November 13, 2007, Volume 54, No. 12
Unanticipated Consequences of Health Care IT
Researchers at Penn’s School of Medicine and the Agency for Healthcare Research and Quality (AHRQ) have developed a framework to help hospital managers, physicians, and nurses handle the tough challenges of implementing health information technology (HIT) by directly addressing the unintended consequences that undermine safety and quality. This study appeared in the September issue of the Journal of American Medical Informatics Association (JAMIA).
Dr. Ross Koppel, principle investigator in Penn’s Center for Clinical Epidemiology and Biostatistics, noted that computerized physician order entries (CPOE) reduce medication errors due to transcription or hand-writing deficiencies, but produce many unintended consequences. For example, in some CPOE systems, physicians must enter the patient’s weight before ordering some types of medications. Physicians will often insert an estimated weight just to order the desired medication, without being able to indicate it as an estimation. That number is then used by subsequent physicians for medications requiring more careful weight measurements. Dr. Koppel is an adjunct professor of sociology. The co-authors are AHRQ’s Dr. Michael I. Harrison and Dr. Shirly Bar-Lev, from the Ruppin Academic Center, Israel.
Use of sophisticated HIT in hospitals is increasing dramatically, yet the results are often disappointing, say researchers.
The authors demonstrated how new HIT changes workplace processes and how practitioners alter these technologies during use. The authors call their new paradigm “Interactive Sociotechnical Analysis.”
“We are strong proponents of HIT,” said Drs. Harrison and Koppel. “But introducing HIT is not like adding a fax machine. HIT involves a whole set of activities and interactions with existing IT, people, the built environment, and with other systems. These interactions generate unpredictable developments. We map these developments to inspire greater awareness of IT implementation problems and increased action to improve new IT systems.”
“Decision makers are taking unnecessary risks if they wait for HIT projects to run for a year or two before doing a post-hoc evaluation,” Dr. Harrison. “Real time evaluations can reveal unintended consequences as they emerge, allowing remedial action to be taken.”
Pinpointing Brain Waves that Distinguish Memories
Penn researches are now able to pinpoint brain waves that distinguish true from false memories, providing a better understanding of how memory works and creating a new strategy to help epilepsy patients retain cognitive function. The study appears in the November edition of the journal Psychological Science.
To test whether distinct patterns of electrophysiological activity prior to a response can distinguish true from false memories, psychologists at Penn recorded brain activity from 52 neurosurgical patients being treated for drug-resistant epilepsy. Patients were asked to perform a verbal free-recall task while researchers used an array of implanted electrodes and intracranial electroencephalographic recordings to locate where in their brains the patients’ seizures originated. Patients volunteered to study lists of words which they were then asked to recall at a later time. When asked to recall the studied words, participants recalled some number of correct items and also made a small number of errors, recalling words that had not appeared on the target list.
While patients performed the memory game, scientists observed electrical activity in their brains to determine whether specific brain waves were associated with successfully storing and retrieving memories. Researchers found that a fast brain wave, known as the gamma rhythm, increased when participants studied a word that they would later recall. The same gamma waves also increased in the half-second prior to participants correctly recalling an item.
These analyses revealed that the same pattern of gamma band oscillatory activity in the hippocampus, prefrontal cortex and left temporal lobe that predicts successful memory formation also re-emerged at retrieval, distinguishing correct from incorrect responses, said Dr. Per B. Sederberg, lead author and former Penn neuroscientist now performing post-doctoral research at Princeton University.
In addition to providing a better understanding of how memory works, the findings may also provide a clearer picture of how to assist those suffering with epilepsy. In epilepsy’s 2.6 million American sufferers, brain oscillations become so strong that they sweep across the brain, producing seizures. Although seizures are controlled with medication in two-thirds of people with epilepsy, the remainder may be candidates for surgery to remove the brain regions where seizures originate.
“Identifying the neural signatures of successful memory storage and retrieval can help neurosurgeons reduce the cognitive deficits that might result from epilepsy surgery,” said Dr. Brian Litt, associate professor of neurology and bioengineering, and co-author of the study. In addition, these techniques could also help in treatment of other neurological disorders, including depression, schizophrenia, and affective disorders.
Effect of Medical Residency on Patient Mortality
Contrary to critics, researchers at the School of Medicine found that new national regulations greatly limiting work hours for physicians-in-training did not lead to increased patient deaths. In order to address issues surrounding sleep deprivation of medical residents, recently implemented regulations required them to work fewer hours, resulting in fewer residents on call at any one time and more patient handoffs due to shorter resident schedules.
Analyzing over 8 million patient hospitalizations in the Medicare system and over 300,000 hospitalizations in the United States Veterans Affairs (VA) System, Penn investigators found that duty hour regulations for medical residents in the VA System significantly improved patient mortality rates; yet these regulations were not associated with either significant worsening or improvement in mortality for Medicare patients. The studies’ corresponding author Dr. Kevin G. Volpp, assistant professor of medicine and health care systems at Penn and core faculty member with the Center for Health Equity Research and Promotion at the Philadelphia Veterans Affairs Medical Center, and co-principal investigator Dr. Jeffrey H. Silber, professor of pediatrics and director of the Center for Outcomes Research at CHOP, reported their findings in two studies in the September 5 issue of Journal of the American Medical Association.
The new regulations created restrictions that included working no more than 80 hours per week with one day per week free of all duties; no more than 24 continuous hours of work with an additional six hours for education and transfer of care; in-house call no more often than every third night; and at least ten hours off between duty periods.
The VA study followed all patients admitted to acute-care VA hospitals from July 1, 2000 to June 30, 2005. The Medicare study followed all patients admitted to acute-care non-federal hospitals during this time period as well.
Both studies focused on medical patients admitted with principle diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, or stroke; or general, orthopedic, or vascular surgery patients. The main outcome measure for both studies was mortality within 30 days of hospital admission.
While there were no significant relative increases or decreases in mortality for either medical or surgical patients in the post-reform years among Medicare patients, the VA system did find some significant relative improvements in mortality rates among medical patients in post-reform year 2. The magnitude of the relative improvements in mortality in post-reform year 2 represented about an 11% improvement in mortality for patients in hospitals in the 75th percentile of teaching intensity as compared to hospitals in the 25th percentile of teaching intensity.
“The positive impact of the duty hours in reducing mortality rates in VA hospitals may be due to VA hospitals being more teaching intensive. In addition, residents working in VA hospitals are probably less over-taxed, allowing higher compliance with these regulations. The VA also has better information systems than most non-VA settings, which may have mitigated the adverse impacts of worsened continuity of care,” said Dr. Volpp.
Older African American Men with HIV Shun Condoms
In a nurse-led study at the School of Nursing, researchers found as many as 40% of older HIV-positive African American men may not be using condoms during sexual activity, potentially putting their partners at risk. The research, “Determinants of perceived barriers to condom use among HIV Infected Middle-aged and Older African American Men,” was published in the Journal of Advanced Nursing in the United Kingdom in October of this year.
A study of 130 men, aged 40-65, found that 25% did not use condoms during vaginal sex, 22% during anal sex, and 38% during oral sex.
“The findings of the study are worrying, particularly in view of rising HIV and AIDS rates in both ethnic communities, and the over 50s. They definitely point to the need for further research into why older African American men with HIV don’t use condoms,” said Dr. Christopher L. Coleman, assistant professor of nursing.