Saverio M Maviglia

Publications of Saverio M Maviglia

• Implementations of the HL7 Context-Aware Knowledge Retrieval ("Infobutton") Standard: Challenges, strengths, limitations, and uptake.

  Authors: Guilherme Del Fiol, Vojtech Huser, Howard R Strasberg, Saverio M Maviglia, Clayton Curtis, James J Cimino

  Journal of biomedical informatics. 01/2012;

  To support clinical decision-making, computerized information retrieval tools known as "infobuttons" deliver contextually-relevant knowledge resources into clinical information systems. The HealthTo support clinical decision-making, computerized information retrieval tools known as "infobuttons" deliver contextually-relevant knowledge resources into clinical information systems. The Health Level Seven International (HL7) Context-Aware Knowledge Retrieval (Infobutton) Standard specifies a standard mechanism to enable infobuttons on a large scale. OBJECTIVE: To examine the experience of organizations in the course of implementing the HL7 Infobutton Standard. METHOD: Cross-sectional online survey and in-depth phone interviews. RESULTS: A total of 17 organizations participated in the study. Analysis of the in-depth interviews revealed 20 recurrent themes. Implementers underscored the benefits, simplicity, and flexibility of the HL7 Infobutton Standard. Yet, participants voiced the need for easier access to standard specifications and improved guidance to beginners. Implementers predicted that the Infobutton Standard will be widely or at least fairly well adopted in the next 5years, but uptake will depend largely on adoption among electronic health record (EHR) vendors. To accelerate EHR adoption of the Infobutton Standard, implementers recommended HL7-compliant infobutton capabilities to be included in the United States Meaningful Use Certification Criteria for EHR systems. LIMITATIONS: Opinions and predictions should be interpreted with caution, since all the participant organizations have successfully implemented the standard and over half of the organizations were actively engaged in the development of the standard. CONCLUSION: Overall, implementers reported a very positive experience with the HL7 Infobutton Standard. Despite indications of increasing uptake, measures should be taken to stimulate adoption of the Infobutton Standard among EHR vendors. Widespread adoption of the Infobutton Standard has the potential to bring contextually relevant clinical decision support content into the healthcare provider workflow.

• 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.

• A large-scale knowledge management method based on the analysis of the use of online knowledge resources.

  Authors: Guilherme Del Fiol, James J Cimino, Saverio M Maviglia, Howard R Strasberg, Brian R Jackson, Nathan C Hulse

  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 01/2010; 2010:142-6.

  Online health knowledge resources can be integrated into electronic health record systems using decision support tools known as "infobuttons." In this study we describe a knowledge management methodOnline health knowledge resources can be integrated into electronic health record systems using decision support tools known as "infobuttons." In this study we describe a knowledge management method based on the analysis of knowledge resource use via infobuttons in multiple institutions. We conducted a two-phase analysis of laboratory test infobutton sessions at three healthcare institutions accessing two knowledge resources. The primary study measure was session coverage, i.e. the rate of infobutton sessions in which resources retrieved relevant content. In Phase One, resources covered 78.5% of the study sessions. In addition, a subset of 38 noncovered tests that most frequently raised questions was identified. In Phase Two, content development guided by the outcomes of Phase One resulted in a 4% average coverage increase. The described method is a valuable approach to large-scale knowledge management in rapidly changing domains.

• Creating shareable decision support services: an interdisciplinary challenge.

  Authors: Marilyn D Paterno, Saverio M Maviglia, Harley Z Ramelson, Molly Schaeffer, Beatriz H Rocha, Tonya Hongsermeier, Adam Wright, Blackford Middleton, Howard S Goldberg

  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 01/2010; 2010:602-6.

  Creating shareable decision support services is a complex task requiring effort from multiple interdisciplinary role players with a wide variety of experience and expertise. The CDS ConsortiumCreating shareable decision support services is a complex task requiring effort from multiple interdisciplinary role players with a wide variety of experience and expertise. The CDS Consortium research project has developed such a service, defining a multi-layer representation of knowledge and building upon an architectural service design created at Partners Health Care, and is demonstrating its use in both a local and an external institutional setting. The process was iterative, and we encountered unexpected requirements based on decisions made at various points. We report in this paper on challenges we faced while pursuing this research: knowledge representation and modeling, data interchange and standards adoption, the process of getting agreement on content, logistics of integrating into a system that already has multiple CDS interventions, legal issues around privacy and access, inter-team communication and organization.

• Viewpoint Paper: Tiering Drug-Drug Interaction Alerts by Severity Increases Compliance Rates.

  Authors: Marilyn D. Paterno, Saverio M. Maviglia, Paul N. Gorman, Diane L. Seger, Eileen Yoshida, Andrew C. Seger, David W. Bates, Tejal K. Gandhi

  JAMIA. 01/2009; 16:40-46.

• Tiering Drug-Drug Interaction Alerts by Severity Increases Compliance Rates.

  Authors: Marilyn D Paterno, Saverio M Maviglia, Paul N Gorman, Diane L Seger, Eileen Yoshida, Andrew C Seger, David W Bates, Tejal K Gandhi

  Journal of the American Medical Informatics Association : JAMIA. 10/2008;

  OBJECTIVE Few data exist measuring the effect of differentiating drug-drug interaction (DDI) alerts in computerized provider order entry systems (CPOE) by level of severity ("tiering"). We sought toOBJECTIVE Few data exist measuring the effect of differentiating drug-drug interaction (DDI) alerts in computerized provider order entry systems (CPOE) by level of severity ("tiering"). We sought to determine if rates of provider compliance with DDI alerts in the inpatient setting differed when a tiered presentation was implemented. DESIGN We performed a retrospective analysis of alert log data on hospitalized patients at two academic medical centers during the period from 2/1/2004 through 2/1/2005. Both inpatient CPOE systems used the same DDI checking service, but one displayed alerts differentially by severity level (tiered presentation, including hard stops for the most severe alerts) while the other did not. PARTICIPANTS were adult inpatients who generated a DDI alert, and providers who wrote the orders. Alerts were presented during the order entry process, providing the clinician with the opportunity to change the patient's medication orders to avoid the interaction. MEASUREMENTS Rate of compliance to alerts at a tiered site compared to a non-tiered site. RESULTS We reviewed 71,350 alerts, of which 39,474 occurred at the non-tiered site and 31,876 at the tiered site. Compliance with DDI alerts was significantly higher at the site with tiered DDI alerts compared to the non-tiered site (29% vs. 10, p<0.001). At the tiered site, 100% of the most severe alerts were accepted, vs. only 34% at the non-tiered site; moderately severe alerts were also more likely to be accepted at the tiered site (29% vs. 10%). CONCLUSION Tiered alerting by severity was associated with higher compliance rates of DDI alerts in the inpatient setting, and lack of tiering was associated with a high override rate of more severe alerts.

• Knowledge management and content integration: a collaborative approach.

  Authors: Debora Scavone Goldman, Judith Colecchi, Tonya M Hongsermeier, Saverio M Maviglia

  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 02/2008;

  Knowledge Management (KM) is the development and maintenance of decision support knowledge within clinical healthcare systems. At Partners Healthcare System (PHS), Knowledge Management is facilitatedKnowledge Management (KM) is the development and maintenance of decision support knowledge within clinical healthcare systems. At Partners Healthcare System (PHS), Knowledge Management is facilitated by a dedicated team consisting of Subject Matter Experts (SME), Knowledge Engineers (KE), and software developers. This group relies upon sound knowledge management principles to support the knowledge lifecycle.

• Cost-benefit analysis of a hospital pharmacy bar code solution.

  Authors: Saverio M Maviglia, Jane Y Yoo, Calvin Franz, Erica Featherstone, William Churchill, David W Bates, Tejal K Gandhi, Eric G Poon

  Archives of internal medicine. 05/2007; 167(8):788-94.

  BACKGROUND: Bar coding can reduce hospital pharmacy dispensing errors, but it is unclear if the benefits of this technology justify its costs. The purpose of this study was to assess the costs andBACKGROUND: Bar coding can reduce hospital pharmacy dispensing errors, but it is unclear if the benefits of this technology justify its costs. The purpose of this study was to assess the costs and benefits and determine the return on investment at the institutional level for implementing a pharmacy bar code system. METHODS: We performed a cost-benefit analysis of a bar code-assisted medication-dispensing system within a large, academic, nonprofit tertiary care hospital pharmacy. We took the implementing hospital's perspective for a 5-year horizon. The primary outcome was the net financial cost and benefit after 5 years. The secondary outcome was the time until total benefits equaled total costs. Single-variable, 2-variable, and multiple-variable Monte Carlo sensitivity analyses were performed to test the stability of the outcomes. RESULTS: In inflation- and time value-adjusted 2005 dollars, total costs during 5 years were $2.24 million ($1.31 million in 1-time costs during the initial 3.5 years and $342 000 per year in recurring costs starting in year 3). The primary benefit was a decrease in adverse drug events from dispensing errors (517 events annually), resulting in an annual savings of $2.20 million. The net benefit after 5 years was $3.49 million. The break-even point for the hospital's investment occurred within 1 year after becoming fully operational. A net benefit was achieved within 10 years under almost all sensitivity scenarios. In the Monte Carlo simulation, the net benefit during 5 years was $3.2 million (95% confidence interval, -$1.2 million to $12.1 million), and the break-even point for return on investment occurred after 51 months (95% confidence interval, 30 to 180 months). CONCLUSION: Implementation of a bar code-assisted medication-dispensing system in hospital pharmacies can result in a positive financial return on investment for the health care organization.

• Integration of health information resources into electronic health records using HL7.

  Authors: Guilherme Del Fiol, James J Cimino, Saverio M Maviglia

  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 02/2007;

  The integration between electronic medical record systems and on-line health information resources via infobuttons is useful for helping clinicians better meet their various information needs at theThe integration between electronic medical record systems and on-line health information resources via infobuttons is useful for helping clinicians better meet their various information needs at the point of care. The HL7 Clinical Decision Support Technical Committee is developing a standard to facilitate the implementation of infobuttons. To validate and demonstrate the usefulness of the standard, Infobutton Manager developers at Intermountain Healthcare, Columbia University, and Partners Healthcare coordinated a pilot implementation integrating their Infobutton Managers with a number of information resource providers using the HL7 draft standard. In this theater-style demonstration, the results of the pilot implementation will be presented and the standard will be discussed in light of the examples used in the demonstration.

• Delivering informed care.

  Authors: Saverio M Maviglia

  Health management technology. 03/2006; 27(2):26-8.

• Patient safety concerns arising from test results that return after hospital discharge.

  Authors: Christopher L Roy, Eric G Poon, Andrew S Karson, Zahra Ladak-Merchant, Robin E Johnson, Saverio M Maviglia, Tejal K Gandhi

  Annals of internal medicine. 08/2005; 143(2):121-8.

  BACKGROUND: Failure to relay information about test results pending when patients are discharged from the hospital may pose an important patient-safety problem. Few data are available on theBACKGROUND: Failure to relay information about test results pending when patients are discharged from the hospital may pose an important patient-safety problem. Few data are available on the epidemiology of test results pending at discharge or on physician awareness of these results. OBJECTIVE: To determine the prevalence, characteristics, and physician awareness of potentially actionable laboratory and radiologic test results returning after hospital discharge. DESIGN: Cross-sectional study. SETTING: Two tertiary care academic hospitals. PATIENTS: 2644 consecutive patients discharged from hospitalist services from February to June 2004. MEASUREMENTS: The main outcomes were the prevalence and characteristics of potentially actionable test results returning after hospital discharge, awareness of these results by inpatient and primary care physicians, and satisfaction of inpatient physicians with current systems for follow-up on test results. The authors prospectively collected data on test results pending at the time of discharge and, as results returned after discharge, surveyed hospitalists, junior residents, and primary care physicians about those results that were potentially actionable according to a physician-reviewer. RESULTS: A total of 1095 patients (41%) had 2033 test results return after discharge. Of these results, 191 (9.4% [95% CI, 8.0% to 11.0%]) were potentially actionable. Surveys were sent regarding 155 results, and 105 responses were returned. Of the 105 results in the surveys with responses, physicians had been unaware of 65 (61.6% [CI, 51.3% to 70.9%]); of these 65, they agreed with physician-reviewers that 24 (37.1% [CI, 25.7% to 50.2%]) were actionable and 8 (12.6% [CI, 6.4% to 23.3%]) required urgent action. Inpatient physicians were dissatisfied with their systems for following up on test results returning after discharge. LIMITATIONS: The authors were unable to determine whether physicians' lack of awareness of test results returning after discharge was associated with adverse outcomes. CONCLUSIONS: Many patients are discharged from hospitals with test results still pending, and physicians are often unaware of potentially actionable test results returning after discharge. Further work is needed to design better follow-up systems for test results returning after hospital discharge.

• Automated coded ambulatory problem lists: evaluation of a vocabulary and a data entry tool.

  Authors: Samuel J Wang, David W Bates, Henry C Chueh, Andrew S Karson, Saverio M Maviglia, Julie A Greim, Jennifer P Frost, Gilad J Kuperman

  International journal of medical informatics. 01/2004; 72(1-3):17-28.

  BACKGROUND: Problem lists are fundamental to electronic medical records (EMRs). However, obtaining an appropriate problem list dictionary is difficult, and getting users to code their problems at theBACKGROUND: Problem lists are fundamental to electronic medical records (EMRs). However, obtaining an appropriate problem list dictionary is difficult, and getting users to code their problems at the time of data entry can be challenging. OBJECTIVE: To develop a problem list dictionary and search algorithm for an EMR system and evaluate its use. METHODS: We developed a problem list dictionary and lookup tool and implemented it in several EMR systems. A sample of 10,000 problem entries was reviewed from each system to assess overall coding rates. We also performed a manual review of a subset of entries to determine the appropriateness of coded entries, and to assess the reasons other entries were left uncoded. RESULTS: The overall coding rate varied significantly between different EMR implementations (63-79%). Coded entries were virtually always appropriate (99%). The most frequent reasons for uncoded entries were due to user interface failures (44-45%), insufficient dictionary coverage (20-32%), and non-problem entries (10-12%). CONCLUSION: The problem list dictionary and search algorithm has achieved a good coding rate, but the rate is dependent on the specific user interface implementation. Problem coding is essential for providing clinical decision support, and improving usability should result in better coding rates.

• KnowledgeLink update: just-in-time context-sensitive information retrieval.

  Authors: Saverio M Maviglia, Howard R Strasberg, David W Bates, Gilad J Kuperman

  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 02/2003;

  Medical knowledge expands at a pace that makes it impossible for the individual clinician to keep up, especially for medications. Medication-related queries are the most common type of query thatMedical knowledge expands at a pace that makes it impossible for the individual clinician to keep up, especially for medications. Medication-related queries are the most common type of query that typically go unanswered during the course of providing care.1 Unanswered questions may result in errors, as found in one study evaluating systems failures associated with adverse drug events. This study found that better information might have prevented half of serious medication errors, and that lack of drug-specific knowledge accounted for the single largest proportion of these events (29%).2 While this information was available somewhere (either on paper or electronically), it was not at the providers' fingertips. Information technology should anticipate clinicians' needs, and bring the information they require to the point of care. For this purpose, we developed an application extender called KnowledgeLink, which provides "just-in-time" context-sensitive information retrieval for drug-related queries.

• KnowledgeLink: Impact of Context-Sensitive Information Retrieval on Clinicians' Information Needs

  Authors: Saverio M. Maviglia, Catherine S. Yoon, David W. Bates, Gilad Kuperman

  Journal of the American Medical Informatics Association.

  ObjectiveInfobuttons are message-based content search and retrieval functions embedded within other applications that dynamically return information relevant to the clinical task at hand. TheObjectiveInfobuttons are message-based content search and retrieval functions embedded within other applications that dynamically return information relevant to the clinical task at hand. The objective of this study was to determine whether infobuttons effectively answer providers' questions about medications or affect patient care decisions.DesignThe authors implemented and evaluated a medication infobutton application called KnowledgeLink. Health care providers at 18 outpatient clinics were randomized to one of two versions of KnowledgeLink, one that linked to information from Micromedex (Thomson Micromedex, Greenwood Village, Co) and the other to material from SkolarMD (Wolters Kluwer Health, Palo Alto, CA).MeasurementsData were collected about the frequency of use and demographics of users, patients, and drugs that were queried. Users were periodically surveyed with short questionnaires and then with a more extensive survey at the end of one year.ResultsDuring the first year, KnowledgeLink was used 7,972 times by 359 users to look up information about 1,723 medications for 4,961 patients. Clinicians used KnowledgeLink twice a month on average, and during an average of 1.2% of patient encounters. KnowledgeLink was used by a wide variety of medical staff, not just physicians and nurse practitioners. The frequency of usage and the questions asked varied with user role (primary care physician, specialist physician, nurse practitioner). Although the median KnowledgeLink session was brief (21 seconds), KnowledgeLink answered users' queries 84% of the time, and altered patient care decisions 15% of the time. Users rated KnowledgeLink favorably on multiple scales, recommended extending KnowledgeLink to other content domains, and suggested enhancing the interface to allow refinement of the query and selection of the target resource.ConclusionAn infobutton can satisfy information needs about medications. Although used infrequently and for brief sessions, KnowledgeLink was positively received, answered most users' questions, and had a significant impact on medical decision making. The next steps would be to broaden the domains that KnowledgeLink covers to more specifically tailor results to the user type, to provide options when queries are not immediately answered, and to implement KnowledgeLink within other electronic clinical applications.

• Automating complex guidelines for chronic disease: lessons learned.

  Authors: Saverio M Maviglia, Rita D. Zielstorff, Marilyn Paterno, Jonathan M. Teich, David W Bates, Gilad J Kuperman

  Journal of the American Medical Informatics Association : JAMIA. 10(2):154-65.

  There is scant published experience with implementing complex, multistep computerized practice guidelines for the long-term management of chronic diseases. We have implemented a system for creating,There is scant published experience with implementing complex, multistep computerized practice guidelines for the long-term management of chronic diseases. We have implemented a system for creating, maintaining, and navigating computer-based clinical algorithms integrated with our electronic medical record. This article describes our progress and reports on lessons learned that might guide future work in this field. We discuss issues and obstacles related to choosing and adapting a guideline for electronic implementation, representing and executing the guideline as a computerized algorithm, and integrating it into the clinical workflow of outpatient care. Although obstacles were encountered at each of these steps, the most difficult were related to workflow integration.

• KnowledgeLink: impact of context-sensitive information retrieval on clinicians' information needs.

  Authors: Saverio M Maviglia, Catherine S Yoon, David W Bates, Gilad Kuperman

  Journal of the American Medical Informatics Association : JAMIA. 13(1):67-73.

  OBJECTIVE: Infobuttons are message-based content search and retrieval functions embedded within other applications that dynamically return information relevant to the clinical task at hand. TheOBJECTIVE: Infobuttons are message-based content search and retrieval functions embedded within other applications that dynamically return information relevant to the clinical task at hand. The objective of this study was to determine whether infobuttons effectively answer providers' questions about medications or affect patient care decisions. DESIGN: The authors implemented and evaluated a medication infobutton application called KnowledgeLink. Health care providers at 18 outpatient clinics were randomized to one of two versions of KnowledgeLink, one that linked to information from Micromedex (Thomson Micromedex, Greenwood Village, Co) and the other to material from SkolarMD (Wolters Kluwer Health, Palo Alto, CA). MEASUREMENTS: Data were collected about the frequency of use and demographics of users, patients, and drugs that were queried. Users were periodically surveyed with short questionnaires and then with a more extensive survey at the end of one year. RESULTS: During the first year, KnowledgeLink was used 7,972 times by 359 users to look up information about 1,723 medications for 4,961 patients. Clinicians used KnowledgeLink twice a month on average, and during an average of 1.2% of patient encounters. KnowledgeLink was used by a wide variety of medical staff, not just physicians and nurse practitioners. The frequency of usage and the questions asked varied with user role (primary care physician, specialist physician, nurse practitioner). Although the median KnowledgeLink session was brief (21 seconds), KnowledgeLink answered users' queries 84% of the time, and altered patient care decisions 15% of the time. Users rated KnowledgeLink favorably on multiple scales, recommended extending KnowledgeLink to other content domains, and suggested enhancing the interface to allow refinement of the query and selection of the target resource. CONCLUSION: An infobutton can satisfy information needs about medications. Although used infrequently and for brief sessions, KnowledgeLink was positively received, answered most users' questions, and had a significant impact on medical decision making. The next steps would be to broaden the domains that KnowledgeLink covers to more specifically tailor results to the user type, to provide options when queries are not immediately answered, and to implement KnowledgeLink within other electronic clinical applications.