Category - Part 4
Prospective Study of the Diagnostic Accuracy of the Simplify D-dimer Assay for Pulmonary Embolism in Emergency Department Patients: Materials and Methods
Typical indications for the PE rule-out protocol included symptoms of dyspnea, chest pain, or syncope, or physical signs such as a rapid pulse or low pulse oximetry reading that could not be explained by another disease process. Exclusions were hemodynamic instability (clinical signs of shock as described by Jones et al), inability to obtain a blood sample for the d-dimer assay, or patient unwillingness to participate. Prior to diagnostic testing, physicians completed a Web-based electronic data collection form that contained > 70 data fields. The contents and methodology of this Web-based form have been published. The form first asks the clinician to provide his or her own three-tiered, unstructured pretest probability (low, < 15%; moderate, 15 to 40%; high, > 40%), and later parts of the data form contained elements required to compute the Canadian score and the Charlotte rule. The Charlotte rule, when negative, predicts a low-enough pretest probability to allow PE to be ruled out safely using either a quantitative d-dimer or a qualitative d-dimer in conjunction with a normal alveolar dead space measurement. comments
Prospective Study of the Diagnostic Accuracy of the Simplify D-dimer Assay for Pulmonary Embolism in Emergency Department Patients
The ideal screening strategy to exclude pulmonary embolism (PE) in the emergency department (ED) setting would be, fast, cheap, accurate, and easy to use. The d-dimer assay (Simplify D-dimer; Agen Biomedical; Brisbane, Australia) is a single-use, individually packaged immunofiltration cartridge assay. The kits and the reagents can be stored at room temperature. The user adds a drop of whole blood to a well, followed by a few drops of buffer. The test result is read in 10 min at the bedside. The test has an acquisition cost of < $20. However, to ensure patient safety and to maintain a defensible standard of care, any PE screening strategy must have sufficiently high sensitivity and specificity to reliably produce a posttest probability < 1.0%. add comment
Applied Medical Informatics for the Chest Physician: The Challenge of Understanding Clinical Workflow
The root causes for problems with interoperability include changing information technologies, competing proprietary vendor systems, and, simply, the complexity of clinical information systems. More recently, it has been recognized that standardization will be essential to the success of the National Health Information Network. Regional Health Information Networks are now beginning to appear in many states as networks of EMRs. All of this interconnection, though, clearly demands the standardization of systems and communications; in a word, interoperability. more
In the discussion of standards and interoperability, however, has appeared the additional issue of the standardization of language. In the AMI world, this notion of standardized medical terminology usually leads to the term lexicon, or dictionary. There are many examples of standardized medical lexicons (Fig 3). However through the efforts of Dr. David Brailer and the Office of the National Center for Healthcare Information Technology, the lexicon SNOMED has been acquired for use throughout the United States in an effort to catalyze the effective information interchange between information systems. The manufacturers of EMRs are now rapidly incorporating this particular lexicon. It has been said that the complexity of the automation of health care is much like the automation in the aerospace industry. Although the precise complexity grading of health-care automation may never be done, the fact is that there are numerous examples of failed clinical information systems over the past 30+ years that are related in part to the poor understanding and oversimplification of the process of clinical care.
Applied Medical Informatics for the Chest Physician: Clinicians Expectation
Clinician time spent and the value perceived in the EMR remains one of the primary concerns in the United States. In more recent studies, physicians have definitely ranked EMRs toward the top of the solutions to decreasing the number of medical errors. However, it is important to understand that, even in the most optimistic investigations, the physician use of EMRs, in particular order entry, takes more time compared to the physical process of writing orders on an order form at this point in time. this
Even in the realm of computer hardware in support of EMR use, there are emerging data suggesting that different clinicians (ie, physicians vs nurses) obtain differing value from the location of computer terminals. In a recent study, the use of bedside terminals and central station desktop computers saved nurses 24.5% and 23.5%, respectively, of their overall time spent documenting during a shift. However, in the same study, the use of central station desktop computers for physician order entry was found to be inefficient, increasing the work time from 98.1 to 328.6% of a physician’s time per working shift.
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Applied Medical Informatics for the Chest Physician: Time Commitment
How much do EMRs cost? The firm First Consulting Group, based in California, said it would cost $210 million in one-time start-up expenditures for the 46 Massachusetts hospitals to install them or to update existing technology to a minimum agreed-on standard. However, the consultant predicted the hospitals would save $275 million annually because the systems reduce errors and, as a result, avoid medical care for unintentional injuries to patients.
Other than the actual cost of CPOE systems, an important consideration is where the financial incentives for adoption occur. In a one report, the Center for Information Technology Leadership estimated that 89% of the economic benefits of CPOE accrues to the holder of the financial risk for health care (ie, insurance companies). At a time when the financial value of EMRs and CPOE specifically are coming under increasing economic scrutiny, perhaps the consideration of where the financial value really exists for CPOE will be better realized and the incentives realigned appropriately. in detail
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Applied Medical Informatics for the Chest Physician: Technology
It is intuitive that the introduction of an EMR into a large academic health system will differ in many ways from its introduction into a small, community, private practice office. However, what may not be as evident is that the characteristics of these different clinical environments may have more to do with success than simply scale alone. That is, in clinical settings where there is a well-established tradition of clinical groups working cooperatively with one another (eg, a typical office practice), there is significantly greater acceptance of a change, such as the introduction of an EMR. Conversely, where there are settings in which there is a discrete group that is expected to bear the brunt of the change resulting from the EMR introduction, tragic failures have been well-documented. These failures may stem from even the perception of the possibility of losing authority or from not being involved in the configuration of the system. so
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Applied Medical Informatics for the Chest Physician: Complexity of the EMR
The elements of achieving success in an EMR selection, configuration, and implementation are complex. The three major categories are “Winning Hearts and Minds,” “Technology,” and “Place and Time” (Fig 1). Credible leadership is essential, and, as has been demonstrated repeatedly, implementing any change in medical practice usually revolves around a group leadership model. The change cannot be achieved without involvement of these pre-EMR clinical leaders. Unfortunately, in the current health-care informatics reality in this country, there is no standard EMR, no standard EMR implementation plan, and, even within an individual commercial EMR product, no standard configuration kit. Therefore, the champions of EMR need to address the following issues. The introduction of an EMR into a clinical practice, even the smallest of offices, should be viewed as a campaign. A campaign requires some element of orientation, education, and credible leadership to achieve success. buy-asthma-inhalers-online.com