Unanticipated consequences of health-care information technology

PHILADELPHIA — Researchers at the University of Pennsylvania 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.

As documented in a 2005 JAMA article by Penn’s Ross Koppel, PhD, computerized physician order entries, CPOE for short, 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. Koppel is the Principal Investigator of an AHRQ-supported study of hospital workplace culture and medication error at Penn’s Center for Clinical Epidemiology and Biostatistics and a faculty member in Penn’s Sociology Department.

In this new paper, co-authors Koppel, AHRQ’s Michael I. Harrison, PhD, and Shirly Bar-Lev, PhD, from the Ruppin Academic Center, Israel, show managers and clinicians how to avoid or catch unintended consequences before they cause lasting harm. This study appears in the September issue of the Journal of American Medical Informatics Association – JAMIA.

Use of sophisticated HIT in hospitals is increasing dramatically. In addition to CPOE, other examples in which unintended consequences can occur are decision support systems and electronic medical records. Health care facilities are investing millions of dollars in health care information technology as they seek to improve patient care, safety, efficiency, and cost savings. Yet the results are often disappointing, say the researchers.

“Managers and clinicians need to prevent more undesirable side effects and recognize unforeseeable consequences early on,” says lead author Harrison. “Then they can take steps to remedy them before damage mounts.”

The authors demonstrate 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,” say 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,” observes Harrison. “Real time evaluations can reveal unintended consequences as they emerge, allowing remedial action to be taken.”

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This release can be viewed at http://www.pennhealth.com/news

PENN Medicine is a $3.5 billion enterprise dedicated to the related missions of medical education, biomedical research, and excellence in patient care. PENN Medicine consists of the University of Pennsylvania School of Medicine (founded in 1765 as the nation’s first medical school) and the University of Pennsylvania Health System.

Penn’s School of Medicine is currently ranked #3 in the nation in U.S.News & World Report’s survey of top research-oriented medical schools; and, according to most recent data from the National Institutes of Health, received over $379 million in NIH research funds in the 2006 fiscal year. Supporting 1,400 fulltime faculty and 700 students, the School of Medicine is recognized worldwide for its superior education and training of the next generation of physician-scientists and leaders of academic medicine.

The University of Pennsylvania Health System includes three hospitals — its flagship hospital, the Hospital of the University of Pennsylvania, rated one of the nation’s “Honor Roll” hospitals by U.S.News & World Report; Pennsylvania Hospital, the nation’s first hospital; and Penn Presbyterian Medical Center — a faculty practice plan; a primary-care provider network; two multispecialty satellite facilities; and home care and hospice.

Contact: Karen Kreeger
karen.kreeger@uphs.upenn.edu
215-349-5658
University of Pennsylvania School of Medicine

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Multicenter study nets new lung tumor-suppressor gene

BOSTON–Collaborating scientists in Boston and North Carolina have found that a particular gene can block key steps of the lung cancer process in mice. The researchers report in the journal Nature that LKB1 is not only a “tumor-suppressor” gene for non-small cell lung cancer in mice, it also may be more powerful than other, better-known suppressors. The study will be published on the journal’s Web site on Aug. 5 and later in a print version.

If further research shows LKB1 has a similar effect in human lung cells, it could influence the way non-small cell lung cancer is diagnosed and treated, says the study’s senior author, Kwok-Kin Wong, MD, PhD, of Dana-Farber, one of three institutions, along with Massachusetts General Hospital and the University of North Carolina School of Medicine, leading the work. If tumors with LKB1 mutations are found to be especially fast-growing, for example, patients with such tumors might be candidates for more aggressive therapy.

People born with defective versions of LKB1 often develop Peutz-Jeghers syndrome, which is marked by intestinal growths and an increased risk for certain cancers. Non-inherited mutations of the gene have been found in some lung cancers. This suggested that LKB1 normally thwarts tumors from forming. Mutated versions may be unable to act as a brake on cancer.

To find out, the investigators ran a series of experiments in mice with a defective form of a gene called Kras, which drives the formation and growth of lung cancer. They tracked the development of lung cancer in animals with mutated LKB1 and compared it to the experience of animals with abnormalities in either of two well-known tumor-suppressor genes.

They found that while Kras “cooperated” with the mutated tumor-suppressor genes to produce lung cancer, it cooperated even more strongly with mutated LKB1. “The LKB1-deficient tumors grew more rapidly and spread more frequently than the others, and comprised all three types of non-small cell lung cancer — squamous cell carcinoma, large-cell carcinoma, and adenocarcinoma — rather than just one or two,” Wong says. “This suggests that LKB1 plays a role at major stages of the tumors’ development: initiation, differentiation of normal lung cells into cancer cells, and metastasis.”

An examination of human non-small-cell lung tissue suggests LKB1 mutations play a role there as well. Of 144 samples analyzed, 34 percent of the lung adenocarcinomas and 19 percent of the squamous cell carcinomas contained abnormal versions of the gene, researchers report.

“We were surprised at how significant a role LKB1 mutations play in non-small cell lung cancer development in mice,” say Wong, who is also an assistant professor of medicine at Harvard Medical School. “This suggests there may be additional lung tumor-suppressor genes yet to be discovered. We’re currently examining whether these results apply to human lung cancers as well and, if so, how such information can improve treatment.”

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The lead author of the study was Hongbin Ji, PhD, of Dana-Farber. Other Dana-Farber co-authors include Dongpo Cai, PhD, Liang Chen, PhD, Pasi Janne, MD, PhD, Bruce Johnson, MD, Jussi Koivunen, MD, PhD, Danan Li, Mei-Chih Liang, PhD, Kate McNamara, Matthew Meyerson, MD, PhD, Samanthi Perera, PhD, Geoffrey Shapiro, MD, PhD, and Takeshi Shimamura, PhD. Other authors were based at Children’s Hospital Boston, Brigham and Women’s Hospital, Broad Institute of Harvard University and Massachusetts Institute of Technology, University of Tennessee Health Science Center, and the University of Texas Southwestern Medical Center.

The research was supported by the National Institutes of Health, the Sidney Kimmel Foundation for Cancer Research, the American Federation of Aging, the Joan Scarangello Foundation to Conquer Lung Cancer, the Flight Attendant Medical Research Institute, the Waxman Foundation, the Harvard Stem Cell Institute, and the Linda Verville Foundation.

Dana-Farber Cancer Institute (www.dana-farber.org) is a principal teaching affiliate of the Harvard Medical School and is among the leading cancer research and care centers in the United States. It is a founding member of the Dana-Farber/Harvard Cancer Center (DF/HCC), designated a comprehensive cancer center by the National Cancer Institute.

Contact: Bill Schaller
william_schaller@dfci.harvard.edu
617-632-5357
Dana-Farber Cancer Institute

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New studies on goat milk show it is more beneficial to health than cow milk

-It helps to prevent diseases such as anaemia and bone demineralisation
-UGR researchers have carried out a comparative study on the properties of goat milk compared to those of cow milk. Rats with induced nutritional ferropenic anaemia have been used in the study
-Goat milk helps digestive and metabolic utilisation of minerals such as iron, calcium, phosphorus and magnesium
-Part of the results of this research have been published in the prestigious scientific journals International Dairy Journal and Journal Dairy Science

C@MPUS DIGITAL Research carried out at the Department of Physiology of the University of Granada has revealed that goat milk has more beneficial properties to health than cow milk. Among these properties it helps to prevent ferropenic anaemia (iron deficiency) and bone demineralisation (softening of the bones).

This project, conducted by Doctor Javier Díaz Castro and directed by professors Margarita Sánchez Campos, Mª Inmaculada López Aliaga and Mª José Muñoz Alférez, focuses on the comparison between the nutritional properties of goat milk and cow milk, both with normal calcium content and calcium enriched, against the bioavailability of iron, calcium, phosphorus and magnesium. To carry out this study, the metabolic balance technique has been used both in rats with experimentally induced nutritional ferropenic anaemia and in a control group of rats.

In order to know how the nutritive utilisation of these minerals may affect their metabolic distribution and destination, the UGR researcher has determined the concentration of these minerals in the different organs involved in their homeostatic regulation and different haematological parameters in relation to the metabolism of the minerals.

Better results with goat milk
Results obtained in the study reveal that ferropenic anaemia and bone demineralisation caused by this pathology have a better recovery with goat milk. Due to the higher bioavailability of iron, calcium, phosphorus and magnesium, the restoration of altered haematological parameters and the better levels of parathyroid hormone (PTH), a hormone that regulates the calcium balance in the organism was found in the rats that consumed this food.

Javier Díaz Castro points out that the inclusion of goat milk with normal or double calcium content in the diet “favours digestive and metabolic utilisation of iron, calcium and phosphorus and their deposit in target organs – parts of the organism to which these minerals are preferably sent – involved in their homeostatic regulation”.

According to this researcher, all these conclusions reveal that regular consumption of goat milk – a natural food with highly beneficial nutritional characteristics – “has positive effects on mineral metabolism, recovery from ferropenic anaemia and bone mineralisation in rats. In addition, and unlike observations in cow milk, its calcium enrichment does not interfere in the bioavailability of the minerals studied”.

Although there is no doubt that these findings may be a base for further in depth study of the multiple health benefits of goat milk, the UGR researcher warns that “studies in humans are still required in order to confirm the findings obtained in rats and to promote goat milk consumption both in the general population and in the population affected by nutritional ferropenic anaemia and pathologies related to bone demineralisation”. Part of the results of this research has been published in the prestigious scientific journals International Dairy Journal and Journal Dairy Science.

Reference: Dr Javier Díaz Castro. Department of Physiology of the University of Granada.
Tel.: +34 958248319. Mobile: +34 654574434. Email: javierdc@ugr.es

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Study shows an electronic medical records system can pay for itself within 16 months

CHICAGO (July 12, 2007) — A new study to be published in the July issue of the Journal of the American College of Surgeons shows that one academic medical center recouped its investment in electronic health records within 16 months. The new analysis counters concerns of health care providers reluctant to invest in electronic medical records systems.

The widespread loss of paper medical records in New Orleans after Hurricane Katrina is one of several factors behind the recent push to get surgeons and other health care providers to go electronic, according to David A. Krusch, MD, FACS, of the University of Rochester Department of Surgery and co-author of the study.

“Health care providers most frequently cite cost as primary obstacle to adopting an electronic medical records system. And, until this point, evidence supporting a positive return on investment for electronic health records technologies has been largely anecdotal,” said Dr. Krusch.

The study measured the return on investment of installing electronic health records at five ambulatory offices representing 28 providers within the University of Rochester (NY) Medical Center. Starting in November 2003, the offices implemented a Touchworks EHR system from Chicago-based Allscripts over the next five months. The study compared the cost of activities such as pulling charts, creating new charts, filing time, support staff salary, and transcription when done electronically in the third quarter of 2005, versus the cost of those same activities performed manually in the third quarter of 2003.

The University of Rochester Medical Center estimated that the new electronic medical records system reduced costs by $393,662 per year, nearly two-thirds of that coming from a sharp reduction in the time required to manually pull charts. Given that its electronic system cost $484,577 to install and operate, it took the University of Rochester Medical Center 16 months to recoup its investment. After the first year, it cost about $114,016 annually to operate the new system, which translates to a savings of $279,546 a year for the medical center, or $9,983 per provider.

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The complete study, “A Pilot Study to Document the Return on Investment for Implementing an Ambulatory Electronic Health Record at an Academic Medical Center”, will appear in the July issue of the Journal of the American College of Surgeons. In addition to Krusch, Dara L. Grieger, MD, of the University of Rochester Department of Surgery and Stephen H. Cohen, MN, CPE, also co-authored the article.

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and to improve the care of the surgical patient. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 71,000 members and it is the largest organization of surgeons in the world. For more information, visit http://www.facs.org.

Contact: Sally Garneski
pressinquiry@facs.org
Weber Shandwick Worldwide

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Demonic possession and miraculous healing

PA110/07 — June 25 2007

Latest research into health in medieval Europe — taking in everything from demonic possession to miracles of healing — is to be revealed at The University of Nottingham.

Experts from all over the world are gathering at the University to exchange their latest findings on concepts of ‘Health and the Healthy Body’ in early medieval times, 400-1200AD.

Their research focuses on our ancestors’ view of sickness, spiritual healing, diet, disability, burial rituals, exorcism, divine intervention, Hebrew medical manuscripts and Christian concepts of the healthy body.

Scholars of the period are particularly interested in how attitudes and beliefs that originated centuries ago continue to resonate today. Until recently there was very little study of early medieval health and illness – but research findings are already suggesting that it may be time to re-think the way we regard this key aspect of life in the early Middle Ages.

The two-day conference, ‘Disease, Disability and Medicine in Early Medieval Europe’ brings together leading experts in the field from the USA, Norway, Germany, Israel and the UK on July 6-7, 2007.

Co-organiser Dr Christina Lee, of The University of Nottingham’s School of English Studies, said: “I am delighted to host the second workshop at The University of Nottingham. We are working closely with colleagues who look at modern attitudes towards disease and this event will once again be a forum for discussion between disciplines.

“We have to look towards the past to understand the ways in which attitudes towards diseases develop. The success of healing is linked to prevalent cultural views. Ethical codes played a major role in past approaches in dealing with the sick, but today we tend regard most of them as superstition.

“Our own reaction to disease and healing, such as for example the hotly-debated stem cell research, is also linked to contemporary views. By looking at past societies we may be able to understand more about our own attitudes. There is a question of what position the sick and impaired hold within a society or how much illness is accepted as part of life, which may differ from modern views where the prevalent idea is that afflictions should be cured and the expectation that bodies should ‘function’ normally.”

Lectures at the conference include:

· ‘Demon possession in Anglo-Saxon England’, Peter Dendle, Pennsylvania State University, USA. Part of an ongoing study of early medieval demonology and constructs of evil — how prevalent was demonic possession and exorcism and how often did it touch on the day-to-day lives of the Anglo-Saxons?

· ‘Healing from God: physically impaired people in miracle reports’, Klaus-Peter Horn, University of Bremen, Germany. Research focusing on pilgrimages by physically impaired people — and how much help they could receive from relatives, neighbours, servants on the long road to miraculous healing.

· ‘You are what you eat: Christian concepts of the healthy body in Old Norse Society’, Anne Irene Riisoy, University of Oslo, Norway. An overview of the dietary regulations introduced in church legislation in Norway and Iceland, with animals that had been a common feature of the pre-Christian menu — such as horses, cats and dogs — acquiring taboo status.

· ‘”This should not be shown to a gentile”: Medico-magical entries in medieval Franco-German Hebrew manuscripts and their social significance’, Ephraim Shoham-Steiner, Ben-Gurion University, Israel. Includes a discussion of texts detailing short potions, charms and medical remedies in the pages of Hebrew manuscripts.

· ‘Miraculous healing in Medieval Iceland’, Joel Anderson, University of Oslo, Norway. Includes a look at stories of saintly healing miracles and how they were viewed by contemporary Icelandic society, particularly miracles attributed to Bishop Guðmundr Arason ‘the Good’, 1161-1237.

Dr Lee will give a session with the title ‘In good company’, looking at burial patterns of people with disease in Anglo-Saxon England.

Dr Sara Goodacre, of The University of Nottingham, will give a lecture entitled ‘The history of modern Europeans: a genetic perspective’. She will present new data showing geographic trends in patterns of maternally and paternally inherited genetic variation with the British Isles, and what these findings suggest about likely patterns of male and female migration.

The meeting, sponsored by the Wellcome Trust, aims to be a forum for scholars working on the topic in a variety of disciplines and regions of Northern Europe, including all aspects of disease, disability and medicine.

Conference organisers are hoping to build bridges between experts in archaeology, palaeopathology — the study of ancient diseases — the history of medicine, as well as the history of religion, philosophy, linguistic and historical sciences.

The event takes place in the School of English Studies, at The University of Nottingham. It is a collaboration between Dr Lee at Nottingham and Dr Sally Crawford and Robert Arnott, of the University of Birmingham.

Academics wishing to attend should request a registration form from Rebecca Peck in the School of English Studies at The University of Nottingham, before June 30, on: Rebecca.peck@nottingham.ac.uk

— Ends —

Notes to editors: The University of Nottingham is Britain’s University of the Year (The Times Higher Awards 2006). It undertakes world-changing research, provides innovative teaching and a student experience of the highest quality. Ranked by Newsweek in the world’s Top 75 universities, its academics have won two Nobel Prizes since 2003. The University is an international institution with campuses in the United Kingdom, Malaysia and China.

More information is available from Dr Christina Lee, School of English Studies, University of Nottingham, on +44 (0)115 846 7194, christina.lee@nottingham.ac.uk; or Media Relations Manager Tim Utton in the University’s Media and Public Relations Office on +44 (0)115 846 8092, tim.utton@nottingham.ac.uk

The full programme and registration form can de downloaded from: http://www.nottingham.ac.uk/english/conference/ddme.htm

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