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2011.10.12 - EBM - electronic health records
Terms in this set (27)
What study designs are used to evaluate Computerized Decision Support Systems (CDSS)?
Time Series, Before and After Studies.
What are the challenges of randomized control trials of Computerized Decision Support Systems (CDSS)? And how can it be minimized?
RCT are strongest design, but blinding isn't possible which leads to contamination (less difference btw groups) and co-interventions (greater difference btw groups). MINIMIZED by randomizing GROUPS of physicians and increasing number of clusters. But need to account for confounding variables.
What are common biases of Computerized Decision Support Systems?
Contamination, co-intervention, data completeness bias (thorough follow-up), surveillance bias
What is the difference between patient and process of care outcomes?
Process of Care Outcomes measures physician compliance with health care processes (NEED SMALLER NUMBER OF PARTICIPANTS TO GENERATE OUTCOME). Patient Outcomes measure the diagnosis of patients (mortality, length of stay, infection, cancer rate, etc) (NEED LARGER NUMBER OF PARTICIPANTS TO GET OUTCOME)
How can we determine if Computerized Decision Support Systems are applicable?
ASK, AQUIRE, APPRAISE, APPLY, ASSESS! Adjust for confounding, adjust for changes over time.
How can we determine if Computerized Decision Support Systems (CDSS) are efficient?
1. Computer logic (is logic too complicated to do on your own). 2. Computer Interface (is the interface easy to use?) 3. Logic and Interface (1 & 2). 4. Work Flow changes to incorporate CDSS
What are some barriers to proliferation of Computerized Decision Support Systems (CDSS)?
1. EXPORTABLE -CDSS must be easliy integrated into existing software 2. Automated databases (not manual entry) 3. Maintanence of software 4. Users (physicians) must accept it 5. Must be able to customize the program 6. Real costs are much higher than initial cost
What are some causes of poor healthcare in the US?
Highest cost, fastest increasing cost, medical errors, variations of care delivery (not meeting known measures of quality),
What are some benefits of using Electronic Health Records (EHR)?
Prevention, Safety, Efficiency, Costs, Duplication/redundancy, Variation in care, computerized decision support systems (CDSS)
What is health care quality?
How much health services increase desired outcomes that are consistent with EBM.
What are some of the functions of CDSS?
Alerting (abnormal values), Reminding, Critiquing, Interpreting, Predicting, Diagnosing, Assisting, Suggesting
What search terms do you use to find CDSS (Computerized Decision Support System)?
"Decision Support Techniques" "Decision Making, Computer Assisted" "Decision Support Systems, Clinical" "Medical Order Entry Systems"
What is the definition of a confounding variable?
A variable that can cause or prevent the outcome of interest, is not an intermediate variable, and is associated with the factor under investigation. A confounding variable may be due chance or bias.
What is a Before and After Study? What is a weakness of this study?
OBSERVATIONAL: Comparing outcomes before and after a technology is implemented. Its validity is threatened by general changes over time (secular trends)
What is a Time Series Design? What is a weakness of this study?
OBSERVATIONAL: Turn the intervention (CDSS) on and off several times. Its validity is threatened by general changes over time (secular trends)
What is Co-intervention bias of studies?
More common in un-blinded studies. Additional treatments given to experimental group than control => increased "effectiveness" of intervention
What is contamination bias of studies?
Common with Randomized Control Trials of CDSS. Control group receives all or part of intervention => minimizing/diluting effect of CDSS.
What is the best way to study CDSS?
Cluster Randomized Control Trial (randomize groups of physicians ie clinic or hospital, rather than individual physicians within the same clinic)
What can cause Unit of Analysis Error bias?
Normally RCT groups should be the same in regards to prognostic factors, and only different in intervention. But in unit of analysis error, prognostic factors are different (Intraclass Correlation = 1)
What does an Intraclass Correlation (ICC) value of 1 mean?
That there is no similarity between the prognostic factors between experimental and control groups. NORMALLY you want prognostic factors the same and only intervention to be different (a good score is 0)
How can you decrease Intraclass Correlation (ICC) value to a better value?
Increase the number of clusters. This will bring value closer to 0.
How does a Unit of Analysis of a clinician or clinician group change the results of a CDSS study?
A Unit of Analysis with clinicians as the unit leaves more room for co-intervention and contamination biases.
What are some issues with Intention to Treat with Physicians in CDSS studies?
Computer Competency Varies! (some may not use CDSS even though assigned to that group).
FACT: EHR (electonic health records) and CDSS do improve PREV MED and decrease MED ERRORS, but they don't improve diagnosis or improve hospital care.
What percentage of American healthcare facilities keep all 9 2009 American Recovery and Reinvestment Act criterion?
2% This makes it difficult to see the full effect of whether or not CDSS is effective in improving care delivery and patient outcomes.
Patients in a single outpatient group practice were randomized to having the alert appear to the physician in the group's EHR or not appear. The results of the study showed that the alert did not significantly improve vaccination rates. What was the most likely source of bias in this study?
The two groups have the same electronic health record but one group has used it for nearly 5 years while the other just started. The group with the longer experience receives the alert for all patients in the practice and the other receives no alerts The results show a 70% improvement in vaccination rates in the patients of the group receiving alerts. What is the possible cause of bias in this study?
Intraclass Correlation (ICC) is high (close to 1) since prognostic factors are not the same for both clusters.
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