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| Name | Class |
|---|---|
| Agency for Healthcare Research and Quality (AHRQ) | FED |
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The purpose of this study is to advance the science of healthcare informatics and to improve medication management through the development of a new approach to the electronic medical record called the Integrated Medication Manager (IMM).
In an attempt to address problems patient non-compliance with quality goals barriers to access and integration of health information that impede achievement of treatment goals, the VA is developing a new approach to the electronic medical record. The VA is moving away from the paper-chart metaphor and towards an integrated representation of the patient's status and care process across time. One of the first steps in the development phase has been to explicitly relate patient conditions, therapies, and goals in the domain of pharmacotherapy. This is called Integrated Medication Management and draws on Hollnagel's Contextual Control Model. Providers will be able to plan care and create orders directly in the context of these explicit relationships. This application will be implemented nationwide through a web interface embedded within the existing Computerized Patient Record System (CPRS), the graphical user interface to VA Information Systems (VistA).
Aim 1: Identify cognitive components of providers' therapeutic decision making in the field.
Aim 2. Refine and evaluate the Integrated Medication Manager using simulation studies.
All hypotheses (below) test the use of IMM versus usual electronic medical record (EMR).
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Integrated Medication Manager | Experimental | Experienced providers that participated in the EHR simulations. Half of the providers were assigned to use the new Integrated Medication Manager (intervention) during the simulation. The other half were assigned the VA's CPRS to use (standard EHR). Providers were randomly assigned which system to use. |
|
| Standard EHR | No Intervention | Experienced providers that participated in the EHR simulations. Half of the providers were assigned to use the new Integrated Medication Manager (intervention) during the simulation. The other half were assigned the VA's CPRS to use (standard EHR). Providers were randomly assigned which system to use. |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Integrated Medication Manager | Other | A theory based electronic health record. Half of the provider participants were assigned the IMM to use. The other half were assigned the VA's CPRS EHR to use for the simulation. Providers were randomly assigned to a EHR to use. |
| Measure | Description | Time Frame |
|---|---|---|
| Amount of Time to Complete Assessment and Plan | Each participant had 10 minutes maximum to review the patient case and write an Assessment and Plan. | 10 minutes |
| Accuracy of Written Assessment and Plan in Terms of Control and Status | Each participant had 10 minutes maximum to review the patient case and write an Assessment and Plan. The primary outcome evaluated participants' recommendations for treatment of patient conditions. Participants reviewed a total of 10 patient cases and received a score between 0 and 3 points for each issue within each patient case. The final score for each participant was a proportion between 0 and 1. The proportion represented the sum of all points assigned to the participant, divided by the total number of points possible. Higher values on the scale represent greater accuracy of the written assessment and plan. | 10 minutes |
| Measure | Description | Time Frame |
|---|---|---|
| Identification of Planned Monitoring and Follow up Encounters in Assessment and Plan | Each participant had 10 minutes maximum to review the patient case and write an Assessment and Plan. . The secondary outcome evaluated participants' recommendation about future monitoring of patient conditions. Participants reviewed a total of 10 patient cases and received a score of 0 or 1 point for each issue within each case. The final score for each participant was a proportion between 0 and 1. The proportion represented the sum of all points assigned to the participant, divided by the total number of points possible. Higher values on the scale represent a greater proportion of appropriate monitoring recommendations made. |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Jonathan Nebeker, MD, MS | University of Utah | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| VA SLC Health Care System | Salt Lake City | Utah | 84148 | United States |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 15611491 | Background | Asch SM, McGlynn EA, Hogan MM, Hayward RA, Shekelle P, Rubenstein L, Keesey J, Adams J, Kerr EA. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med. 2004 Dec 21;141(12):938-45. doi: 10.7326/0003-4819-141-12-200412210-00010. | |
| 16585667 | Background | Perlin JB, Pogach LM. Improving the outcomes of metabolic conditions: managing momentum to overcome clinical inertia. Ann Intern Med. 2006 Apr 4;144(7):525-7. doi: 10.7326/0003-4819-144-7-200604040-00012. No abstract available. |
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Recruitment 12/2010 to 3/2011 at the Salt Lake City VA and University of Utah health care systems. Simulations took place at either of these locations.
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| ID | Title | Description |
|---|---|---|
| FG000 | Integrated Medication Manager | Experienced providers that participated in the EHR simulations. Half of the providers were assigned to use the new Integrated Medication Manager (intervention) during the simulation. The other half were assigned the VA's CPRS to use (standard EHR). Providers were randomly assigned which system to use. |
| FG001 | Standard EHR | Experienced providers that participated in the EHR simulations. Half of the providers were assigned to use the new Integrated Medication Manager (intervention) during the simulation. The other half were assigned the VA's CPRS to use (standard EHR). Providers were randomly assigned which system to use. |
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
Half of the providers were assigned to use the new Integrated Medication Manager (intervention) during the simulation. The other half were assigned to use VA's CPRS (standard EHR). Providers were randomly assigned which system to use.
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| ID | Title | Description |
|---|---|---|
| BG000 | Integration Medication Manager | Experienced providers that participated in the EHR simulations. Half of the providers were assigned to use the new Integrated Medication Manager (intervention) during the simulation. The other half were assigned the VA's CPRS to use (standard EHR). Providers were randomly assigned which system to use. |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Categorical | Count of Participants |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Amount of Time to Complete Assessment and Plan | Each participant had 10 minutes maximum to review the patient case and write an Assessment and Plan. | 58 providers were enrolled | Posted | Mean | Standard Deviation | minutes | 10 minutes |
|
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Integrated Medication Manager | Experienced providers that participated in the EHR simulations. Half of the providers were assigned to use the new Integrated Medication Manager (intervention) during the simulation. The other half were assigned the VA's CPRS to use (standard EHR). Providers were randomly assigned which system to use. Integrated Medication Manager: A theory based electronic health record. Half of the provider participants were assigned the IMM to use. The other half were assigned the VA's CPRS EHR to use for the simulation. Providers were randomly assigned to a EHR to use. |
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We were not able to evaluate a system-wide deployment of the resulting graphical user interface (GUI) (IMM) in terms of patient outcomes (Aim 3). We were unable to conduct Aim 3, which would have evaluated IMM in a cluster-randomized trial.
| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr. Jonathan Nebeker | University of Utah Health Care System | 801-582-1565 | 2458 | Jonathan.Nebeker@hsc.utah.edu |
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|
| 10 minutes |
| 10691588 | Background | Morris AH. Developing and implementing computerized protocols for standardization of clinical decisions. Ann Intern Med. 2000 Mar 7;132(5):373-83. doi: 10.7326/0003-4819-132-5-200003070-00007. |
| 15537204 | Background | Fox J, Alabassi A, Black E, Hurt C, Rose T. Modelling clinical goals: a corpus of examples and a tentative ontology. Stud Health Technol Inform. 2004;101:31-45. |
| 8976626 | Background | Xiao Y, Hunter WA, Mackenzie CF, Jefferies NJ, Horst RL. Task complexity in emergency medical care and its implications for team coordination. LOTAS Group. Level One Trauma Anesthesia Simulation. Hum Factors. 1996 Dec;38(4):636-45. doi: 10.1518/001872096778827206. |
| 11694107 | Background | Phillips LS, Branch WT, Cook CB, Doyle JP, El-Kebbi IM, Gallina DL, Miller CD, Ziemer DC, Barnes CS. Clinical inertia. Ann Intern Med. 2001 Nov 6;135(9):825-34. doi: 10.7326/0003-4819-135-9-200111060-00012. |
| 14528038 | Background | Nebeker JR, Hurdle JF, Bair BD. Future history: medical informatics in geriatrics. J Gerontol A Biol Sci Med Sci. 2003 Sep;58(9):M820-5. doi: 10.1093/gerona/58.9.m820. |
| 16046562 | Background | Crosson JC, Stroebel C, Scott JG, Stello B, Crabtree BF. Implementing an electronic medical record in a family medicine practice: communication, decision making, and conflict. Ann Fam Med. 2005 Jul-Aug;3(4):307-11. doi: 10.1370/afm.326. |
| 16050875 | Background | Hayward RA, Asch SM, Hogan MM, Hofer TP, Kerr EA. Sins of omission: getting too little medical care may be the greatest threat to patient safety. J Gen Intern Med. 2005 Aug;20(8):686-91. doi: 10.1111/j.1525-1497.2005.0152.x. |
| 15625341 | Background | Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004 Dec 30;351(27):2870-4. doi: 10.1056/NEJMsb042458. No abstract available. |
| 15755945 | Background | Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, Sam J, Haynes RB. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005 Mar 9;293(10):1223-38. doi: 10.1001/jama.293.10.1223. |
| 17106490 | Background | Shekelle PG. Invited commentary: Implementation of health information technology: an important but challenging field of inquiry. Proc (Bayl Univ Med Cent). 2006 Oct;19(4):313. doi: 10.1080/08998280.2006.11928190. No abstract available. |
| 17068345 | Background | Weir CR, Nebeker JJ, Hicken BL, Campo R, Drews F, Lebar B. A cognitive task analysis of information management strategies in a computerized provider order entry environment. J Am Med Inform Assoc. 2007 Jan-Feb;14(1):65-75. doi: 10.1197/jamia.M2231. Epub 2006 Oct 26. |
| 9533188 | Background | Berg CA, Strough JN, Calderone KS, Sansone C, Weir C. The role of problem definitions in understanding age and context effects on strategies for solving everyday problems. Psychol Aging. 1998 Mar;13(1):29-44. doi: 10.1037//0882-7974.13.1.29. |
| 9929232 | Background | Weir CR. Linking information needs with evaluation: the role of task identification. Proc AMIA Symp. 1998:310-4. |
| 1065968 | Background | Taatz H. [The problem of the time factor in orthodontic treatment]. Stomatol DDR. 1976 Feb;26(2):102-5. No abstract available. German. |
| 10787581 | Background | Campbell M, Grimshaw J, Steen N. Sample size calculations for cluster randomised trials. Changing Professional Practice in Europe Group (EU BIOMED II Concerted Action). J Health Serv Res Policy. 2000 Jan;5(1):12-6. doi: 10.1177/135581960000500105. |
| 15046136 | Background | Miller RH, Sim I. Physicians' use of electronic medical records: barriers and solutions. Health Aff (Millwood). 2004 Mar-Apr;23(2):116-26. doi: 10.1377/hlthaff.23.2.116. |
| 10414834 | Background | Bradley EH, Bogardus ST Jr, Tinetti ME, Inouye SK. Goal-setting in clinical medicine. Soc Sci Med. 1999 Jul;49(2):267-78. doi: 10.1016/s0277-9536(99)00107-0. |
| BG001 |
| Standard EHR |
Experienced providers that participated in the EHR simulations. Half of the providers were assigned to use the new Integrated Medication Manager (intervention) during the simulation. The other half were assigned the VA's CPRS to use (standard EHR). Providers were randomly assigned which system to use. |
| BG002 | Total | Total of all reporting groups |
| Participants |
|
| Sex: Female, Male | Count of Participants | Participants |
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| Region of Enrollment | Number | participants |
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|
| Primary | Accuracy of Written Assessment and Plan in Terms of Control and Status | Each participant had 10 minutes maximum to review the patient case and write an Assessment and Plan. The primary outcome evaluated participants' recommendations for treatment of patient conditions. Participants reviewed a total of 10 patient cases and received a score between 0 and 3 points for each issue within each patient case. The final score for each participant was a proportion between 0 and 1. The proportion represented the sum of all points assigned to the participant, divided by the total number of points possible. Higher values on the scale represent greater accuracy of the written assessment and plan. | Posted | Mean | 95% Confidence Interval | units on a scale | 10 minutes |
|
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|
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| Secondary | Identification of Planned Monitoring and Follow up Encounters in Assessment and Plan | Each participant had 10 minutes maximum to review the patient case and write an Assessment and Plan. . The secondary outcome evaluated participants' recommendation about future monitoring of patient conditions. Participants reviewed a total of 10 patient cases and received a score of 0 or 1 point for each issue within each case. The final score for each participant was a proportion between 0 and 1. The proportion represented the sum of all points assigned to the participant, divided by the total number of points possible. Higher values on the scale represent a greater proportion of appropriate monitoring recommendations made. | Posted | Mean | 95% Confidence Interval | proportion | 10 minutes |
|
|
|
|
| 0 |
| 30 |
| 0 |
| 30 |
| EG001 | Standard EHR | Experienced providers that participated in the EHR simulations. Half of the providers were assigned to use the new Integrated Medication Manager (intervention) during the simulation. The other half were assigned the VA's CPRS to use (standard EHR). Providers were randomly assigned which system to use. Integrated Medication Manager: A theory based electronic health record. Half of the provider participants were assigned the IMM to use. The other half were assigned the VA's CPRS EHR to use for the simulation. Providers were randomly assigned to a EHR to use. | 0 | 28 | 0 | 28 |
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