Keywords
Key points
- •Medical errors will occur: how teams deal with mistakes is what matters most.
- •Punition does not work, and rather serves to isolate team members and precipitate greater errors as a consequence of the atmosphere of fear, uncertainty, and disempowerment that such an approach breeds.
- •A well-structured, highly reliable, and functional team has the potential to significantly affect the patient’s experience in the pediatric intensive care unit.
- •Handoffs or communications between providers at all phases of care are crucial for accurate, timely, and efficient delivery of care.
- •When skilled pediatric providers work closely with patients and their families, the results can be mutually rewarding.
- •The specifics of implementing an electronic health records system with attention to alterations of workflow and other unintended consequences could be the decisive factors in determining the success or failure of such a system.
- •Health information exchange, a specific implementation of “interoperability,” the ability of systems to work with one another, improves quality by increasing the availability of data on patients who have care delivered by different organizations.
- •By eliminating unnecessary practice variation, protocols should result in more efficient and effective care with lower overall cost of health care without compromising quality.
- •The key feature of an adequately explicit protocol is that it would lead different clinicians to the same decision when faced with the same clinical scenario, allowing the treatment to vary based on patient variability rather than on physician variability.
Quality analysis and performance improvement
How quality is defined and measured is at times elusive, and almost always variable (Table 1).
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Although most health environments have in place a systematic method for reporting and reviewing medical errors and disseminating the lessons learned from such analyses, the processes are typically institution-specific and formulated on the needs of a distinct medical environment. The integrity and rigor of such systems are sufficiently different to make a collective assessment of best practice difficult. Nevertheless, we know there is value to acknowledging errors, particularly in real time, and benefit further from designing initiatives to prevent rather than to merely correct similar occurrences. Beyond the formal processes by which medical errors are evaluated, health providers can also benefit from ad hoc debriefing and education, both of which contribute to a unified shared mental model of the goals for care delivery. Together, these initiatives comprise the basis of the quality review process in many pediatric units.Table 1Six aims for health care improvement
From Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. National Academies Press; 2001. Available at: http://www.nap.edu/openbook.php?record_id=10027&page=R1. Accessed September 17, 2012; with permission.
| Aims for Health Care Improvement | Definition |
|---|---|
| Safe | Avoid unintentional harm associated with the delivery of health care |
| Effective | Provide evidence-based health care with observance of best practice balanced with scientific evidence and clinical expertise |
| Patient-centered | Ensure health care that reflects understanding and awareness of the patient’s values, needs and preferences while maintaining compassion and respect |
| Timely | Minimize delays and waits when possible for those both receiving and providing care to facilitate access to care for patients |
| Efficient | Avoid waste across all aspects of health care including equipment and personnel resources |
| Equitable | Provide equal quality and standard of care free from bias related to factors such as gender, race, ethnicity, or socioeconomic status |
Error Reporting
Recent literature suggests that medical errors are greatly underreported; however, where the culture is perceived as less punitive, self-reporting occurs more frequently.
2
Ideally, reporting of medical errors should be characterized by transparency, consistency, and accuracy, principles that in theory are easily achieved but in reality are difficult to attain. Individuals are reluctant to report errors because they fear retribution, humiliation, or alienation. Failing to do so propagates more mistakes and takes clinicians further from the goals of safe delivery of care.Even when health care workers strive to provide exemplary care for their patients, there are inevitable system failures that hinder their ability to be at once efficient, and sometimes timely, in their work. Most clinicians working in the pediatric intensive care unit (PICU) can relate to the experience of how a delayed test or procedure for a child can strain a therapeutic relationship with a family or, worse yet, adversely affect the patient’s overall care. Yet, consider how often we do (or rather do not) report such incidents. To many, these situations are a routine part of care; however, when considered and reported as medical errors these “system issues” can both inform and improve clinical practice.
3
Error-reporting systems have become sophisticated; many are electronic and most allow for retrospective review of data, identification of patterns in types of errors made, and selection of what factors most contribute to the error, that is, human factors or system failures. When used, such tools can help to mitigate the gaps generated by “institutional memory,” whereby vague and incomplete recollections of lessons learned from previous events guide initiatives for improvement and move us away from the provision of equitable and effective care. Moreover, when based on reality and fact, remediation for medical errors becomes relevant and sustainable.
Morbidity and Mortality: Review and Analysis
Medical errors will occur: how teams deal with mistakes is what matters most. Despite the efforts to mitigate risk in such susceptible environments, errors do and will occur. No process can be entirely foolproof. When medical mistakes occur, especially in children, several emotions—anger, remorse, disappointment, and mistrust—result among the patient, family, and clinical staff. Errors in care leave the medical team in a position of especial vulnerability and, if not openly addressed, can essentially “paralyze” the subsequent therapeutic relationship with the patient and family. Essential to the successful appraisal of medical mistakes are nonthreatening, secure forums in which providers can openly discuss potential deficiencies in clinical knowledge and understanding that may have contributed to the error; opportunities for experienced providers to discuss clinical alternatives to the choices made when appropriate; and methods of education and training to enhance staff competency and confidence. Punition does not work, and rather serves to isolate team members and precipitate greater errors as a consequence of the atmosphere of fear, uncertainty, and disempowerment that such an approach breeds.
Debriefing and Huddles
Both formal debriefs and ad hoc huddles provide opportunities for informal learning, generation of a shared mental model, and team building.
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Such elements provide medical teams with the opportunity to evaluate the safety and efficiency of care delivery in an integrated and collaborative way. Unlike formal quality-assurance forums, debriefs often occur in real time, following significant events, and typically include spontaneous and undiluted discussion of key issues, concerns, and patient outcomes. When skillfully moderated, such sessions can provide invaluable insight toward process improvement in that the participants have improved recall of events. Furthermore, the less structured format allows for emotional and nonclinical subject matter to be discussed with greater ease.Among other disciplines, huddles serve to rally and organize the team; this is no different in medicine. Team huddles in the PICU can be useful for clarifying patient-care objectives, improving workforce morale, and consolidating multiple information sources into a unified plan of care. These “check-ins” can occur at scheduled times or impromptu when specific events prompt their necessity. Both debriefings and huddles help to improve the quality of the delivery of care by adding a measure of (necessary) redundancy and cooperation that underlies patient-centered care.
Postintervention Education
Acknowledging that practice may not make perfect but at least makes better, it is of equal import to consider how to deliver and sustain the lessons learned from quality and performance review. It is known that failures in both provider and system function contribute to medical errors. Although human factors seemingly cannot be modified, enhancing awareness among staff regarding areas of inherent vulnerability, creating modes of redundancy to minimize reliance on human intervention alone, and providing decision-making support are all essential steps in mitigating human error.
While across all aspects of care human factors account for a significant portion of medical errors, system inadequacies can be equally implicated in breakdowns of patient care. System design should therefore account for known risks in performance and implementation and be regularly reevaluated in the context of previous errors, the goals of care delivery, and evidence-based practice. Sustainable modalities that have been used in pediatric settings for performance improvement include Plan-Do-Study-Act and failure modes and effects analysis strategies.
5
Such tools emphasize multidisciplinary collaboration in identifying targeted problems to be addressed by simple, goal-directed initiatives that have measurable outcomes.Using Quality Analysis to Achieve the Domains of Quality
The process of quality analysis and performance improvement is complex, yet integral to achieving the quality hoped for in the defined domains of our health systems. From the inevitable errors, the lessons learned are invaluable. When grounded with this knowledge and approached with transparency, we are able to provide high-quality patient care.
Teamwork and workflow
We cannot expect to improve medical outcomes, even in the face of scientific advancement, without a true commitment to the improvement of the function and structure of pediatric medical teams. When asked to identify characteristics of successful teams, even across disciplines, there are several recurring themes. Communication, mutual respect, reliability, cooperation, and creativity are among the qualities that arise most often. Similarly, experience, honesty, patience, and compassion are regarded as necessary attributes of well-performing teams. Cultivating these characteristics requires practice, because although some of these behaviors are innate, if not used they will not develop further. When pediatric teams confront medical illness, they are charged with an exceptional responsibility: to deliver the highest quality of medical care to the patient while balancing the personal and professional challenges such a task can bring. When executed well, however, there is no match for the satisfying and gratifying outcomes that cohesive and productive pediatric teams can bring about.
Why Do Teams Matter?
As already acknowledged, the care of pediatric patients requires special commitment and unique skills. Strong pediatric teams provide a mechanism of support and rejuvenation for their members. The sense of camaraderie and mutual understanding that specialty teams provide for their members is what enables them to survive. Professional teams can also be a source of motivation and self-improvement for their members. By providing a consistent group of individuals with common goals, medical teams serve as a forum for academic enrichment and personal growth. Besides the professional and personal benefits that pediatric teams bring to patients, families, and care providers, their value to health care systems is indisputable. A well-functioning medical team can serve to reduce medical error, increase revenue, improve reputation, and facilitate better health outcomes in almost any medical environment. What distinguishes facilities with strong teams is not their lack of medical errors or inefficiencies; rather, a strong team will promote recognition and acknowledgment of mistakes but also work to devise constructive means of performance improvement. Without organized and efficient teams, health systems become disorganized and unproductive; their performance and reputations suffer. The shared burden of health care is great, but made lesser by the strength of successful medical teams.
Team Composition and Leadership
A well-structured, highly reliable, and functional team has the potential to significantly affect the patient’s experience in the PICU. Traditional team structure in the PICU consists of an attending physician, medical trainees such as postgraduate fellows, residents, and students, as well as clinical nurses, pharmacists, respiratory therapists, dieticians, social workers, case managers, and specialty or consultant physicians. In such a team, the attending physician assumes ultimate responsibility for the medical management of the patient while balancing the assessments and opinions of the team at large with his or her experience, expertise, and judgment, to develop a coordinated plan of care for the patient.
Central to the team is the patient and his or her parents and family. Given that no care plan can be executed without the support and consent of patients and parents, patient-centered care remains the clear standard that must be achieved. The value of parents in the care-delivery experience is irrefutable in terms of providing comfort and understanding for their sick children, in the intangible elements of healing they provide, and even in the avoidance of medical errors, given that often no one individual in the medical team can be as attentive to a child’s medical needs as a parent. That being said, a careful balance must be achieved to avoid family-centered care from becoming family-dictated care and, perhaps worse, to prevent parents from feeling the burden of having to make medical decisions for their children in areas where they should rather be able to rely on effective medical expertise.
Rounding
A clearly defined shared mental model of care is essential to goal achievement. Foremost among the goals of rounds is the establishment of such a common vision of the key health issues, risks, treatment goals, and plan of care for the patient. As a result of poor system design, workflow interruptions, and unanticipated, but sometimes necessary intrusions, medical team members frequently leave a bedside after making rounds without this unified and clear understanding of the patient.
It is difficult for a pediatric clinical team to achieve its goals without a unified, structured plan of care, often termed a shared mental model. Without such a “road map,” individual team members may independently be working toward goals of care without a defined end point or measures of success. Such behaviors place patients at greater risk because the propensity for task duplication and omission increases in the absence of a common goal. The value of shared mental modeling is particularly apparent within the PICU, where the functional efficiency of the office depends on each team member fulfilling his or her role to completion; otherwise, the “downstream” members of the team cannot work at maximum efficiency.
Beyond the clinical team there exists the patient and family. All of these individuals share a common goal: to improve the health of the critically ill patient by providing the highest-quality medical care. The institution of family-centered care and family presence during medical rounds, resuscitation, and procedures in many PICUs provides such opportunities. The direct participation of patients and their families can facilitate understanding, trust, and clarity within the medical team; however, it is not without its challenges. Some team members may feel inhibited by the presence of families; for example, trainees may be reticent to ask questions that may suggest to families that they are insufficiently competent to care for their child. In addition, when there is disagreement among the medical practitioners about the plan of care, long-term outcomes, or disposition, it may be uncomfortable for such discussions to occur in front of parents. Of course, not all members of the team will agree on how to achieve its common goal. It is thereby imperative for the team to have measures in place that promote collaboration and compromise without sacrificing the advancement of medical care for the patient.
What is unique to intensive care unit (ICU) teams is the frequency with which they confront critical illness and the complex, emotional circumstances that the care of acutely ill children raises. For a pediatric clinical team to successfully navigate such issues, it must be prepared to incorporate families directly into its work but also recognize the objective, yet nurturing role it must serve. Pediatric intensive care teams must also devise means for stress release and mutual support because their work is uniquely demanding and psychologically draining. If however, all of these elements function well, pediatric intensive care teams are among the most skilled and proficient at caring for pediatric patients. Optimal team performance in the PICU will be cohesive, yet facilitate a climate in which individual opinions regarding the child’s care are readily expressed and valued; where there is a single clearly identified team ultimately responsible for the child’s care, despite collaboration with other medical specialists; and in which there is both regard and support for the emotional and professional stresses that uniquely accompany the care of such critically ill children.
Handoffs
Compared with the ICU, few other environments have greater stress, intensity, and propensity for errors. Therefore, handoffs or communications between providers at all phases of care are crucial for accurate, timely, and efficient care delivery.
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Structured handoffs typically occur during transitions of care, for example, at shift changes, between clinical care units, and when patients are transferred to other sites for care. Less formal handoffs may occur between providers during temporary periods of coverage such as staff breaks or when transient clinical support is needed. Each handoff provides an opportunity for providers to communicate relevant information about the patient and, theoretically, to confirm and validate medical facts about the patient and plan of care.Unfortunately, the reality is that handoffs are mostly unstandardized, fragmented, and incomplete, so the risk associated with them is high. Factors such as duty-hour limitations, multiple caregivers for individual patients, and unexpected transitions of care result in inefficient handoffs.
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Partial or sometimes incorrect information may be passed forward across multiple layers of care without recognition, and in the most extreme examples management plans may be based on such information. The goal of handoffs should include transfer of relevant and timely information in a consistent format. The redundancy of such a system would go far in mitigating error and revitalizing the utility of handoff encounters.Health Care Delivery
Successful teams must strengthen their adaptability and efficiency across clinical situations. Particularly in the pediatric critical care unit, where clinical circumstances change rapidly, teams must remain malleable and competent. Serving patients in the acute setting requires an appreciation of the sadness, anger, frustration, fear, and uncertainty that families often experience with a seriously ill child. Beyond compassion must exist a fundamentally integrative approach to the delivery of patient-centered care.
Patient- and family-centered care represents a practice paradigm designed to involve parents and families more directly in their child’s medical care. It is assumed that by providing families with the opportunity to participate directly in their child’s care, they will have a more satisfying, cohesive, and safe medical experience. Although this principle holds true in most instances, it can quickly evolve into family-directed care if pediatric practitioners are not careful to maintain the boundaries between practitioner and patient. What may begin as a collaborative, well-intentioned endeavor can degenerate into an antagonistic and uncomfortable practice environment.
When skilled pediatric providers learn to work closely with patients and their families in a mutually rewarding way, the results can be significant. Countless medical errors are averted each year simply by family members who ask for information about medications being administered to their child. Similarly, medical history and information from parents is invaluable, particularly when a patient is unknown to the medical facility and the care team. Families who are engaged with the medical team are typically more satisfied with and less distrusting of the medical experience. Likewise, children thrive in medical environments where their needs are both anticipated and met with the support of their families.
Using Teamwork to Achieve the Domains of Quality
Given the spectrum of unique clinical and environmental circumstances presented, there is no single effort that will completely eliminate the risk of pediatric medical errors; however, high-functioning teams will serve to diminish the risk of errors through several mechanisms. First, teams that are familiar with children have a better understanding of the special clinical considerations that should be observed in the care of children. Such providers are less likely to err simply because of their familiarity and experience with pediatric protocols and specifications.
Teams that work with children must be especially patient, flexible, and understanding not only of the patient but also of parents and families who often are actively involved in their child’s care. This process can be demanding for any care provider, but a practiced and efficient team can often derive support and camaraderie through the shared challenges of its practice. As in other work environments, strong teams and leaders can incite energy, passion, and commitment as quickly as they can cultivate frustration, inefficiency, and discord if they are not cohesive and functional. The absolute necessity of dedicated, pediatric specialty care teams in any successful clinical environment that cares for children must be acknowledged and emphasized.
Several models for team composition and structure can be used in pediatric medical settings, but as already emphasized, those models that enable patients, families, and medical personnel to function cooperatively, rather than in parallel, are most likely to succeed. The ideal pediatric medical team model will incorporate the best elements of both vertical and horizontal team dynamics. In vertical teams, there is a defined leader who has primary responsibility for providing the direction, priorities, and goals for the team. The team may create a vision based on a shared mental model; however, the implementation of these goals is often dependent on the leader’s initiative and commitment. The team leader is placed in a position of ultimate control for advancing the team’s work. By contrast, horizontal-performing teams may also have a team leader; however, the entire team takes ownership for realization of the team’s objectives. The team leader does not retain an isolated position of power because hierarchy does not define horizontal teams. Such a team resembles one in which the needs of the pediatric patient is at the core of health care delivery; at various points during the care experience, team members may need to collaborate and compromise to advance the patient’s care, but ultimately the medical team bears the responsibility for managing the child’s medical needs. In such a system, all participants are invested in success, and there is a means for ensuring accountability in the process, but the roles of the medical providers do not overshadow the value of the contributions of patient and family to the medical care plan.
Information technology and quality
Information technology will rescue health care from inefficiency and waste, and will prevent its practitioners from drowning in an ever-expanding ocean of information and complexity; at least that is the hope of its many proponents. From its 2001 report, Crossing the Quality Chasm,
1
to the recently released Best Care at Lower Cost,8
the Institute of Medicine (IOM) documented its faith in information technology in improving quality and efficiency. This conviction helped prompt the federal government to pass the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act designed to hasten adoption of electronic health records (EHR).Institute of Medicine. Best care at lower cost: the path to continuously learning health care in America. The National Academies Press; 2012. Available at: http://www.nap.edu/openbook.php?record_id=13444. Accessed September 18, 2012.
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There are also technologies beyond EHR that will further improve the quality of care, which include smart pumps, bar codes, telecommunications, and a wide variety of clinical decision-support tools. The possibilities are encouraging.In the decade between the 2 IOM reports some of the promise has been realized, but much remains to be done. Potential benefits of information technology include providing rapid access to integrated clinical data and extant medical knowledge, eliminating illegibility, improving communication, and issuing applicable reminders and checks for appropriate medical actions, thereby improving adherence to guidelines and decreasing some medical errors.
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Some of the benefits touted by early research have been criticized for being results of highly customized systems built and designed by a dedicated crew of medical informatics enthusiasts, leaving the remainder of us to struggle with commercial products that may not mesh well with the way we work.11
Nonetheless, recent data suggest that having an EHR with specific, key functions is associated with high-quality hospitals,12
, 13
fewer complications, lower mortality rates, and lower costs.14
The benefits of information technologies can be assessed across the 6 domains of quality: that they make health care safe, effective, patient-centered, timely, efficient, and equitable.
Electronic Health Records
EHRs improve efficiency by collating and organizing health information that had previously been scattered on paper, and provide immediate, remote access to information to allow clinicians to better care for patients, particularly those with whom they are not familiar.
8
EHRs can reduce redundant and unnecessary tests and procedures, improve communication among multiple providers about individual patients, and supply data for performance and outcome measures.Institute of Medicine. Best care at lower cost: the path to continuously learning health care in America. The National Academies Press; 2012. Available at: http://www.nap.edu/openbook.php?record_id=13444. Accessed September 18, 2012.
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EHRs can improve safety by potentially increasing the completeness and accuracy of documentation, thus potentially reducing “dropped balls,”16
and can also improve timeliness through the use of electronic messaging to speed accurate communication among practitioners.17
This information technology can also enhance patient-centered care that is respectful of and responsive to patient preferences, needs, and values by recording them and appropriately reminding the health care professional.1
Trigger-tool methodologies analyze patient records to identify adverse events.
18
For example, the use of naloxone documented in a chart may indicate an opiate overdose. Trigger tools can detect adverse events that might otherwise go unreported. The EHR can be used to automate this process and improve its efficiency.19
These measurements over time can be used to gauge the success of new safety protocols.Human factors engineering (HFE) is the multidisciplinary field that studies the interactions between humans and technology. Its principles are increasingly used to help evaluate and refine information technology used in clinical practice. According to these principles, information technology does not directly affect patient safety; it affects the entire system of patient care and only indirectly produces conditions that are safer or more hazardous. Improving safety is contingent on improving the cognitive performance of the health care providers (Table 2).
17
Table 2Unintended adverse consequences related to CPOE
Data from Refs.
20
, 21
, 22
| Effect | Examples |
|---|---|
| New kinds of errors | Juxtaposition errors in which clinicians mistakenly select an item among a long list of similar items displayed in a small font Excessive alerts that interrupt thought processes and result in errors Missed doses of phenobarbital or methadone because automatic stop orders are required for controlled substances, a regulation more easily enforced with CPOE |
| Increased work for clinicians | Requiring physicians to select precise timing schedules for medications, a function formerly performed by nurses Prolonged log-in processes or poorly designed interfaces that require complex navigation to commonly used functions Loss of notes or orders in progress because of interface crashes or inopportune automatic time-outs and log-offs |
| Unfavorable alteration of workflow | Medications prepared for patients expected to arrive emergently can no longer be ordered through a CPOE system that requires the patient to be formally admitted to the system Computerized orders bypass the nurse who used to “pick up” the order before it was sent to pharmacy and who would know that a medication in pill form could not be administered via a nasogastric tube |
| Untoward changes in communications patterns | Users assume that the right person will see relevant information just because it went into the system, producing an “illusion of communication” Consultants may write a note after seeing a patient but may edit their recommendations after leaving the unit and the primary team may not recognize that the document had been revised |
| High system demands and frequent changes | Frequent upgrades of hardware and software ensure the system will never be static or stable Ongoing changes to the systems require ongoing training to use the new features |
| Persistence of paper | Increase in paper-towel consumption because it is used as scrap paper to record vital signs to be entered later |
| Overdependence on technology | Breakdown in the delivery of care as a direct result of EHR downtime Overreliance on clinical alerts leading to an erroneous medication order assumed to be correct because no alert was triggered |
Abbreviations: CPOE, computerized physician order entry; EHR, electronic health record.
Besides creating new kinds of errors, there are other unintended consequences that can result from implementing an EHR, including increased work for clinicians, untoward alteration of workflow, changes in communication patterns, increased system demands, persistence of paper use, and potentially fostering overdependence on the technology.
20
, 21
, 22
Information technology has changed the pace of our lives, and the effect is no less apparent in the delivery of health care. It can greatly improve the timeliness of care. The disadvantage of information technology is that it can take over our lives. It has been reported that physicians now spend more time interfacing with the computer than interacting with their colleagues and staff (Table 3).22
Table 3Ways in which an EHR might affect cognitive performance
| Improve | Reduce |
|---|---|
| Improve legibility and accessibility Increase availability of problem lists or allergy lists that were often lost in the paper record Improve completeness of documentation Reduce delays in receiving results of diagnostic tests Automatically collate and sort relevant data Reduce fragmentation of the medical record Automatically flag abnormal results Increase availability of references | Decrease efficiency with poorly designed interfaces, and slow start-up and log-in processes Bury relevant data among the irrelevant Encourage excessively long notes with copy-and-paste functions Encourage documentation without cognition with automatic data dumps into notes Increase work by introducing additional steps that were previously performed by others Increase confusion with distracting alerts |
Computerized Physician Order Entry
EHRs with a computerized physician order entry (CPOE) have resulted in documented, significant reductions in the time that it takes to for an order to be written to a medication administered, a radiograph displayed, or a laboratory test to be carried out.
23
, 24
CPOEs can also rapidly transmit the results of important abnormalities to key clinicians.25
Perhaps the greatest benefits to safety offered by information technology lie in CPOE. Numerous studies seem to confirm this benefit, some of which report significant reduction of medication errors,
26
, 27
and “almost a complete elimination” of medication errors even with commercial products.28
, 29
, 30
The impact on adverse drug events was less dramatic but still positive.28
, 29
, 30
Most of the single-site observational studies cited here suggest a benefit, but many do not distinguish error severity. The minor errors are often reported to decrease the most.
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Other studies are even less positive, showing either little benefit16
, 32
or an unexpected increase in mortality.33
Although the ultimate conclusions of many studies seem to depend more on the author than on the specific aspects of information technology being studied,25
, 26
, 27
, 32
, 34
, 35
, 36
the discrepant results point to the possibility that the specifics of the implementation process could be a decisive factor that determines success or failure.30
Other investigators point out that although electronic prescribing can reduce certain types of medication errors, it can increase the rates of other errors and can also facilitate new types of errors.
34
, 37
, 38
Transcription errors are the most commonly cited errors that are eliminated by CPOE.23
There are reports of increases in the rate of duplicate orders or failure to discontinue medications because of problems with the human interface.31
Other errors include orders that are written in the open chart of one patient being mistaken for that of another. New types of errors include “juxtaposition errors” whereby clinicians intending to select one item select a different but nearby item within a long, dense pick-list displayed in a small font. Inflexible data input can result in misinterpretation of orders because important data can be misplaced or not found. Other aspects of the EHR can contribute to creating other kinds of new errors. Fragmentation of data displays can prevent coherent views of information or might induce physicians to write duplicate orders if the original order is not visible. Interface issues can lead to the misdirection of data to the wrong patient’s chart. Transfers of the patient that are not coordinated with the electronic transfer of the chart may result in missed care or care delivered to the wrong patient.15
Electronic Medication Administration Record
Implementation of an electronic medication administration record (eMAR) with CPOE improves effectiveness, measuring quality by 11 CMS quality indicators related to medication use that adheres to specific guidelines for acute myocardial infarction, heart failure, pneumonia, and surgical infection prophylaxis. In addition, the duration these technologies have been in use is also correlated with improved quality by these measures.
39
Decision Support
Decision support is an innovation designed to improve the cognitive performance of practitioners. For example, an automated alert system can warn clinicians of dangerous drug-drug interactions. Safety improvements secondary to CPOE systems are extended with the development and implementation of integrated clinical decision-support systems.
27
, 40
Decision-support systems can also help clinicians make better choices of medications
25
, 41
or laboratory tests,23
, 25
and thereby reduce costs.25
Clinical decision support designed to affect specific aspects of care such as adherence to clinical guidelines for specific diseases,42
administration of preventive care,43
or optimizing drug ordering41
, 43
have been shown to improve quality and sometimes reduce costs, but few studies show any benefit on patient outcomes.43
Use of automated reminders based on clinical practice guidelines, computer-assisted diagnosis or management, and evidence-based medicine can improve the effectiveness of medical care.15
Implementations of clinical decision support can make care more patient-centered by providing interactive patient-specific guidelines or protocols at the bedside,
44
, 45
, 46
and by tailoring information and disease-management messages to both the patient and physician based on the patient’s individual needs.15
Although our understanding of the complex interactions of clinical decision-support systems is limited, they seem most effective when reminders are generated automatically rather than by requiring users to ask for advice.
47
Systems that advise users about existing therapies by adjusting the dose or by recommending laboratory testing seem to be particularly effective.47
Nonetheless, the safety benefits of these tools are not always clear,31
and at least one study reports that the majority of providers prefer that the drug-interaction alerts be turned off to reduce “alert overload.”48
A recent survey of commercially available EHRs revealed that not all had the full range of clinical decision-support tools,
49
and careful evaluation of these tools should play a role in deciding which product to purchase and implement.Barcode Medication Administration
Converging technologies are those positioned between health information technology and medical devices. These technologies include barcode medication administration (BCMA) systems integrated into the eMAR,
50
and were developed to enhance safety. Although BCMA has been reported to reduce time spent by nurses on medication administration,51
the benefits of this and other similar technologies can be undermined by workarounds that nurses might develop to save time (paradoxically) or to counter other unintended consequences of altered workflows.52
Health Information Exchange
Health information exchange (HIE) allows for sharing of health care information electronically across organizations, and is a specific implementation of interoperability, the ability of systems to work with one another. Formal organizations (governmental or independent) or partnerships (public and private) are emerging to allow for HIE. The 2009 HITECH legislation provided for grants designed to develop Regional Health Information Organizations.
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The potential benefits of these exchanges include increasing the availability of data on patients who have care delivered by different organizations. Through these exchanges an emergency department can access data from the outpatient health records from the numerous specialists who follow a patient with a complicated medical history, and a rehabilitation facility can access data from a patient’s recent hospitalization. There is some evidence that HIE can reduce diagnostic imaging and improve adherence to evidence-based guidelines.Institute of Medicine. Best care at lower cost: the path to continuously learning health care in America. The National Academies Press; 2012. Available at: http://www.nap.edu/openbook.php?record_id=13444. Accessed September 18, 2012.
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Telemedicine
Telemedicine can improve the timeliness of care. For patients who live in remote locales, it can allow patients to see a consultant without long-distance travel, or even allow pediatric patients to safely receive care in a local adult ICU if they cannot be safely transported to a distant PICU.
54
, 55
It is also possible for intensivists to remotely monitor patients and participate in emergency care without any delay even if the physician is not on site.56
, 57
These solutions have been implemented by fixed cameras and electronic connections in patient rooms, and by mobile robots that can roam from bedside to bedside; they can also be inexpensively implemented by staff members armed with a smartphone or a mobile computer configured with a webcam and wireless connection.Enhancing equity among patients and across socioeconomic, geographic, race, and ethnic lines can be achieved with communication technologies that can enhance access to clinicians and clinical knowledge. Such improvements depend less on the availability of the health care resources and more on the technology infrastructure.
15
, 46
, 58
Teleconsultations have been shown to reduce the number of diagnostic tests and medical interventions, reduce the number of contacts with the health care system, and improve patient satisfaction, all while saving patients’ time and money.
59
In at least one PICU with an expansive catchment area whose families might live at great distances from the hospital, Web-based communication is made available to patients and their families. This tool allows parents to give access to other family members, friends, and the referring physician, and provides a means of communication between these users and the PICU staff. Although not quite the same as in-person presence, the families reported that this service helped to empower the families during a most difficult time.
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The Internet
The Internet gives clinicians ready access to the medical literature
1
including recent studies and current guidelines. It also give patients access to clinical knowledge through a multitude of Web sites, some reliable and understandable, others not.61
In 2006, 30% of surveyed health professionals reported that 80% of their patients were Web informed, and 63% of professionals recommended a Web site to their patients for more information.62
These numbers are most certainly higher now. The Internet can also allow access to online support groups that can reduce the feelings of isolation and can direct patients to resources, of which they would otherwise be unaware.61
The Internet can also afford patients access to consumer information on health plans, participating providers, eligibility for procedures, and covered drugs in a formulary.
8
, Institute of Medicine. Best care at lower cost: the path to continuously learning health care in America. The National Academies Press; 2012. Available at: http://www.nap.edu/openbook.php?record_id=13444. Accessed September 18, 2012.
63
Information regarding cost, outcomes, and value associated with hospitals, practices, or individual physicians may be collected and made available through information technology. Access to practical, usable, and transparent information could help improve the value of care as patients approach health care as consumers.64
The increasingly frustrated consumer of health care uses the Internet to acquire information to manage his or her own health. Purveyors of electronic health are providing health information, decision support, and Web-based tools to navigate the health care system and insurance plans while perhaps influencing patterns of health care consumption.
63
Spurred by the HITECH legislation, the development of patient portals gives patients unprecedented access to their medical records. Clinicians consider valuable the patient’s ability to review and comment on data in his or her EHR, as it may increase accuracy of that data.
65
For many of these portals, a delay is imposed between test results and release of such data to allow the patient’s physician time to review the results and contact the patient to discuss the meaning of those results. Although intended to limit the panic that some patients may experience when the implications of certain results are initially unclear, many programs are reducing this imposed delay, perhaps encouraging physicians to address those results in an even timelier fashion.Through patient portals connected to their EHRs, patients can communicate with their physician, obtain medical advice, or receive customized information on health education and disease management.
63
These portals can decrease the number of office visits or telephone contacts, readily allow for changes in the medication regimens, and improve adherence to treatment.66
At least one health care system implemented electronic visits through these portals to substitute for some types of office visits.67
Personal health records, whether they are independently managed by patients themselves or hosted by insurance companies or the health care systems to which they belong, are empowering patients to control their health information, although there may be some serious concerns over privacy and security.68
For those who consider information technology to be a panacea, the Joint Commission issued this warning:
The overall safety and effectiveness of technology in health care ultimately depend on its human users, ideally working in close concert with properly designed and installed electronic systems. Any form of technology may adversely affect the quality and safety of care if it is designed or implemented improperly or is misinterpreted. Not only must the technology or device be designed to be safe, it must also be operated safely within a safe workflow process.69The Joint Commission. Sentinel Event Alert, Issue 42: Safely implementing health information and converging technologies. 2008. Available at: http://www.jointcommission.org/sentinel_event_alert_issue_42_safely_implementing_health_information_and_converging_technologies/. Accessed September 16, 2012.
Protocols
Medicine is faced with many challenges, but the most pressing issue for the system as a whole is the quality of health care. Quality is threatened by the unbridled escalations in health care costs, particularly when those costs do not buy improved outcomes. The explosive pace of the accumulation of medical knowledge has made medical care overwhelmingly complex. Paradoxically, the health care system is slow to gather evidence directly applicable to clinicians and their patients, and even when such evidence exists, the system is slow to incorporate that evidence into practice.
8
These challenges may be even more acute in critical care. Delivering care is increasingly demanding in the ICU, where patients are monitored and supported by devices of increasing number and complexity, and treated with great numbers of medications from a bloated formulary. The expanding therapeutic armamentarium often succeeds in supporting patients who are more ill and more complicated than ever before, and these factors are among the many that contribute to the rising costs of health care.Institute of Medicine. Best care at lower cost: the path to continuously learning health care in America. The National Academies Press; 2012. Available at: http://www.nap.edu/openbook.php?record_id=13444. Accessed September 18, 2012.
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, 71
For these and many other reasons, more if not most of medical care should be protocolized. The idea of protocolized care is not new. For example, clinicians have been using protocols to manage cardiopulmonary arrest for decades. Protocolizing this high-acuity, high-stakes treatment has allowed several things to occur. At the most basic level it allows for knowledge, from expert opinion to cutting-edge research, to be transferred to the patient’s bedside with relative efficiency. Cadres of medical professionals and lay persons are regularly trained and retrained in resuscitation, ensuring, to the extent reasonably possible, that patients receive the best care even as they lie on the threshold of death. Furthermore, protocolization allows all members of the team caring for the patient to understand their role when it is assigned. Besides improving the efficiency of care, the shared mental model of the team facilitates ready detection of protocol deviations and, thus, application of corrections. Protocolized care also allows outcomes to be measured and compared more consistently. Changes in protocol can be compared with older protocols and medical knowledge can be advanced, even outside formal clinical trials and within the process of routine care. The routine reevaluation of these cardiopulmonary resuscitation protocols also helps identify areas where additional and perhaps more rigorous research is required.
More recently, some sustained success has been gained with improved outcomes by protocolizing the treatment of early septic shock.
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, 73
, 74
Development and implementation of an evidence-based protocol or “care process model” for febrile infants younger than 90 days of age was shown to decrease practice variation, improve outcomes, and decrease costs.75
However, the broad transfer of knowledge to clinical practice is a significant challenge, with multiple barriers in knowledge, attitude, and behaviors.76
Guidelines or Protocols
The National Guideline Clearinghouse
77
has more than 3000 guidelines from nearly 300 organizations.Agency for Healthcare Research and Quality. National guideline clearinghouse. Available at: http://guideline.gov. Accessed October 19, 2012.
64
Some of these guidelines are redundant but also contradictory. There is clearly a need for a trusted means to reconcile the differences and to channel these guidelines into effective use.64
Furthermore, many guidelines may be flawed because they are inadequately explicit. Adequately explicit protocols contain sufficient detail to lead different clinicians to the same decision when faced with the same clinical scenario.78
Evidence-based care process models are protocols that are designed to decrease variation, improve quality, and support local preferences.75
, 79
Objections
Although some protocols are fairly well accepted, many physicians would balk at the idea of protocolizing most aspects of care. Many objections concern the threat this would pose to the role of the physician and the need to preserve physician judgment. Some of these concerns are justified, because the clinician must determine whether the protocol truly applies to his or her specific patient. The protocol may be based on a study performed on a very specific study sample, and therefore has insufficient external validity to address the patient at hand. Tight glycemic control may have a significant mortality benefit for adult surgical patients but may not be beneficial to pediatric medical patients. However, the most common reason for rejecting a validated protocol instruction that the clinician opinion expressed is not based on fact, and that physicians are usually overconfident in the correctness of their beliefs and opinions.
78
The other objections to protocolized care relate to the apparent rigidity in comparison with the inherently flexible physician judgment.
78
Clearly some protocols can be excessively rigid, and this can become unacceptable if a “practice misalignment” occurs whereby the protocol calls for a treatment that is contrary to “usual care.”80
However, protocols need not be excessively rigid. Protocols should be able to account for a broad range of patients’ conditions. The key is to allow the treatment to vary based on patient variability rather than on physician variability. If the patient veers into territory not mapped out in the protocol, the care of that patient must be allowed to deviate, and this deviation can be used to modify the protocol so that it can cover more territory.Practice Variation
One goal of protocolizing care is to reduce practice variation. Unexplained practice variation is associated with significant variations in the cost of medical care, but higher costs are not associated with higher-quality care or better outcomes.
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It is presumed that decreasing practice variation will result in an overall lower cost of health care without compromising other measures of quality. Although this may not necessarily be true in every case, it is hoped that the incremental increase in cost would purchase better outcomes.Research Benefits
Other reasons for protocolizing care are related to clinical research. Despite all the clinical research in critical care medicine, very few randomized, multicenter studies have shown durable benefits in mortality reduction.
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Protocolization of care outside of study interventions can decrease the “noise” generated by unnecessary practice variation, making clinical studies more likely to detect the “signal” resulting from the study intervention. Protocolization of care can also enhance the validity of randomized trials in contradistinction to those whereby a study intervention is compared with a control arm of usual care,89
, 90
although it is important to avoid “practice misalignments.”80
Certainly such studies would have greater power than those with a third arm consisting of usual care, as has been suggested.90
Research in most domains of pediatric critical care can little afford such loss of power, given the already small numbers available for study.Unfortunately, despite the great strides in the practice of evidence-based medicine, the vast majority of care delivered in state-of-the-art ICUs has little or no evidence to support it.
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Even the things we think we know today will be overthrown tomorrow. Certainly there are too few effectiveness data to verify the external validity of the positive studies that have been conducted. It may be that we are reaching the limits of the randomized controlled trial design, and that we may need to use different research paradigms, particularly in the ICU.91
In the absence of evidence it does not matter which expert opinion is chosen as the standard, but simply standardizing to one specific practice may yield significant benefits.Consider the advances in the treatment of childhood cancer. In the span of 40 years, 5-year survival rates are approaching 80%, improved from a baseline of almost uniform fatality.
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This progress is likely a result of protocolized care and enrollment of most patients in those study protocols with meticulous data collection and analysis. This research paradigm may be used to further medicine in general, and specifically pediatric critical care, otherwise known as “critical care for rare diseases.”93
The Future
One vision for the future is to have standard protocols of care in PICUs where information technology is deployed with sufficient interoperability to allow data sharing. As data are captured at the time care is rendered, novel interventions for rare diseases can be assessed across institutions with the noise of unnecessary practice variation damped to extinction. The Pediatric Acute Lung Injury and Sepsis Investigators,
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the clinical research network for pediatric critical care, has recently embraced the idea of protocolizing “routine” care. The Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care UnitPediatric Acute Lung Injury and Sepsis Investigators. PALISI. 2011. Available at: http://www.palisi.org. Accessed October 21, 2012.
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has been working to improve the interoperability of data among PICUs. The path to the future is being mapped. The hard work is yet to come.Virtual Pediatric Intensive Care Unit. VPICU. Available at: http://vpicu.org/. Accessed October 21, 2012.
Summary
There is no question that we can do better to improve the quality of care delivered to patients. This article reviews the domains of quality outlined by the IOM; examines the current theories and practice of quality assessment, performance improvement, teamwork, and workflow; reviews the promise and current impact of information technologies on the quality of care; and outlines a possible shifting paradigm for the delivery of care and knowledge discovery based on protocols. Although advances exist in the frameworks used to promote quality, with some resulting improvement in outcomes, achieving quality is an elusive goal that requires ceaseless attention and relentless effort.
References
- Crossing the quality chasm: a new health system for the 21st century.National Academies Press, 2001 (Available at:) (Accessed September 17, 2012)
- What contributes to internists’ willingness to disclose medical errors?.Neth J Med. 2012; 70: 242-248
- Disclosure of “nonharmful” medical errors and other events: duty to disclose.Arch Surg. 2012; 147: 282-286
- Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning be enhanced? A narrative review.Adv Health Sci Educ Theory Pract. 2012; 17: 1-19
- Patient safety and quality improvement an overview of QI.Pediatr Rev. 2012; 33: 353-360
- Adaptation of a post-operative handoff communication process for children with heart disease: a quantitative study.Am J Med Qual. 2011; 26: 380-386
- Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements.Acad Med. 2012; 87: 403-410
Institute of Medicine. Best care at lower cost: the path to continuously learning health care in America. The National Academies Press; 2012. Available at: http://www.nap.edu/openbook.php?record_id=13444. Accessed September 18, 2012.
- Stimulating the adoption of health information technology.N Engl J Med. 2009; 360: 1477-1479
- The computer-based patient record: an essential technology for health care.Revised edition. The National Academies Press, Washington, DC1997
- Health information technology in the era of care delivery reform: to what end?.JAMA. 2012; 307: 2593-2594
- Electronic health record functions differ between best and worst hospitals.Am J Manag Care. 2011; 17: e121-e147
- Hospital implementation of health information technology and quality of care: are they related?.BMC Med Inform Decis Mak. 2012; 12: 109
- Clinical information technologies and inpatient outcomes: a multiple hospital study.Arch Intern Med. 2009; 169: 108-114
- Information technology in critical care.in: Fuhrman B.P. Zimmerman J.J. Pediatric critical care: expert consult premium. 4th edition. Elsevier, Philadelphia2011: 75-91
- The state of the evidence for computerized provider order entry: a systematic review and analysis of the quality of the literature.Int J Med Inform. 2009; 78: 365-374
- Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety.Cogn Technol Work. 2011; 13: 11-29
- Measuring hospital adverse events: assessing inter-rater reliability and trigger performance of the Global Trigger Tool.Int J Qual Health Care. 2010; 22: 266-274
- Using EHR data for monitoring and promoting patient safety: reviewing the evidence on trigger tools.Stud Health Technol Inform. 2012; 180: 786-790
- The unintended consequences of computerized provider order entry: findings from a mixed methods exploration.Int J Med Inform. 2009; 78: S69-S76
- Some unintended consequences of information technology in health care: the nature of patient care information system-related errors.J Am Med Inform Assoc. 2004; 11: 104-112
- Categorizing the unintended sociotechnical consequences of computerized provider order entry.Int J Med Inform. 2007; 76: S21-S27
- Immediate benefits realized following implementation of physician order entry at an academic medical center.J Am Med Inform Assoc. 2002; 9: 529-539
- The impact of computerized provider order entry systems on inpatient clinical workflow: a literature review.J Am Med Inform Assoc. 2009; 16: 539-549
- Measuring and improving quality using information systems.Stud Health Technol Inform. 1998; 52: 814-818
- Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.JAMA. 1998; 280: 1311-1316
- The impact of computerized physician order entry on medication error prevention.J Am Med Inform Assoc. 1999; 6: 313-321
- The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients.Pediatrics. 2003; 112: 506-509
- Computerized physician order entry and medication errors in a pediatric critical care unit.Pediatrics. 2004; 113: 59-63
- The effect of computerized physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a systematic review.Pediatrics. 2009; 123: 1184-1190
- Does computerized provider order entry reduce prescribing errors for hospital inpatients? A systematic review.J Am Med Inform Assoc. 2009; 16: 613-623
- Effect of computer order entry on prevention of serious medication errors in hospitalized children.Pediatrics. 2008; 121: e421-e427
- Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.Pediatrics. 2005; 116: 1506-1512
- Medication errors related to computerized order entry for children.Pediatrics. 2006; 118: 1872-1879
- Health information technology: fallacies and sober realities.J Am Med Inform Assoc. 2010; 17: 617-623
- A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional.Qual Saf Health Care. 2006; 15: i59-i65
- Role of computerized physician order entry systems in facilitating medication errors.JAMA. 2005; 293: 1197-1203
- Unexpected effects of unintended consequences: EMR prescription discrepancies and hemorrhage in patients on warfarin.AMIA Annu Symp Proc. 2011; 2011: 1412-1417
- Medication administration quality and health information technology: a national study of US hospitals.J Am Med Inform Assoc. 2012; 19: 360-367
- Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review.Arch Intern Med. 2003; 163: 1409-1416
- A computer-assisted management program for antibiotics and other antiinfective agents.N Engl J Med. 1998; 338: 232-238
- A clinical decision support system for prevention of venous thromboembolism: effect on physician behavior.JAMA. 2000; 283: 2816-2821
- Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings.J Am Med Inform Assoc. 2011; 18: 327-334
- The evolution of eProtocols that enable reproducible clinical research and care methods.J Clin Monit Comput. 2012; 26: 305-317
- Computers and the quality of care—a clinician’s perspective.N Engl J Med. 1998; 338: 259-260
- Thirty years of critical care medicine.Crit Care. 2010; 14: 311
- Do computerised clinical decision support systems for prescribing change practice? A systematic review of the literature (1990-2007).BMC Health Serv Res. 2009; 9: 154
- Turning off frequently overridden drug alerts: limited opportunities for doing it safely.J Am Med Inform Assoc. 2008; 15: 439-448
- Clinical decision support capabilities of commercially-available clinical information systems.J Am Med Inform Assoc. 2009; 16: 637-644
- Effect of bar-code technology on the safety of medication administration.N Engl J Med. 2010; 362: 1698-1707
- Effect of bar-code-assisted medication administration on nurses’ activities in an intensive care unit: a time-motion study.Am J Health Syst Pharm. 2011; 68: 1026-1031
- Medication administration technologies and patient safety: a mixed-method systematic review.J Adv Nurs. 2011; 67: 2080-2095
- Does health information exchange reduce unnecessary neuroimaging and improve quality of headache care in the Emergency Department?.J Gen Intern Med. 2012; (Available at:) (Accessed September 21, 2012)
- Use of telemedicine to provide pediatric critical care inpatient consultations to underserved rural Northern California.J Pediatr. 2004; 144: 375-380
- The use of telemedicine to provide pediatric critical care consultations to pediatric trauma patients admitted to a remote trauma intensive care unit: a preliminary report.Pediatr Crit Care Med. 2004; 5: 251-256
- Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care.Crit Care Med. 2000; 28: 3925-3931
- Telemedicine and intensive care: are we ready and willing?.J Intensive Care Med. 2004; 19: 117-118
- Wired for health and well-being: the emergence of interactive health communication.U.S. Department of Health and Human Services, U.S. Government Printing Office, Washington, DC1999
- Virtual outreach: a randomised controlled trial and economic evaluation of joint teleconferenced medical consultations.Health Technol Assess. 2004; 8 (iii–iv): 1-106
- Interactive Web sites for families and physicians of pediatric intensive care unit patients: a preliminary report.Pediatr Crit Care Med. 2004; 5: 434-439
- Health e-people: the online consumer experience.California HealthCare Foundation, 2000 (Available at:) (Accessed September 20, 2012)
- Assessment of internet use and effects among healthcare professionals: a cross sectional survey.Postgrad Med J. 2006; 82: 274-279
- The Internet and managed care: a new wave of innovation.Health Aff (Millwood). 2000; 19: 42-56
- Roundtable on evidence-based medicine, institute of medicine. The healthcare imperative: lowering costs and improving outcomes: workshop series summary.The National Academies Press, 2010 (Available at:) (Accessed September 19, 2012)
- Clinicians recognize value of patient review of their electronic health record data.AMIA Annu Symp Proc. 2006; 2006: 1101
- Patient empowerment by electronic health records: first results of a systematic review on the benefit of patient portals.Stud Health Technol Inform. 2011; 165: 63-67
- Patient portals and e-visits.J Ambul Care Manage. 2006; 29: 222-224
- Self-tracking, social media and personal health records for patient empowered self-care. Contribution of the IMIA Social Media Working Group.Yearb Med Inform. 2012; 7: 16-24
The Joint Commission. Sentinel Event Alert, Issue 42: Safely implementing health information and converging technologies. 2008. Available at: http://www.jointcommission.org/sentinel_event_alert_issue_42_safely_implementing_health_information_and_converging_technologies/. Accessed September 16, 2012.
- Economics of ICU organization and management.Crit Care Clin. 2012; 28: 25-37
- Economic stress and misaligned incentives in critical care medicine in the United States.Crit Care Med. 2007; 35: S36-S43
- Early goal-directed therapy in the treatment of severe sepsis and septic shock.N Engl J Med. 2001; 345: 1368-1377
- Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.Crit Care Med. 2008; 36: 296-327
- One year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study.Crit Care. 2009; 13: R167
- Costs and infant outcomes after implementation of a care process model for febrile infants.Pediatrics. 2012; 130: e16-e24
- Disseminating clinical trial results in critical care.Crit Care Med. 2009; 37: S147-S153
Agency for Healthcare Research and Quality. National guideline clearinghouse. Available at: http://guideline.gov. Accessed October 19, 2012.
- Treatment algorithms and protocolized care.Curr Opin Crit Care. 2003; 9: 236-240
- Understanding the implementation of complex interventions in health care: the normalization process model.BMC Health Serv Res. 2007; 7: 148
- Better conduct of clinical trials: the control group in critical care trials.Crit Care Med. 2009; 37: S80-S90
- Effect of practice variation on resource utilization in infants hospitalized for viral lower respiratory illness.Pediatrics. 2001; 108: 851-855
- Evaluating the effects of variation in clinical practice: a risk adjusted cost-effectiveness (RAC-E) analysis of acute stroke services.BMC Health Serv Res. 2012; 12: 266
- Area-level variations in cancer care and outcomes.Med Care. 2012; 50: 366-373
- Clarifying sources of geographic differences in Medicare spending.N Engl J Med. 2010; 363: 54-62
- Regional variations in diagnostic practices.N Engl J Med. 2010; 363: 45-53
- Medical practice variations: what the literature tells us (or does not) about what are warranted and unwarranted variations.J Eval Clin Pract. 2011; 17: 671-677
- An explanatory model of medical practice variation: a physician resource demand perspective.J Eval Clin Pract. 2002; 8: 167-174
- Multicenter, randomized, controlled trials evaluating mortality in intensive care: doomed to fail?.Crit Care Med. 2008; 36: 1311-1322
- Usual care as the control group in clinical trials of nonpharmacologic interventions.Proc Am Thorac Soc. 2007; 4: 577-582
- Control group selection in critical care randomized controlled trials evaluating interventional strategies: an ethical assessment.Crit Care Med. 2004; 32: 852-857
- We should abandon randomized controlled trials in the intensive care unit.Crit Care Med. 2010; 38: S534-S538
- The Childhood Cancer Survivor study: a National Cancer Institute-supported resource for outcome and intervention research.J Clin Oncol. 2009; 27: 2308-2318
- Critical care for rare diseases.Pediatr Crit Care Med. 2002; 3: 89-90
Pediatric Acute Lung Injury and Sepsis Investigators. PALISI. 2011. Available at: http://www.palisi.org. Accessed October 21, 2012.
Virtual Pediatric Intensive Care Unit. VPICU. Available at: http://vpicu.org/. Accessed October 21, 2012.
Article info
Publication history
Published online: January 21, 2013
Identification
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© 2013 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
