1. © VANDERBILT UNIVERSITY 2009 B I O M E D I C A L I N F O R M A T I C S A System to Improve Medication Safety in the Setting of Acute Kidney Injury Intervention Passive Alert Intrusive Alert Allison B. McCoy, MS Josh F. Peterson, MD, MPH Cynthia S. Gadd, PhD, MBA, MS Lemuel R. Waitman, PhD Department of Biomedical Informatics Vanderbilt University Medical Center OBJECTIVE: To improve provider response to acute kidney injury using a computerized provider order entry intervention. INTRODUCTION Inadequate dosing for nephrotoxic or renally cleared drugs in patients with acute kidney injury (AKI) is common, though recent clinical decision support systems have proven successful in decreasing errors. INTERVENTION A computerized provider order entry (CPOE) intervention alerted providers about 0.5 mg/dl or greater increases in serum creatinine, advising discontinuation or modification of nephrotoxic or renally cleared drugs. A passive alert appeared as persistent text within the CPOE system and on rounding reports, requiring no provider response. An intrusive alert interrupted the provider at the end of the CPOE session, requiring the provider to modify or discontinue the drug order, assert that the current dose was correct, or defer the alert to reappear in the next CPOE session. MEASUREMENTS We evaluated the interventions, using as our outcomes the rate of order modification or discontinuation within 24 hours, the time to modification or discontinuation, and the provider response to the alerts. RESULTS The rate of order modification or discontinuation increased from 40.1 to 61 actions per 100 events (p < 0.001) for high toxicity drugs and 38.9 to 48.4 actions per 100 events (p < 0.001) for moderate toxicity drugs. The median time to order modification or discontinuation decreased from 28.3 to 10.2 hours (p < 0.001) for high toxicity drugs and 31.1 to 20.4 hours (p < 0.001) for moderate toxicity drugs. After viewing only a passive alert, providers modified or discontinued 26.9% of orders. For those not immediately modified or discontinued, providers chose to initially defer 78.1% of the intrusive alerts. Providers selected “modify” or “discontinue” as the terminal response during 12.2% and 8.1% of the displayed intrusive alerts respectively, and “correct dose” during 42.5%. CONCLUSION The intervention improved provider response to AKI, though frequent provider deferrals suggested future enhancements to increase success. ACKNOWLEDGEMENT: This work was funded by T15 LM007450-06 and R03 LM009238-02. Results Post-InterventionPre-Intervention

2. © VANDERBILT UNIVERSITY 2009 B I O M E D I C A L I N F O R M A T I C S Implementation Sciences Vanderbilt Implementation Sciences Laboratory Nancy Lorenzi, PhD, MLS, MA, Director Department of Biomedical Informatics Vanderbilt University Medical Center OBJECTIVE: The Implementation Sciences Laboratory (ISL) in the Department of Biomedical Informatics is a community of scholars interested in achieving implementation goals for information-based systems to support operations, research, and education in complex healthcare organizations... CURRENT PROJECTS Current Implementation Sciences Laboratory Projects are focused on three areas of translational research:  Understanding and improving adoption of technology-enabled treatment strategies  Gaining clinical acceptance of Evidence-Based Medicine by clinicians  Developing strategies, processes, and methods that lead to greater adoption and acceptance for community health research. Implementation Chasm The Department of Biomedical Informatics has a number of full-time faculty, clinical faculty and students studying biomedical informatics and adoption of information-based systems. Research in the understanding of why people do or do not adopt new technology, processes, and other innovations is primarily qualitative and people/organization-based. Project ConceptPersonnelDescription Evaluation of regional information access by clinicians (RHIO) Johnson, GaddEmergency Medicine physicians can now readily gain additional information to support patient care. In addition to the traditional evaluation, data will also be collected to determine if physicians seek information from the regional resource for care of the patient. The impact of workflow-related issues on adoption of a new technologies Unertl, Lorenzi, JohnsonOne of the constant challenges to the adoption and acceptance of new technology or methods is that they are not compatible with the workflow of the clinical area. This will be a major study to assess the impact of workflow on technology adoption and to develop new tools and methodologies for workflow studies. The use and adoption of personal health records Johnson, WeissThe Robert Wood Johnson Foundation created Project Health Design to see how personal health records could be effectively designed for use by patients. New technology can help to address the medication safety issues in health care, but adoption is a problem Novak, Lorenzi, GaddCreating Safety Research: Research has shown benefits of medication safety technologies such as barcode medication administration and electronic prescribing. However, implementation and adoption of these systems are a major challenge. A qualitative study of the strategies that individuals and organizations use to incorporate medication safety technologies into everyday clinical practice will be implemented. Connecting clinicians and patients for more successful long term outcome Weiss, LorenziThe Middle Survivorship Network: The purpose of this research is to design and evaluate an online environment for individuals and groups in the middle cancer survivorship community. Decision Support to Improve Medication Safety in Changing Renal Function McCoy, Waitman, Peterson, Gadd An evaluation of a multi-level decision support intervention to improve provider response to medication safety in changing renal function. Investigating Nurse-Managed Protocol UsageCampion, Waitman, Lorenzi, Gadd A qualitative study of nurse management of patient care protocols and advisors embedded in care provider order entry systems. Lorenzi NM, Novak LL, Weiss JB, Gadd CS, Unertl KM. Crossing the Implementation Chasm: A Proposal for Bold Action. Journal of the American Medical Informatics Association 15(3) May/June 2008.