Clinical Problem Lists in the Electronic Health Record PDF
Preview Clinical Problem Lists in the Electronic Health Record
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He rdlthorRe Adam Wright, PhD the leahdaesr sah Piph tDe ainm M feodr itchael IAngfoenrmcya ftoicrs H freoamlth tchaer eO rReegsoena rHche aIaSlnthdB aQNnud:a lS9itc7yie-8nF-uc1en -dU7end7iv C1elr8isni8itcy-a 0al nD9de1 ca-is 6BioSn i nS upport dc ConsorMtiuamth,e wmhaitcihca ils afoncdu Csoemd opnu tdaetvioenloapl iSncgie mnceetsh fordosm f oSrt ashnaforirndg U cnIlSiinvBeicraNsli td:y e.9c7isi8o-n1 s-u7p7po1r98t 0c8o-0n0t0e9n01t.- H6e R o 90000 e r has a PhD in Medical Informatics from the Oregon Health and Science University and a BS in c d ISBN: 978-1-77188-091-6 o Mathematical and Computational Sciences from Stanford University. 90000 r d ISBN: 978-1-77188-091-6 9 781771 880916 90000 9 781771 880916 9 781771 880916 www.appleacademicpress.com 9 781771 880916 CLINICAL PROBLEM LISTS IN THE ELECTRONIC HEALTH RECORD CLINICAL PROBLEM LISTS IN THE ELECTRONIC HEALTH RECORD Edited by Adam Wright, PhD Apple Academic Press TORONTO NEW JERSEY CRC Press Apple Academic Press, Inc Taylor & Francis Group 3333 Mistwell Crescent 6000 Broken Sound Parkway NW, Suite 300 Oakville, ON L6L 0A2 Boca Raton, FL 33487-2742 Canada © 2015 by Apple Academic Press, Inc. Exclusive worldwide distribution by CRC Press an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Version Date: 20141104 International Standard Book Number-13: 978-1-4987-1206-4 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources. Reason- able efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www. copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organiza- tion that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com For information about Apple Academic Press product http://www.appleacademicpress.com ABOUT THE EDITOR ADAM WRIGHT, PhD Adam Wright is an Assistant Professor of Medicine at Harvard Medical School, whose research interests include electronic health records, clini- cal decision support, and data mining. In addition to research, Dr. Wright teaches introductory medical informatics at Harvard Medical School as well as clinical epidemiology and healthcare policy to medical students. He is also a member of the leadership team for the Agency for Health- care Research and Quality-Funded Clinical Decision Support Consortium, which is focused on developing methods for sharing clinical decision sup- port content. Adam has a PhD in Medical Informatics from the Oregon Health and Science University, and a BS in Mathematical and Computa- tional Sciences from Stanford University. CONTENTS Acknowledgment and How to Cite ..................................................xi List of Contributors .......................................................................xiii Introduction ...................................................................................xvii Part I: History and Importance 1. Bringing Science to Medicine: An Interview with Larry Weed, Inventor of the Problem-Oriented Medical Record ................................3 Adam Wright, Dean F. Sittig, Julie McGowan, Joan S. Ash, and Lawrence L. Weed 2. Medical Records That Guide and Teach ................................................19 Lawrence L. Weed 3. Clinical Implications of an Accurate Problem List on Heart Failure Treatment .....................................................................45 Daniel M. Hartung, Jacquelyn Hunt, Joseph Siemienczuk, Heather Miller, and Daniel R. Touchette Part II: Attitudes and Use 4. Clinician Attitudes Toward and Use of Electronic Problem Lists: A Thematic Analysis ................................................................................ 59 Adam Wright, Francine L. Maloney, and Joshua C. Feblowitz 5. Healthcare Provider Attitudes Towards the Problem List in an Electronic Health Record: A Mixed-Methods Qualitative Study ..................................................................................... 83 Casey Holmes, Michael Brown, Daniel St Hilaire, and Adam Wright 6. Use of an Electronic Problem List by Primary Care Providers and Specialists .........................................................................................121 Adam Wright, Joshua Feblowitz, Francine L. Maloney, Stanislav Henkin, and David W. Bates 7. Distribution of Problems, Medications and Lab Results in Electronic Health Records: The Pareto Principle at Work ................135 Adam Wright and David W. Bates viii Clinical Problem Lists in the Electronic Health Record Part III: Improving the Problem List 8. An Automated Technique for Identifying Associations Between Medications, Laboratory Results and Problems .................................147 Adam Wright, Elizabeth S. Chen, and Francine L. Maloney 9. A Method and Knowledge Base for Automated Inference of Patient Problems from Structured Data in an Electronic Medical Record .......................................................................................183 Adam Wright, Justine Pang, Joshua C. Feblowitz, Francine L. Maloney, Allison R. Wilcox, Harley Z. Ramelson, Louise I. Schneider, and David W. Bates 10. Improving Completeness of Electronic Problem Lists Through Clinical Decision Support: A Randomized, Controlled Trial .............209 Adam Wright, Justine Pang, Joshua C. Feblowitz, Francine L. Maloney, Allison R. Wilcox, Karen Sax McLoughlin, Harley Ramelson, Louise Schneider, and David W. Bates 11. Computerized Physician Order Entry of Medications and Clinical Decision Support Can Improve Problem List Documentation Compliance ..................................................................229 William L. Galanter, Daniel B. Hier, Chiang Jao, and David Sarne 12. Randomized Controlled Trial of an Automated Problem List With Improved Sensitivity ...............................................................................245 Stéphane M. Meystre and Peter J. Haug Part IV: Applications of the Problem List 13. Incomplete Care: On the Trail of Flaws in the System .......................273 Tejal K. Gandhi, Gianna Zuccotti, and Thomas H. Lee 14. Leveraging Electronic Health Records to Support Chronic Disease Management: The Need for Temporal Data Views .............................279 Lipika Samal, Adam Wright, Bang Wong, Jeffrey Linder, and David Bates 15. Indication-Based Prescribing Prevents Wrong-Patient Medication Errors In Computerized Provider Order Entry (CPOE) ...................299 William Galanter, Suzanne Falck, Matthew Burns, Marci Laragh, and Bruce L. Lambert Author Notes ....................................................................................................313 Index .................................................................................................................321 ACKNOWLEDGMENT AND HOW TO CITE The editor and publisher thank each of the authors who contributed to this book. All chapters were previously published in various places in various formats; to cite the work contained in this book and to view the individual permissions, please refer to the citation at the beginning of each chapter. Each chapter was read individually and carefully selected by the editor; the result is a book that examines the use of clinical problem lists in elec- tronic health records from many different perspectives, including their im- portance, history, possible improvements, and current applications.
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