Joan S Ash

Publications of Joan S Ash

• Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study.

  Authors: Joan S Ash, Dean F Sittig, Kenneth P Guappone, Richard H Dykstra, Joshua Richardson, Adam Wright, James Carpenter, Carmit McMullen, Michael Shapiro, Arwen Bunce, Blackford Middleton

  BMC medical informatics and decision making. 02/2012; 12(1):6.

  ABSTRACT: BACKGROUND: The purpose of this study was to identify recommended practices for computerized clinical decision support (CDS) development and implementation and for knowledge management (KM)ABSTRACT: BACKGROUND: The purpose of this study was to identify recommended practices for computerized clinical decision support (CDS) development and implementation and for knowledge management (KM) processes in ambulatory clinics and community hospitals using commercial or locally developed systems in the U.S. METHODS: Guided by the Multiple Perspectives Framework, the authors conducted ethnographic field studies at two community hospitals and five ambulatory clinic organizations across the U.S. Using a Rapid Assessment Process, a multidisciplinary research team: gathered preliminary assessment data; conducted on-site interviews, observations, and field surveys; analyzed data using both template and grounded methods; and developed universal themes. A panel of experts produced recommended practices. RESULTS: The team identified ten themes related to CDS and KM. These include: 1) workflow; 2) knowledge management; 3) data as a foundation for CDS; 4) user computer interaction; 5) measurement and metrics; 6) governance; 7) translation for collaboration; 8) the meaning of CDS; 9) roles of special, essential people; and 10) communication, training, and support. Experts developed recommendations about each theme. The original Multiple Perspectives framework was modified to make explicit a new theoretical construct, that of Translational Interaction. CONCLUSIONS: These ten themes represent areas that need attention if a clinic or community hospital plans to implement and successfully utilize CDS. In addition, they have implications for workforce education, research, and national-level policy development. The Translational Interaction construct could guide future applied informatics research endeavors.

• A clinical decision support needs assessment of community-based physicians.

  Authors: Joshua E Richardson, Joan S Ash

  Journal of the American Medical Informatics Association : JAMIA. 09/2011; 18 Suppl 1:i28-35.

  To conduct a grounded needs assessment to elicit community-based physicians' current views on clinical decision support (CDS) and its desired capabilities that may assist future CDS design andTo conduct a grounded needs assessment to elicit community-based physicians' current views on clinical decision support (CDS) and its desired capabilities that may assist future CDS design and development for community-based practices. To gain insight into community-based physicians' goals, environments, tasks, and desired support tools, we used a human-computer interaction model that was based in grounded theory. We conducted 30 recorded interviews with, and 25 observations of, primary care providers within 15 urban and rural community-based clinics across Oregon. Participants were members of three healthcare organizations with different commercial electronic health record systems. We used a grounded theory approach to analyze data and develop a user-centered definition of CDS and themes related to desired CDS functionalities. Physicians viewed CDS as a set of software tools that provide alerts, prompts, and reference tools, but not tools to support patient management, clinical operations, or workflow, which they would like. They want CDS to enhance physician-patient relationships, redirect work among staff, and provide time-saving tools. Participants were generally dissatisfied with current CDS capabilities and overall electronic health record usability. Physicians identified different aspects of decision-making in need of support: clinical decision-making such as medication administration and treatment, and cognitive decision-making that enhances relationships and interactions with patients and staff. Physicians expressed a need for decision support that extended beyond their own current definitions. To meet this requirement, decision support tools must integrate functions that align time and resources in ways that assist providers in a broad range of decisions.

• Clinical decision support in small community practice settings: a case study.

  Authors: Joan S Ash, Dean F Sittig, Adam Wright, Carmit McMullen, Michael Shapiro, Arwen Bunce, Blackford Middleton

  Journal of the American Medical Informatics Association : JAMIA. 04/2011; 18(6):879-82.

  Using an eight-dimensional model for studying socio-technical systems, a multidisciplinary team of investigators identified barriers and facilitators to clinical decision support (CDS) implementationUsing an eight-dimensional model for studying socio-technical systems, a multidisciplinary team of investigators identified barriers and facilitators to clinical decision support (CDS) implementation in a community setting, the Mid-Valley Independent Physicians Association in the Salem, Oregon area. The team used the Rapid Assessment Process, which included nine formal interviews with CDS stakeholders, and observation of 27 clinicians. The research team, which has studied 21 healthcare sites of various sizes over the past 12 years, believes this site is an excellent example of an organization which is using a commercially available electronic-health-record system with CDS well. The eight-dimensional model proved useful as an organizing structure for the evaluation.

• Development and evaluation of a comprehensive clinical decision support taxonomy: comparison of front-end tools in commercial and internally developed electronic health record systems.

  Authors: Adam Wright, Dean F Sittig, Joan S Ash, Joshua Feblowitz, Seth Meltzer, Carmit McMullen, Ken Guappone, Jim Carpenter, Joshua Richardson, Linas Simonaitis, R Scott Evans, W Paul Nichol, Blackford Middleton

  Journal of the American Medical Informatics Association : JAMIA. 03/2011; 18(3):232-42.

  Clinical decision support (CDS) is a valuable tool for improving healthcare quality and lowering costs. However, there is no comprehensive taxonomy of types of CDS and there has been limited researchClinical decision support (CDS) is a valuable tool for improving healthcare quality and lowering costs. However, there is no comprehensive taxonomy of types of CDS and there has been limited research on the availability of various CDS tools across current electronic health record (EHR) systems. To develop and validate a taxonomy of front-end CDS tools and to assess support for these tools in major commercial and internally developed EHRs. We used a modified Delphi approach with a panel of 11 decision support experts to develop a taxonomy of 53 front-end CDS tools. Based on this taxonomy, a survey on CDS tools was sent to a purposive sample of commercial EHR vendors (n=9) and leading healthcare institutions with internally developed state-of-the-art EHRs (n=4). Responses were received from all healthcare institutions and 7 of 9 EHR vendors (response rate: 85%). All 53 types of CDS tools identified in the taxonomy were found in at least one surveyed EHR system, but only 8 functions were present in all EHRs. Medication dosing support and order facilitators were the most commonly available classes of decision support, while expert systems (eg, diagnostic decision support, ventilator management suggestions) were the least common. We developed and validated a comprehensive taxonomy of front-end CDS tools. A subsequent survey of commercial EHR vendors and leading healthcare institutions revealed a small core set of common CDS tools, but identified significant variability in the remainder of clinical decision support content.

• Comparison of clinical knowledge management capabilities of commercially-available and leading internally-developed electronic health records.

  Authors: Dean F Sittig, Adam Wright, Seth Meltzer, Linas Simonaitis, R Scott Evans, W Paul Nichol, Joan S Ash, Blackford Middleton

  BMC medical informatics and decision making. 02/2011; 11:13.

  We have carried out an extensive qualitative research program focused on the barriers and facilitators to successful adoption and use of various features of advanced, state-of-the-art electronicWe have carried out an extensive qualitative research program focused on the barriers and facilitators to successful adoption and use of various features of advanced, state-of-the-art electronic health records (EHRs) within large, academic, teaching facilities with long-standing EHR research and development programs. We have recently begun investigating smaller, community hospitals and out-patient clinics that rely on commercially-available EHRs. We sought to assess whether the current generation of commercially-available EHRs are capable of providing the clinical knowledge management features, functions, tools, and techniques required to deliver and maintain the clinical decision support (CDS) interventions required to support the recently defined "meaningful use" criteria. We developed and fielded a 17-question survey to representatives from nine commercially available EHR vendors and four leading internally developed EHRs. The first part of the survey asked basic questions about the vendor's EHR. The second part asked specifically about the CDS-related system tools and capabilities that each vendor provides. The final section asked about clinical content. All of the vendors and institutions have multiple modules capable of providing clinical decision support interventions to clinicians. The majority of the systems were capable of performing almost all of the key knowledge management functions we identified. If these well-designed commercially-available systems are coupled with the other key socio-technical concepts required for safe and effective EHR implementation and use, and organizations have access to implementable clinical knowledge, we expect that the transformation of the healthcare enterprise that so many have predicted, is achievable using commercially-available, state-of-the-art EHRs.

• The effects of a hands-free communication device system in a surgical suite.

  Authors: Joshua E Richardson, Sina Shah-Hosseini, John E Fiadjoe, Joan S Ash, Mohamed A Rehman

  Journal of the American Medical Informatics Association : JAMIA. 01/2011; 18(1):70-2.

  This case report describes a qualitative investigation into how a Hands-free Communication Device (HCD) system impacted communication among anesthesia staff in a pediatric surgical suite. The authorsThis case report describes a qualitative investigation into how a Hands-free Communication Device (HCD) system impacted communication among anesthesia staff in a pediatric surgical suite. The authors recruited a purposive sample that included anesthesiologists, certified registered nurse anesthetists, circulating nurses, a charge nurse, and a postanesthesia care unit nurse. Data were collected using semistructured interviews and observations, then analyzed using a constant comparison approach. The results corroborate and enrich themes that were discovered in a previous qualitative study of HCD systems: (1) communication access, (2) control, (3) training, (4) environment and infrastructure. The results also generated new subthemes and themes: (1) technical control, (2) choosing communication channels, and (3) reliability. The authors conclude that HCD systems profoundly impacted communication in a largely positive way, although reliability of the technology remained an issue. The authors' findings contribute a valuable insight into the growing body of knowledge about implementation and use of HCD systems.

• Governance for clinical decision support: case studies and recommended practices from leading institutions.

  Authors: Adam Wright, Dean F Sittig, Joan S Ash, David W Bates, Joshua Feblowitz, Greg Fraser, Saverio M Maviglia, Carmit McMullen, W Paul Nichol, Justine E Pang, Jack Starmer, Blackford Middleton

  Journal of the American Medical Informatics Association : JAMIA. 01/2011; 18(2):187-94.

  Clinical decision support (CDS) is a powerful tool for improving healthcare quality and ensuring patient safety; however, effective implementation of CDS requires effective clinical and technicalClinical decision support (CDS) is a powerful tool for improving healthcare quality and ensuring patient safety; however, effective implementation of CDS requires effective clinical and technical governance structures. The authors sought to determine the range and variety of these governance structures and identify a set of recommended practices through observational study. Three site visits were conducted at institutions across the USA to learn about CDS capabilities and processes from clinical, technical, and organizational perspectives. Based on the results of these visits, written questionnaires were sent to the three institutions visited and two additional sites. Together, these five organizations encompass a variety of academic and community hospitals as well as small and large ambulatory practices. These organizations use both commercially available and internally developed clinical information systems. Characteristics of clinical information systems and CDS systems used at each site as well as governance structures and content management approaches were identified through extensive field interviews and follow-up surveys. Six recommended practices were identified in the area of governance, and four were identified in the area of content management. Key similarities and differences between the organizations studied were also highlighted. Each of the five sites studied contributed to the recommended practices presented in this paper for CDS governance. Since these strategies appear to be useful at a diverse range of institutions, they should be considered by any future implementers of decision support.

• Studying the vendor perspective on clinical decision support.

  Authors: Joan S Ash, Dean F Sittig, Carmit K McMullen, James L McCormack, Adam Wright, Arwen Bunce, Joseph Wasserman, Vishnu Mohan, Deborah J Cohen, Michael Shapiro, Blackford Middleton

  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 01/2011; 2011:80-7.

  In prior work, using a Rapid Assessment Process (RAP), we have investigated clinical decision support (CDS) in ambulatory clinics and hospitals. We realized that individuals in these settings provideIn prior work, using a Rapid Assessment Process (RAP), we have investigated clinical decision support (CDS) in ambulatory clinics and hospitals. We realized that individuals in these settings provide only one perspective related to the CDS landscape, which also includes content vendors and electronic health record (EHR) vendors. To discover content vendors' perspectives and their perceived challenges, we modified RAP for industrial settings. We describe how we employed RAP, and show its utility by describing two illustrative themes. We found that while the content vendors believe they provide unique much-needed services, the amount of labor involved in content development is underestimated by others. We also found that the content vendors believe their products are resources to be used by practitioners, so they are somewhat protected from liability issues. To promote adequate understanding about these issues, we recommend a "three way conversation" among content vendors, EHR vendors, and user organizations.

• Health Information Technology Systems profoundly impact users: a case study in a dental school.

  Authors: Heather K Hill, Denice C L Stewart, Joan S Ash

  Journal of dental education. 04/2010; 74(4):434-45.

  The purpose of this study was to increase our understanding of the impact of Health Information Technology Systems (HITS) on dental school users when the systems are integrated into chair-sideThe purpose of this study was to increase our understanding of the impact of Health Information Technology Systems (HITS) on dental school users when the systems are integrated into chair-side patient care. We used qualitative research methods, including interviews, focus groups, and observations, to capture the experiences of HITS users at a single institution. Users included administrators, clinical faculty members, predoctoral students, support staff, and residents. The data were analyzed using a grounded theory approach, and nine themes emerged: 1) HITS benefits were disproportionate among users; 2) communicating about the HITS was challenging; 3) users experienced a range of strong emotions; 4) the instructor persona diminished; 5) there were shifts in the school's power structure; 6) allocation of end-users' time shifted; 7) the training and support needs of end-users were significant; 8) perceived lack of HITS usability made documentation cumbersome for clinicians; and 9) clinicians' workflow was disrupted. HITS integration into patient care impacts the work of all system users, especially end-users. The themes highlight areas of potential concern for implementers and users in integrating a HITS into patient care.

• Research paper: The effects of hands-free communication device systems: communication changes in hospital organizations.

  Authors: Joshua E. Richardson, Joan S. Ash

  JAMIA. 01/2010; 17:91-98.

• The training and support needs of faculty and students using a health information technology system were significant: a case study in a dental school.

  Authors: Heather K Hill, Denice C L Stewart, Joan S Ash

  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 01/2010; 2010:301-5.

  Health Information Technology Systems (HITS) are becoming more widely integrated into patient care in the dental school setting. The purpose of this study was to evaluate the impact of a chairsideHealth Information Technology Systems (HITS) are becoming more widely integrated into patient care in the dental school setting. The purpose of this study was to evaluate the impact of a chairside HITS on users in the dental school setting. Qualitative techniques, including interviews, focus groups and observations, were used. Using grounded theory, we saw 9 themes emerge. One theme of particular interest was that "training and support needs of end-users were significant." This paper explores this theme in detail and discusses the implications.

• Identifying best practices for clinical decision support and knowledge management in the field.

  Authors: Joan S Ash, Dean F Sittig, Richard Dykstra, Adam Wright, Carmit McMullen, Joshua Richardson, Blackford Middleton

  Studies in health technology and informatics. 01/2010; 160(Pt 2):806-10.

  To investigate best practices for implementing and managing clinical decision support (CDS) in community hospitals and ambulatory settings, we carried out a series of ethnographic studies to gatherTo investigate best practices for implementing and managing clinical decision support (CDS) in community hospitals and ambulatory settings, we carried out a series of ethnographic studies to gather information from nine diverse organizations. Using the Rapid Assessment Process methodology, we conducted surveys, interviews, and observations over a period of two years in eight different geographic regions of the U.S.A. We first utilized a template organizing method for an expedited analysis of the data, followed by a deeper and more time consuming interpretive approach. We identified five major categories of best practices that require careful consideration while carrying out the planning, implementation, and knowledge management processes related to CDS. As more health care organizations implement clinical systems such as computerized provider order entry with CDS, descriptions of lessons learned by CDS pioneers can provide valuable guidance so that CDS can have optimal impact on health care quality.

• Multiple perspectives on the meaning of clinical decision support.

  Authors: Joshua E Richardson, Joan S Ash, Dean F Sittig, Arwen Bunce, James Carpenter, Richard H Dykstra, Ken Guappone, Carmit K McMullen, Michael Shapiro, Adam Wright

  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 01/2010; 2010:672-6.

  Clinical Decision Support (CDS) is viewed as a means to improve safety and efficiency in health care. Yet the lack of a consensus around what is meant by CDS represents a barrier to effective design,Clinical Decision Support (CDS) is viewed as a means to improve safety and efficiency in health care. Yet the lack of a consensus around what is meant by CDS represents a barrier to effective design, use, and utilization of CDS tools. We conducted a multi-site qualitative inquiry to understand how different people define and describe CDS. Using subjects' multiple perspectives we were able to gain new insights as to what stakeholders want CDS to achieve and how to achieve it; even at times when those perspectives are competing and conflicting.

• Multiple perspectives on the meaning of clinical decision support.

  Authors: Joshua E Richardson, Joan S Ash, Dean F Sittig, Arwen Bunce, James Carpenter, Richard H Dykstra, Ken Guappone, James McCormack, Carmit K McMullen, Michael Shapiro, Adam Wright, Blackford Middleton

  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 01/2010; 2010:1427-31.

  Clinical Decision Support (CDS) is viewed as a means to improve safety and efficiency in health care. Yet the lack of consensus about what is meant by CDS represents a barrier to effective design,Clinical Decision Support (CDS) is viewed as a means to improve safety and efficiency in health care. Yet the lack of consensus about what is meant by CDS represents a barrier to effective design, implementation, and utilization of CDS tools. We conducted a multi-site qualitative inquiry to understand how different people define and describe CDS. Using subjects' multiple perspectives we were able to gain new insights as to what stakeholders want CDS to achieve and how to achieve it even when those perspectives are competing and conflicting.

• The state of the art in clinical knowledge management: An inventory of tools and techniques.

  Authors: Dean F Sittig, Adam Wright, Linas Simonaitis, James D Carpenter, George O Allen, Bradley N Doebbeling, Anwar Mohammad Sirajuddin, Joan S Ash, Blackford Middleton

  International journal of medical informatics. 10/2009;

  PURPOSE: To explore the need for, and use of, high-quality, collaborative, clinical knowledge management (CKM) tools and techniques to manage clinical decision support (CDS) content. METHODS: InPURPOSE: To explore the need for, and use of, high-quality, collaborative, clinical knowledge management (CKM) tools and techniques to manage clinical decision support (CDS) content. METHODS: In order to better understand the current state of the art in CKM, we developed a survey of potential CKM tools and techniques. We conducted an exploratory study by querying a convenience sample of respondents about their use of specific practices in CKM. RESULTS: The following tools and techniques should be priorities in organizations interested in developing successful computer-based provider order entry (CPOE) and CDS implementations: (1) a multidisciplinary team responsible for creating and maintaining the clinical content; (2) an external organizational repository of clinical content with web-based viewer that allows anyone in the organization to review it; (3) an online, collaborative, interactive, Internet-based tool to facilitate content development; (4) an enterprise-wide tool to maintain the controlled clinical terminology concepts. Even organizations that have been successfully using computer-based provider order entry with advanced clinical decision support features for well over 15 years are not using all of the CKM tools or practices that we identified. CONCLUSIONS: If we are to further stimulate progress in the area of clinical decision support, we must continue to develop and refine our understanding and use of advanced CKM capabilities.

• Clinical Decision Support Capabilities of Commercially-available Clinical Information Systems.

  Authors: Adam Wright, Dean F Sittig, Joan S Ash, Sapna Sharma, Justine E Pang, Blackford Middleton

  Journal of the American Medical Informatics Association : JAMIA. 07/2009;

  Background The most effective decision support systems are integrated with clinical information systems, such as inpatient and outpatient electronic health records (EHRs) and computerized providerBackground The most effective decision support systems are integrated with clinical information systems, such as inpatient and outpatient electronic health records (EHRs) and computerized provider order entry (CPOE) systems. Purpose The goal of this project was to describe and quantify the results of a study of decision support capabilities in Certification Commission for Health Information Technology (CCHIT) certified electronic health record systems. METHODS We conducted a series of interviews with representatives of nine commercially available clinical information systems, evaluating their capabilities against 42 different clinical decision support features. RESULTS Six of the nine reviewed systems offered all of the applicable event-driven, action-oriented, real-time clinical decision support triggers required for initiating clinical decision support interventions. Five of the nine systems could access all of the patient-specific data items identified as necessary. Six of the nine systems supported all the intervention types identified as necessary to allow clinical information systems to tailor their interventions based on the severity of the clinical situation and the user's workflow. Only one system supported all of the offered choices identified as key to allowing physicians to take action directly from within the alert. Discussion The principal finding relates to system-by-system variability. The best system in our analysis had only a single missing feature (from 42 total) while the worst had eighteen. This dramatic variability in CDS capability among commercially available systems was unexpected and is a cause for concern. CONCLUSION These findings have implications for four distinct constituencies: purchasers of clinical information systems, developers of clinical decision support, vendors of clinical information systems and certification bodies.

• Research Paper: Clinical Decision Support Capabilities of Commercially-available Clinical Information Systems.

  Authors: Adam Wright, Dean F. Sittig, Joan S. Ash, Sapna Sharma, Justine E. Pang, Blackford Middleton

  JAMIA. 01/2009; 16:637-644.

• Persistent paper: the myth of "going paperless".

  Authors: Richard H Dykstra, Joan S Ash, Emily Campbell, Dean F Sittig, Ken Guappone, James Carpenter, Joshua Richardson, Adam Wright, Carmit McMullen

  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 01/2009; 2009:158-62.

  How does paper usage change following the introduction of Computerized Physician Order Entry and the Electronic Medical Record (EMR/CPOE)? To answer that question we analyzed data collected fromHow does paper usage change following the introduction of Computerized Physician Order Entry and the Electronic Medical Record (EMR/CPOE)? To answer that question we analyzed data collected from fourteen sites across the U.S. We found paper in widespread use in all institutions we studied. Analysis revealed psychological, ergonomic, technological, and regulatory reasons for the persistence of paper in an electronic environment. Paper has unique attributes allowing it to fill gaps in information timeliness, availability, and reliability in pursuit of improved patient care. Creative uses have led to "better paper."

• A set of preliminary standards recommended for achieving a national repository of clinical decision support interventions.

  Authors: Dean F Sittig, Adam Wright, Joan S Ash, Blackford Middleton

  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 01/2009; 2009:614-8.

  We are investigating the development, implementation and evaluation of clinical decision support (CDS) projects to advance our understanding of how best to incorporate these interventions into theWe are investigating the development, implementation and evaluation of clinical decision support (CDS) projects to advance our understanding of how best to incorporate these interventions into the delivery of healthcare. Our overall goal is to explore how the translation of clinical knowledge into CDS and its incorporation into practice can be routinely achieved to improve the quality of healthcare delivered in the U.S.A. Toward this end, we have developed a 7-step model that provides a framework for clinical decision support-related standards that are necessary if we wish to achieve these goals. We believe that if all commercially available EHR systems had the features and functions described in these recommendations, many more healthcare organizations could begin to develop and implement the basic CDS features that are necessary to radically transform the quality, safety, and cost of the current healthcare system.

• The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration.

  Authors: Joan S Ash, Dean F Sittig, Richard Dykstra, Emily Campbell, Kenneth Guappone

  International journal of medical informatics. 10/2008;

  OBJECTIVE: To describe the foci, activities, methods, and results of a 4-year research project identifying the unintended consequences of computerized provider order entry (CPOE). METHODS: Using aOBJECTIVE: To describe the foci, activities, methods, and results of a 4-year research project identifying the unintended consequences of computerized provider order entry (CPOE). METHODS: Using a mixed methods approach, we identified and categorized into nine types 380 examples of the unintended consequences of CPOE gleaned from fieldwork data and a conference of experts. We then conducted a national survey in the U.S.A. to discover how hospitals with varying levels of infusion, a measure of CPOE sophistication, recognize and deal with unintended consequences. The research team, with assistance from experts, identified strategies for managing the nine types of unintended adverse consequences and developed and disseminated tools for CPOE implementers to help in addressing these consequences. RESULTS: Hospitals reported that levels of infusion are quite high and that these types of unintended consequences are common. Strategies for avoiding or managing the unintended consequences are similar to best practices for CPOE success published in the literature. CONCLUSION: Development of a taxonomy of types of unintended adverse consequences of CPOE using qualitative methods allowed us to craft a national survey and discover how widespread these consequences are. Using mixed methods, we were able to structure an approach for addressing the skillful management of unintended consequences as well.