent tuberculosis infection.

The vision of integrating information-from a variety of sources, into the way people work, to improve decisions and process-is one of the cornerstones of biomedical informatics. Thoughts on how this vision might be realized have evolved as improvements in information and communication technologies, together with discoveries in biomedical informatics, and have changed the art of the possible. This review identified three distinct generations of "integration" projects. First-generation projects create a database and use it for multiple purposes. Second-generation projects integrate by bringing information from various sources together through enterprise information architecture. Third-generation projects inter-relate disparate but accessible information sources to provide the appearance of integration. The review suggests that the ideas developed in the earlier generations have not been supplanted by ideas from subsequent generations. Instead, the ideas represent a continuum of progress along the three dimensions of workflow, structure, and extraction.

Informatics and information technology hold the promise of a consumer-centered health enterprise--one that provides quality care at a cost society is willing to pay; one where need-based, adaptive, competency-based learning results in cost-effectiveness of health education; one where team-based health and learning on demand, coupled with monitoring of process outcomes and network access to expertise, guarantee quality. The barriers to this promise are the professional guilds, the cross-subsidies that support the health enterprise of 1998, and the lack of respect for privacy. Collectively, the informatics community needs to develop a compelling vision that will galvanize the health community to action. If the health community does not step up to this challenge, consumers will take advantage of disintermediation. Empowered by the network, they will go outside the system into hands that meet their needs.

The changing economic environment in which our biomedical enterprises operate presents unparalleled opportunities to the profession of medical librarianship. Evidence-based medicine, patient empowerment, asynchronous learning networks, and research colaboratories each involve a new type of shared information, or access to information in new ways or by different people. These tasks are ones with which librarianship is directly involved. Librarians are therefore placed perfectly to provide new products and services. To position the library at the epicenter of the networked biomedical enterprise we must meet three challenges: We must align the library's business strategy with that of the larger enterprise. We must provide services in ways that will scale-up to enable new business strategies. We must measure the effectiveness of services in ways that document their role in supporting the enterprise.

Epidemiologic relatedness of Mycobacterium tuberculosis isolates from Arkansas residents diagnosed with tuberculosis in 1992-1993 was assessed using IS6110- and pTBN12-based restriction fragment length polymorphism (RFLP) and epidemiologic investigation. Patients with isolates having similar IS6110 patterns had medical records reviewed and were interviewed to identify epidemiologic links. Complete RFLP analyses were obtained for isolates of 235 patients; 78 (33%) matched the pattern of > or = 1 other isolate, forming 24 clusters. Epidemiologic connections were found for 33 (42%) of 78 patients in 11 clusters. Transmission of M. tuberculosis likely occurred many years in the past for 5 patients in 2 clusters. Of clusters based only on IS6110 analyses, those with > or = 6 IS6110 copies had both a significantly greater proportion of isolates that matched by pTBN12 analysis and patients with epidemiologic connections, indicating IS6110 patterns with few bands lack strain specificity. Secondary RFLP analysis increased specificity, but most clustered patients still did not appear to be epidemiologically related. RFLP clustering in rural areas may not represent recent transmission.

The Integrated Academic (Advanced) Information Management System (IAIMS) initiative emerged in the early 1980s to respond to trends in biomedical information, transfer and access, and to identify the implications for health sciences libraries. Three recurrent themes have emerged as being essential to the creation of IAIMs: changing the paradigm; redirecting expenditures to build reuseable infrastructure; and working across cultural boundaries. An IAIMS penetrates an organization in four stages: from creating awareness; through development of foundation infrastructure; through integration as an extra effort; to integration as a byproduct of organizational structure and information architecture. Extension of the IAIMS to support a regional area is a natural fifth stage that reapplies the processes of the first four stages and re-uses the infrastructure that has been built within the cooperating organizations. Area IAIMSs have the potential to transform biomedicine by enabling new paradigms for manpower development and publication of information.

The eighth annual workshop of the IAIMS Consortium was devoted to exploring how information technology might provide the tools to allow health care practices to compete in the new health care environment while maintaining independence. The options that were discussed included: optimizing care of the patient in the local setting; reducing practice overhead by improving efficiency and effectiveness; and finding innovative strategies for providing health care and new products.

In 1992-1993, we investigated possible cross-contamination of Mycobacterium tuberculosis cultures as part of a study of tuberculosis in Arkansas by using DNA fingerprint analysis. Of patients whose isolates were matched, those for whom smears were negative and only one culture was positive were identified from laboratory records. Clinical, laboratory, DNA fingerprint, and epidemiological data were reviewed. Of 259 patients, nine (3.5%) were judged to be due to cross-contamination. None of these patients had a clinical course consistent with tuberculosis. All nine specimens were processed with another isolate with a matching DNA fingerprint, and epidemiological connections were not identified among any of the patients. To avoid erroneous diagnoses and unnecessary therapy and public health investigations, specimens from patients with tuberculosis whose smears are negative and only one culture is positive should be investigated for cross-contamination. An inconsistent clinical course and a DNA fingerprint that matches those of other culture-positive specimens processed concurrently, coupled with the lack of an epidemiological connection, suggest cross-contamination.

Objective: Refine the understanding of the desirable skills for health sciences librarians as a basis for developing a training program model that reflects the fundamental changes in health care delivery and information technology., Design: A four-step needs assessment process: focus groups developed lists of desirable skills; the research team organized candidate skills into a taxonomy; a survey of a random sample of librarians and library users assessed perception of importance of individual skills; and the research team framed, as a unifying hypothesis, a training model., Survey Methods: The survey was distributed to random samples of 150 librarians, stratified by type of library, and 150 library users, stratified by type of use. A non-randomized sample was obtained by mounting the survey on a World Wide Web server. The survey instrument included 96 distinct skills organized into 13 categories. Respondents rated the importance of each skill on a Likert scale and provided a separate ranking by identifying the ten most important skills for the profession., Results: Among the participants, 51% of librarians and 36% of library users responded to the survey. All categories of skills were rated above the midpoint of priority on the Likert scale. All groups rated personality characteristics and skills as most important, with an understanding of the health sciences, education, and research being rated comparably to technical skills., Conclusions: Health sciences librarians need a new educational model that provides them with broad-based tools to discover new roles and new resources for acquiring individual skills as the need arises. A unifying training model would involve trainees in developing their learning plan in a way that promotes proactive inquiry and self-directed learning, and it would rotate the trainees through projects to provide skills and an understanding of end-user work processes.

Vanderbilt University Medical Center (VUMC) developed a model training program to prepare current and future health sciences librarians for roles that are integrated into the diverse fabric of the health care professions. As a complement to the traditional and theoretical aspects of a librarian's education, this mixture of supplemental coursework and intensive practical training emphasizes active management of information, problem-solving skills, learning in context, and direct participation in research, while providing the opportunity for advanced academic pursuits. The practical training will take place under the auspices of an established Integrated Advanced Information Management Systems (IAIMS) library that is fully integrated with the Health Center Information Management Unit and Academic Biomedical Informatics Unit. During the planning phase, investigators are analyzing the model's aims and requirements, concentrating on (a) refining the current understanding of the roles health sciences librarians occupy; (b) developing educational strategies that prepare librarians to fulfill expanded roles; and (c) planning for an evaluation process that will support iterative revision and refinement of the model.

Vanderbilt University Medical Center is implementing an Integrated Advanced Information Management System (IAIMS) using a fast-track approach. The elapsed time between start-up and completion of implementation will be 7.5 years. The Start-Up and Planning phases of the project are complete. The Implementation phase asks one question: How does an organization create an environment that redirects and coordinates a variety of individual activities so that they come together to provide an IAIMS? Four answers to this question are being tested. First, design resources to be "scalable"--i.e., capable of supporting enterprise-wide use. Second, provide information technology planning activities as ongoing core functions that direct local efforts. Third, design core infrastructure resources to be both reusable and expandable at the local level. Fourth, use milestones to measure progress toward selected endpoints to permit early refinement of plans and strategies.

Specific amplification of Mycobacterium tuberculosis DNA was investigated as an alternative to conventional microbiologic follow-up in 31 cases of smear- and culture-positive pulmonary tuberculosis. Strand displacement amplification (SDA) and the polymerase chain reaction (PCR) were applied to 438 sequential sputum specimens: 67 (15%) were positive by culture, 248 (57%) by SDA, and 231 (53%) by PCR (chi2=3.94, P=.05). Of 200 specimens collected >180 days after treatment started, none yielded positive cultures, while 50 (25%), representing 16 patients, were positive by both DNA assays. A weak correlation was demonstrated between DNA persistence in sputum and duration of culture positivity (r=0.45, P=.01), although no correlation was found with the radiographic extent of disease. The inability to distinguish live and dead organisms precludes DNA amplification from use in therapeutic monitoring. For this purpose, quantitative RNA assays are needed if such techniques are to supplant conventional microbiology.

Direct computer-based physician order entry has been the subject of debate for over 20 years. Many sites have implemented systems successfully. Others have failed outright or flirted with disaster, incurring substantial delays, cost overruns, and threatened work actions. The rationale for physician order entry includes process improvement, support of cost-conscious decision making, clinical decision support, and optimization of physicians' time. Barriers to physician order entry result from the changes required in practice patterns, roles within the care team, teaching patterns, and institutional policies. Key ingredients for successful implementation include: the system must be fast and easy to use, the user interface must behave consistently in all situations, the institution must have broad and committed involvement and direction by clinicians prior to implementation, the top leadership of the organization must be committed to the project, and a group of problem solvers and users must meet regularly to work out procedural issues. This article reviews the peer-reviewed scientific literature to present the current state of the art of computer-based physician order entry.

Careful study of medical informatics research and library-resource projects is necessary to increase the productivity of the research and development enterprise. Medical informatics research projects can present unique problems with respect to evaluation. It is not always possible to adapt directly the evaluation methods that are commonly employed in the natural and social sciences. Problems in evaluating medical informatics projects may be overcome by formulating system development work in terms of a testable hypothesis; subdividing complex projects into modules, each of which can be developed, tested and evaluated rigorously; and utilizing qualitative studies in situations where more definitive quantitative studies are impractical.