Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2012 Jul-Aug;19(4):555-61.
doi: 10.1136/amiajnl-2011-000521. Epub 2012 Jan 3.

Improving completeness of electronic problem lists through clinical decision support: a randomized, controlled trial

Adam Wright  1 , Justine Pang, Joshua C Feblowitz, Francine L Maloney, Allison R Wilcox, Karen Sax McLoughlin, Harley Ramelson, Louise Schneider, David W Bates
Affiliations
Randomized Controlled Trial

Improving completeness of electronic problem lists through clinical decision support: a randomized, controlled trial

Adam Wright et al. J Am Med Inform Assoc. 2012 Jul-Aug.

Abstract

Background: Accurate clinical problem lists are critical for patient care, clinical decision support, population reporting, quality improvement, and research. However, problem lists are often incomplete or out of date.

Objective: To determine whether a clinical alerting system, which uses inference rules to notify providers of undocumented problems, improves problem list documentation.

Study design and methods: Inference rules for 17 conditions were constructed and an electronic health record-based intervention was evaluated to improve problem documentation. A cluster randomized trial was conducted of 11 participating clinics affiliated with a large academic medical center, totaling 28 primary care clinical areas, with 14 receiving the intervention and 14 as controls. The intervention was a clinical alert directed to the provider that suggested adding a problem to the electronic problem list based on inference rules. The primary outcome measure was acceptance of the alert. The number of study problems added in each arm as a pre-specified secondary outcome was also assessed. Data were collected during 6-month pre-intervention (11/2009-5/2010) and intervention (5/2010-11/2010) periods.

Results: 17,043 alerts were presented, of which 41.1% were accepted. In the intervention arm, providers documented significantly more study problems (adjusted OR=3.4, p<0.001), with an absolute difference of 6277 additional problems. In the intervention group, 70.4% of all study problems were added via the problem list alerts. Significant increases in problem notation were observed for 13 of 17 conditions.

Conclusion: Problem inference alerts significantly increase notation of important patient problems in primary care, which in turn has the potential to facilitate quality improvement.

Trial registration: ClinicalTrials.gov: NCT01105923.

PubMed Disclaimer

Conflict of interest statement

Competing interests: None.

Figures

Figure 1
Figure 1
Screenshot of problem inference alerts.
Figure 2
Figure 2
Participant flow for study clusters (subclinic randomization). Because randomization was carried out at the subclinical level, a small number of patients (n=3849) appear in both arms of the study.
Figure 3
Figure 3
Cumulative number of study problems added during pre-intervention and intervention periods.
See this image and copyright information in PMC

References

    1. Hartung DM, Hunt J, Siemienczuk J, et al. Clinical implications of an accurate problem list on heart failure treatment. J Gen Intern Med 2005;20:143–7 - PMC - PubMed
    1. Wright A, Goldberg H, Hongsermeier T, et al. A description and functional taxonomy of rule-based decision support content at a large integrated delivery network. J Am Med Inform Assoc 2007;14:489–96 - PMC - PubMed
    1. Kaplan DM. Clear writing, clear thinking and the disappearing art of the problem list. J Hosp Med 2007;2:199–202 - PubMed
    1. Szeto HC, Coleman RK, Gholami P, et al. Accuracy of computerized outpatient diagnoses in a Veterans Affairs general medicine clinic. Am J Manag Care 2002;8:37–43 - PubMed
    1. Tang PC, LaRosa MP, Gorden SM. Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions. J Am Med Inform Assoc 1999;6:245–51 - PMC - PubMed

Publication types

Associated data