Jerome A Osheroff

Publications of Jerome A Osheroff

• Improving clinical quality indicators through electronic health records: it takes more than just a reminder.

  Authors: Dean F Sittig, Jonathan M. Teich, Jerome A Osheroff, Hardeep Singh

  Pediatrics. 08/2009; 124(1):375-7.

• Implementation pearls from a new guidebook on improving medication use and outcomes with clinical decision support. Effective CDS is essential for addressing healthcare performance improvement imperatives.

  Authors: Anwar M Sirajuddin, Jerome A Osheroff, Dean F Sittig, John Chuo, Ferdinand Velasco, David A Collins

  Journal of healthcare information management : JHIM. 01/2009; 23(4):38-45.

  Effective clinical decision support (CDS) is essential for addressing healthcare performance improvement imperatives, but care delivery organizations (CDO) typically struggle with CDS deployment.Effective clinical decision support (CDS) is essential for addressing healthcare performance improvement imperatives, but care delivery organizations (CDO) typically struggle with CDS deployment. Ensuring safe and effective medication delivery to patients is a central focus of CDO performance improvement efforts, and this article provides an overview of best-practice strategies for applying CDS to these goals. The strategies discussed are drawn from a new guidebook, co-published and co-sponsored by more than a dozen leading organizations. Developed by scores of CDS implementers and experts, the guidebook outlines key steps and success factors for applying CDS to medication management. A central thesis is that improving outcomes with CDS interventions requires that the CDS five rights be addressed successfully. That is, the interventions must deliver the right information, to the right person, in the right format, through the right channel, at the right point in workflow. This paper provides further details about these CDS five rights, and highlights other important strategies for successful CDS programs.

• Grand challenges in clinical decision support.

  Authors: Dean F Sittig, Adam Wright, Jerome A Osheroff, Blackford Middleton, Jonathan M. Teich, Joan S Ash, Emily Campbell, David W Bates

  Journal of biomedical informatics. 05/2008; 41(2):387-92.

  There is a pressing need for high-quality, effective means of designing, developing, presenting, implementing, evaluating, and maintaining all types of clinical decision support capabilities forThere is a pressing need for high-quality, effective means of designing, developing, presenting, implementing, evaluating, and maintaining all types of clinical decision support capabilities for clinicians, patients and consumers. Using an iterative, consensus-building process we identified a rank-ordered list of the top 10 grand challenges in clinical decision support. This list was created to educate and inspire researchers, developers, funders, and policy-makers. The list of challenges in order of importance that they be solved if patients and organizations are to begin realizing the fullest benefits possible of these systems consists of: improve the human-computer interface; disseminate best practices in CDS design, development, and implementation; summarize patient-level information; prioritize and filter recommendations to the user; create an architecture for sharing executable CDS modules and services; combine recommendations for patients with co-morbidities; prioritize CDS content development and implementation; create internet-accessible clinical decision support repositories; use freetext information to drive clinical decision support; mine large clinical databases to create new CDS. Identification of solutions to these challenges is critical if clinical decision support is to achieve its potential and improve the quality, safety and efficiency of healthcare.

• Recommendations for clinical decision support deployment: synthesis of a roundtable of medical directors of information systems.

  Authors: Robert A Jenders, Jerome A Osheroff, Dean F Sittig, Eric A Pifer, Jonathan M. Teich

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

  BACKGROUND: Ample evidence exists that clinical decision support (CDS) can improve clinician performance. Nevertheless, additional evidence demonstrates that clinicians still do not performBACKGROUND: Ample evidence exists that clinical decision support (CDS) can improve clinician performance. Nevertheless, additional evidence demonstrates that clinicians still do not perform adequately in many instances. This suggests an ongoing need for implementation of CDS, in turn prompting development of a roadmap for national action regarding CDS. OBJECTIVE: Develop practical advice to aid CDS implementation in order to improve clinician performance. METHOD: Structured group interview during a roundtable discussion by medical directors of information systems (N = 30), with subsequent review by participants and synthesis. RESULTS: Participant consensus was that CDS should be comprehensive and should involve techniques such as order sets and facilitated documentation as well as alerts; should be subject to ongoing feedback; and should flow from and be governed by an organization's clinical goals. CONCLUSION: A structured roundtable discussion of clinicians experienced in health information technology can yield practical, consensus advice for implementation of CDS.

• Research Paper: Patient-Care Questions that Physicians Are Unable to Answer.

  Authors: John W. Ely, Jerome A. Osheroff, Saverio M. Maviglia, Marcy E. Rosenbaum

  JAMIA. 01/2007; 14:407-414.

• White paper: A Roadmap for National Action on Clinical Decision Support.

  Authors: Jerome A. Osheroff, Jonathan M. Teich, Blackford Middleton, Elaine B. Steen, Adam Wright, Don E. Detmer

  JAMIA. 01/2007; 14:141-145.

• Lessons from "Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system".

  Authors: Dean F Sittig, Joan S Ash, Jiajie Zhang, Jerome A Osheroff, M Michael Shabot

  Pediatrics. 09/2006; 118(2):797-801.

• AMIA Position Paper: Clinical Decision Support in Electronic Prescribing: Recommendations and an Action Plan: Report of the Joint Clinical Decision Support Workgroup.

  Authors: Jonathan M. Teich, Jerome A. Osheroff, Eric A. Pifer, Dean F. Sittig, Robert A. Jenders

  JAMIA. 01/2005; 12:365-376.

• Research Paper: Answering Physicians' Clinical Questions: Obstacles and Potential Solutions.

  Authors: John W. Ely, Jerome A. Osheroff, M. Lee Chambliss, Mark H. Ebell, Marcy E. Rosenbaum

  JAMIA. 01/2005; 12:217-224.

• Clinical decision support in electronic prescribing: recommendations and an action plan: report of the joint clinical decision support workgroup

  Authors: Jonathan M Teich, Jerome A Osheroff, Eric A Pifer, Dean F Sittig, Robert A Jenders, CDS Expert Review Panel

  01/2005; 12:365-76.

  Clinical decision support (CDS) in electronic prescribing (eRx) systems can improve the safety, quality, efficiency, and cost-effectiveness of care. However, at present, these potential benefits haveClinical decision support (CDS) in electronic prescribing (eRx) systems can improve the safety, quality, efficiency, and cost-effectiveness of care. However, at present, these potential benefits have not been fully realized. In this consensus white paper, we set forth recommendations and action plans in three critical domains: (1) advances in system capabilities, including basic and advanced sets of CDS interventions and knowledge, supporting database elements, operational features to improve usability and measure performance, and management and governance structures; (2) uniform standards, vocabularies, and centralized knowledge structures and services that could reduce rework by vendors and care providers, improve dissemination of well-constructed CDS interventions, promote generally applicable research in CDS methods, and accelerate the movement of new medical knowledge from research to practice; and (3) appropriate financial and legal incentives to promote adoption.

• Obstacles to answering doctors' questions about patient care with evidence: qualitative study.

  Authors: John W Ely, Jerome A Osheroff, Mark H Ebell, M Lee Chambliss, Daniel C Vinson, James J Stevermer, Eric A Pifer

  BMJ (Clinical research ed.). 04/2002; 324(7339):710.

  OBJECTIVE: To describe the obstacles encountered when attempting to answer doctors' questions with evidence. DESIGN: Qualitative study. SETTING: General practices in Iowa. PARTICIPANTS: 9 academicOBJECTIVE: To describe the obstacles encountered when attempting to answer doctors' questions with evidence. DESIGN: Qualitative study. SETTING: General practices in Iowa. PARTICIPANTS: 9 academic generalist doctors, 14 family doctors, and 2 medical librarians. MAIN OUTCOME MEASURE: A taxonomy of obstacles encountered while searching for evidence based answers to doctors' questions. RESULTS: 59 obstacles were encountered and organised according to the five steps in asking and answering questions: recognise a gap in knowledge, formulate a question, search for relevant information, formulate an answer, and use the answer to direct patient care. Six obstacles were considered particularly salient by the investigators and practising doctors: the excessive time required to find information; difficulty modifying the original question, which was often vague and open to interpretation; difficulty selecting an optimal strategy to search for information; failure of a seemingly appropriate resource to cover the topic; uncertainty about how to know when all the relevant evidence has been found so that the search can stop; and inadequate synthesis of multiple bits of evidence into a clinically useful statement. CONCLUSIONS: Many obstacles are encountered when asking and answering questions about how to care for patients. Addressing these obstacles could lead to better patient care by improving clinically oriented information resources.

• Analysis of questions asked by family physicians regarding patient care.

  Authors: John W Ely, Jerome A Osheroff, Mark H Ebell, George R Bergus, Barcey T Levy, M Lee Chambliss, Eric R Evans

  The Western journal of medicine. 06/2000; 172(5):315-319.

  Objectives To characterize the information needs of family physicians by collecting the questions they asked about patient care during consultations and to classify these in ways that would be usefulObjectives To characterize the information needs of family physicians by collecting the questions they asked about patient care during consultations and to classify these in ways that would be useful to developers of knowledge bases. Design An observational study in which investigators visited physicians for two half-days and collected their questions. Taxonomies were developed to characterize the clinical topic and generic type of information sought for each question. Setting Eastern Iowa. Participants Random sample of 103 family physicians. Main outcome measures Number of questions posed, pursued, and answered; topic and generic type of information sought for each question; time spent pursuing answers; and information resources used. Results Participants asked a total of 1,101 questions. Questions about drug prescribing, obstetrics and gynecology, and adult infectious disease were most common, comprising 36% of the total. The taxonomy of generic questions included 69 categories; the three most common types, comprising 24% of all questions, were "What is the cause of symptom X?" "What is the dose of drug X?" and "How should I manage disease or finding X?" Answers to most questions (n = 702 [64%]) were not immediately pursued, but of those pursued, most (n = 318 [80%]) were answered. Physicians spent an average of less than 2 minutes pursuing an answer, and they used readily available print and human resources. Only two questions led to a formal literature search. Conclusions Family physicians in this study did not pursue answers to most of their questions. Questions about patient care can be organized into a limited number of generic types, which could help guide the efforts of knowledge-base developers.

• Clinical decision support in electronic prescribing: recommendations and an action plan: report of the joint clinical decision support workgroup.

  Authors: Jonathan M. Teich, Jerome A Osheroff, Eric A Pifer, Dean F Sittig, Robert A Jenders

  Journal of the American Medical Informatics Association : JAMIA. 12(4):365-76.

  Clinical decision support (CDS) in electronic prescribing (eRx) systems can improve the safety, quality, efficiency, and cost-effectiveness of care. However, at present, these potential benefits haveClinical decision support (CDS) in electronic prescribing (eRx) systems can improve the safety, quality, efficiency, and cost-effectiveness of care. However, at present, these potential benefits have not been fully realized. In this consensus white paper, we set forth recommendations and action plans in three critical domains: (1) advances in system capabilities, including basic and advanced sets of CDS interventions and knowledge, supporting database elements, operational features to improve usability and measure performance, and management and governance structures; (2) uniform standards, vocabularies, and centralized knowledge structures and services that could reduce rework by vendors and care providers, improve dissemination of well-constructed CDS interventions, promote generally applicable research in CDS methods, and accelerate the movement of new medical knowledge from research to practice; and (3) appropriate financial and legal incentives to promote adoption.

• Answering physicians' clinical questions: obstacles and potential solutions.

  Authors: John W Ely, Jerome A Osheroff, M Lee Chambliss, Mark H Ebell, Marcy E Rosenbaum

  Journal of the American Medical Informatics Association : JAMIA. 12(2):217-24.

  OBJECTIVE: To identify the most frequent obstacles preventing physicians from answering their patient-care questions and the most requested improvements to clinical information resources. DESIGN:OBJECTIVE: To identify the most frequent obstacles preventing physicians from answering their patient-care questions and the most requested improvements to clinical information resources. DESIGN: Qualitative analysis of questions asked by 48 randomly selected generalist physicians during ambulatory care. MEASUREMENTS: Frequency of reported obstacles to answering patient-care questions and recommendations from physicians for improving clinical information resources. RESULTS: The physicians asked 1,062 questions but pursued answers to only 585 (55%). The most commonly reported obstacle to the pursuit of an answer was the physician's doubt that an answer existed (52 questions, 11%). Among pursued questions, the most common obstacle was the failure of the selected resource to provide an answer (153 questions, 26%). During audiotaped interviews, physicians made 80 recommendations for improving clinical information resources. For example, they requested comprehensive resources that answer questions likely to occur in practice with emphasis on treatment and bottom-line advice. They asked for help in locating information quickly by using lists, tables, bolded subheadings, and algorithms and by avoiding lengthy, uninterrupted prose. CONCLUSION: Physicians do not seek answers to many of their questions, often suspecting a lack of usable information. When they do seek answers, they often cannot find the information they need. Clinical resource developers could use the recommendations made by practicing physicians to provide resources that are more useful for answering clinical questions.

• Grand challenges in clinical decision support

  Authors: Dean F. Sittig, Adam Wright, Jerome A. Osheroff, Blackford Middleton, Jonathan M. Teich, Joan S. Ash, Emily Campbell, David W. Bates

  Journal of Biomedical Informatics.

  There is a pressing need for high-quality, effective means of designing, developing, presenting, implementing, evaluating, and maintaining all types of clinical decision support capabilities forThere is a pressing need for high-quality, effective means of designing, developing, presenting, implementing, evaluating, and maintaining all types of clinical decision support capabilities for clinicians, patients and consumers. Using an iterative, consensus-building process we identified a rank-ordered list of the top 10 grand challenges in clinical decision support. This list was created to educate and inspire researchers, developers, funders, and policy-makers. The list of challenges in order of importance that they be solved if patients and organizations are to begin realizing the fullest benefits possible of these systems consists of: improve the human–computer interface; disseminate best practices in CDS design, development, and implementation; summarize patient-level information; prioritize and filter recommendations to the user; create an architecture for sharing executable CDS modules and services; combine recommendations for patients with co-morbidities; prioritize CDS content development and implementation; create internet-accessible clinical decision support repositories; use freetext information to drive clinical decision support; mine large clinical databases to create new CDS. Identification of solutions to these challenges is critical if clinical decision support is to achieve its potential and improve the quality, safety and efficiency of healthcare.

• Patient-Care Questions that Physicians Are Unable to Answer

  Authors: John W. Ely, Jerome A. Osheroff, Saverio M. Maviglia, Marcy E. Rosenbaum

  Journal of the American Medical Informatics Association.

  ObjectiveTo describe the characteristics of unanswered clinical questions and propose interventions that could improve the chance of finding answers.DesignIn a previous study, investigators observedObjectiveTo describe the characteristics of unanswered clinical questions and propose interventions that could improve the chance of finding answers.DesignIn a previous study, investigators observed primary care physicians in their offices and recorded questions that arose during patient care. Questions that were pursued by the physician, but remained unanswered, were grouped into generic types. In the present study, investigators attempted to answer these questions and developed recommendations aimed at improving the success rate of finding answers.MeasurementsFrequency of unanswered question types and recommendations to increase the chance of finding answers.ResultsIn an earlier study, 48 physicians asked 1062 questions during 192 half-day office observations. Physicians could not find answers to 237 (41%) of the 585 questions they pursued. The present study grouped the unanswered questions into 19 generic types. Three types accounted for 128 (54%) of the unanswered questions: (1) “Undiagnosed finding” questions asked about the management of abnormal clinical findings, such as symptoms, signs, and test results (What is the approach to finding X?); (2) “Conditional” questions contained qualifying conditions that were appended to otherwise simple questions (What is the management of X, given Y? where “given Y” is the qualifying condition that makes the question difficult.); and (3) “Compound” questions asked about the association between two highly specific elements (Can X cause Y?). The study identified strategies to improve clinical information retrieval, listed below.ConclusionTo improve the chance of finding answers, physicians should change their search strategies by rephrasing their questions and searching more clinically oriented resources. Authors of clinical information resources should anticipate questions that may arise in practice, and clinical information systems should provide clearer and more explicit answers.

• Answering Physicians' Clinical Questions: Obstacles and Potential Solutions

  Authors: John W. Ely, Jerome A. Osheroff, M. Lee Chambliss, Mark H. Ebell, Marcy E. Rosenbaum

  Journal of the American Medical Informatics Association.

  ObjectiveTo identify the most frequent obstacles preventing physicians from answering their patient-care questions and the most requested improvements to clinical informationObjectiveTo identify the most frequent obstacles preventing physicians from answering their patient-care questions and the most requested improvements to clinical information resources.DesignQualitative analysis of questions asked by 48 randomly selected generalist physicians during ambulatory care.MeasurementsFrequency of reported obstacles to answering patient-care questions and recommendations from physicians for improving clinical information resources.ResultsThe physicians asked 1,062 questions but pursued answers to only 585 (55%). The most commonly reported obstacle to the pursuit of an answer was the physician's doubt that an answer existed (52 questions, 11%). Among pursued questions, the most common obstacle was the failure of the selected resource to provide an answer (153 questions, 26%). During audiotaped interviews, physicians made 80 recommendations for improving clinical information resources. For example, they requested comprehensive resources that answer questions likely to occur in practice with emphasis on treatment and bottom-line advice. They asked for help in locating information quickly by using lists, tables, bolded subheadings, and algorithms and by avoiding lengthy, uninterrupted prose.ConclusionPhysicians do not seek answers to many of their questions, often suspecting a lack of usable information. When they do seek answers, they often cannot find the information they need. Clinical resource developers could use the recommendations made by practicing physicians to provide resources that are more useful for answering clinical questions.

• Patient-care questions that physicians are unable to answer.

  Authors: John W Ely, Jerome A Osheroff, Saverio M Maviglia, Marcy E Rosenbaum

  Journal of the American Medical Informatics Association : JAMIA. 14(4):407-14.

  OBJECTIVE: To describe the characteristics of unanswered clinical questions and propose interventions that could improve the chance of finding answers. DESIGN: In a previous study, investigatorsOBJECTIVE: To describe the characteristics of unanswered clinical questions and propose interventions that could improve the chance of finding answers. DESIGN: In a previous study, investigators observed primary care physicians in their offices and recorded questions that arose during patient care. Questions that were pursued by the physician, but remained unanswered, were grouped into generic types. In the present study, investigators attempted to answer these questions and developed recommendations aimed at improving the success rate of finding answers. MEASUREMENTS: Frequency of unanswered question types and recommendations to increase the chance of finding answers. RESULTS: In an earlier study, 48 physicians asked 1062 questions during 192 half-day office observations. Physicians could not find answers to 237 (41%) of the 585 questions they pursued. The present study grouped the unanswered questions into 19 generic types. Three types accounted for 128 (54%) of the unanswered questions: (1) "Undiagnosed finding" questions asked about the management of abnormal clinical findings, such as symptoms, signs, and test results (What is the approach to finding X?); (2) "Conditional" questions contained qualifying conditions that were appended to otherwise simple questions (What is the management of X, given Y? where "given Y" is the qualifying condition that makes the question difficult.); and (3) "Compound" questions asked about the association between two highly specific elements (Can X cause Y?). The study identified strategies to improve clinical information retrieval, listed below. CONCLUSION: To improve the chance of finding answers, physicians should change their search strategies by rephrasing their questions and searching more clinically oriented resources. Authors of clinical information resources should anticipate questions that may arise in practice, and clinical information systems should provide clearer and more explicit answers.

• A roadmap for national action on clinical decision support.

  Authors: Jerome A Osheroff, Jonathan M. Teich, Blackford Middleton, Elaine B Steen, Adam Wright, Don E Detmer

  Journal of the American Medical Informatics Association : JAMIA. 14(2):141-5.

  This document comprises an AMIA Board of Directors approved White Paper that presents a roadmap for national action on clinical decision support. It is published in JAMIA for archival andThis document comprises an AMIA Board of Directors approved White Paper that presents a roadmap for national action on clinical decision support. It is published in JAMIA for archival and dissemination purposes. The full text of this material has been previously published on the AMIA Web site (www.amia.org/inside/initiatives/cds). AMIA is the copyright holder.

• Approach to leg edema of unclear etiology.

  Authors: John W Ely, Jerome A Osheroff, M Lee Chambliss, Mark H Ebell

  Journal of the American Board of Family Medicine : JABFM. 19(2):148-60.

  A common challenge for primary care physicians is to determine the cause and find an effective treatment for leg edema of unclear etiology. We were unable to find existing practice guidelines thatA common challenge for primary care physicians is to determine the cause and find an effective treatment for leg edema of unclear etiology. We were unable to find existing practice guidelines that address this problem in a comprehensive manner. This article provides clinically oriented recommendations for the management of leg edema in adults. We searched on-line resources, textbooks, and MEDLINE (using the MeSH term, "edema") to find clinically relevant articles on leg edema. We then expanded the search by reviewing articles cited in the initial sources. Our goal was to write a brief, focused review that would answer questions about the management of leg edema. We organized the information to make it rapidly accessible to busy clinicians. The most common cause of leg edema in older adults is venous insufficiency. The most common cause in women between menarche and menopause is idiopathic edema, formerly known as "cyclic" edema. A common but under-recognized cause of edema is pulmonary hypertension, which is often associated with sleep apnea. Venous insufficiency is treated with leg elevation, compressive stockings, and sometimes diuretics. The initial treatment of idiopathic edema is spironolactone. Patients who have findings consistent with sleep apnea, such as daytime somnolence, loud [corrected] snoring, or neck circumference >17 inches, should be evaluated for pulmonary hypertension with an echocardiogram. If time is limited, the physician must decide whether the evaluation can be delayed until a later appointment (eg, an asymptomatic patient with chronic bilateral edema) or must be completed at the current visit (eg, a patient with dyspnea or a patient with acute edema [<72 hours]). If the evaluation should be conducted at the current visit, the algorithm shown in Figure 1 could be used as a guide. If the full evaluation could wait for a subsequent visit, the patient should be examined briefly to rule out an obvious systemic cause and basic laboratory tests should be ordered for later review (complete blood count, urinalysis, electrolytes, creatinine, blood sugar, thyroid stimulating hormone, and albumin).