Richard Dykstra

Publications of Richard Dykstra

• 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.

• Computerized Provider Order Entry Adoption: Implications for Clinical Workflow.

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

  Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine. 12/2008;

  OBJECTIVE: To identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems. METHODS: We analyzedOBJECTIVE: To identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems. METHODS: We analyzed qualitative data from field observations and formal interviews gathered over a three-year period at five hospitals in three organizations. Five multidisciplinary researchers worked together to identify themes related to the impacts of CPOE systems on clinical workflow. RESULTS: CPOE systems can affect clinical work by 1) introducing or exposing human/computer interaction problems, 2) altering the pace, sequencing, and dynamics of clinical activities, 3) providing only partial support for the work activities of all types of clinical personnel, 4) reducing clinical situation awareness, and 5) poorly reflecting organizational policy and procedure. CONCLUSIONS: As CPOE systems evolve, those involved must take care to mitigate the many unintended adverse effects these systems have on clinical workflow. Workflow issues resulting from CPOE can be mitigated by iteratively altering both clinical workflow and the CPOE system until a satisfactory fit is achieved.

• 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.

• A rapid assessment process for clinical informatics interventions.

  Authors: Joan Ash, Dean Forrest Sittig, Carmit K McMullen, Ken Guappone, Richard Dykstra, James Carpenter

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

  Informatics interventions generally take place in rapidly changing settings where many variables are outside the control of the evaluator. Assessment must be timely so that feedback can instigateInformatics interventions generally take place in rapidly changing settings where many variables are outside the control of the evaluator. Assessment must be timely so that feedback can instigate modification of the intervention. Adapting a methodology from international health and epidemiology, we have developed and refined a Rapid Assessment Process (RAP) for informatics while conducting a study of clinical decision support (CDS) in community hospitals. Using RAP, we have not only been able to provide implementers with actionable feedback, but we have also discovered that users and informaticians conceptualize CDS in vastly different ways. Further understanding of this difference will be needed if we are to improve CDS acceptance by users.

• Exploring the unintended consequences of computerized physician order entry.

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

  Studies in health technology and informatics. 02/2007; 129(Pt 1):198-202.

  This paper summarizes the foci, activities, methods, and results of a three-year research project. Using a mixed methods approach, the Physician Order Entry Team has identified and categorized theThis paper summarizes the foci, activities, methods, and results of a three-year research project. Using a mixed methods approach, the Physician Order Entry Team has identified and categorized the unintended consequences of computerized physician order entry (CPOE). After analyzing 380 examples of unintended adverse consequences, the team described in detail nine major types and conducted a national survey in the U.S. to discover how hospitals recognize and deal with unintended consequences. With the assistance of a panel of experts, the team identified strategies for managing unintended adverse consequences and outlined contents of a toolkit for CPOE implementers for addressing them.

• Recommendations for monitoring and evaluation of in-patient Computer-based Provider Order Entry systems: results of a Delphi survey.

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

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

  A survey of 20 clinical informaticists with experience in implementing Computer-based Provider Order Entry (CPOE) systems revealed the lack of easily accessible measurements of success. Using aA survey of 20 clinical informaticists with experience in implementing Computer-based Provider Order Entry (CPOE) systems revealed the lack of easily accessible measurements of success. Using a Delphi approach, the authors, together with a group of CPOE experts, selected eight key CPOE-related measures to assess system availability, use, benefits, and e-Iatrogenesis. We suggest collecting these measures on a widespread/national basis would be wise stewardship and result in tighter feedback about both clinician workflow and patient safety. Establishing reliable benchmarks against which new implementations and existing systems can be compared will enhance organizations' ability to effectively manage and hence to realize the full benefits of their CPOE implementations.

• A survey of factors affecting clinician acceptance of clinical decision support

  Authors: Dean Sittig, Michael Krall, Richard Dykstra, Allen Russell, Homer Chin

  BMC Medical Informatics and Decision Making. 01/2006;

  Abstract Background Real-time clinical decision support (CDS) integrated into clinicians' workflow has the potential to profoundly affect the cost, quality, and safety of health care delivery.Abstract Background Real-time clinical decision support (CDS) integrated into clinicians' workflow has the potential to profoundly affect the cost, quality, and safety of health care delivery. Recent reports have identified a surprisingly low acceptance rate for different types of CDS. We hypothesized that factors affecting CDS system acceptance could be categorized as relating to differences in patients, physicians, CDS-type, or environmental characteristics. Methods We conducted a survey of all adult primary care physicians (PCPs, n = 225) within our group model Health Maintenance Organization (HMO) to identify factors that affect their acceptance of CDS. We defined clinical decision support broadly as "clinical information" that is either provided to you or accessible by you, from the clinical workstation (e.g., enhanced flow sheet displays, health maintenance reminders, alternative medication suggestions, order sets, alerts, and access to any internet-based information resources). Results 110 surveys were returned (49%). There were no differences in the age, gender, or years of service between those who returned the survey and the entire adult PCP population. Overall, clinicians stated that the CDS provided "helps them take better care of their patients" (3.6 on scale of 1:Never – 5:Always), "is worth the time it takes" (3.5), and "reminds them of something they've forgotten" (3.2). There was no difference in the perceived acceptance rate of alerts based on their type (i.e., cost, safety, health maintenance). When asked about specific patient characteristics that would make the clinicians "more", "equally" or "less" likely to accept alerts: 41% stated that they were more (8% stated "less") likely to accept alerts on elderly patients (> 65 yrs); 38% were more (14% stated less) likely to accept alerts on patients with more than 5 current medications; and 38% were more (20% stated less) likely to accept alerts on patients with more than 5 chronic clinical conditions. Interestingly, 80% said they were less likely to accept alerts when they were behind schedule and 84% of clinicians admitted to being at least 20 minutes behind schedule "some", "most", or "all of the time". Conclusion Even though a majority of our clinical decision support suggestions are not explicitly followed, clinicians feel they are of benefit and would be even more beneficial if they had more time available to address them.

• Implementing computerized physician order entry: the importance of special people.

  Authors: Joan S Ash, P Zoë Stavri, Richard Dykstra, Lara Fournier

  International journal of medical informatics. 04/2003; 69(2-3):235-50.

  OBJECTIVE: To articulate important lessons learned during a study to identify success factors for implementing computerized physician order entry (CPOE) in inpatient and outpatient settings. DESIGN:OBJECTIVE: To articulate important lessons learned during a study to identify success factors for implementing computerized physician order entry (CPOE) in inpatient and outpatient settings. DESIGN: Qualitative study by a multidisciplinary team using data from observation, focus groups, and both formal and informal interviews. Data were analyzed using a grounded approach to develop a taxonomy of patterns and themes from the transcripts and field notes. RESULTS: The theme we call Special People is explored here in detail. A taxonomy of types of Special People includes administrative leaders, clinical leaders (champions, opinion leaders, and curmudgeons), and bridgers or support staff who interface directly with users. CONCLUSION: The recognition and nurturing of Special People should be among the highest priorities of those implementing computerized physician order entry. Their education and training must be a goal of teaching programs in health administration and medical informatics.

• Principles for a successful computerized physician order entry implementation.

  Authors: Joan S Ash, Lara Fournier, P Zoë Stavri, Richard Dykstra

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

  To identify success factors for implementing computerized physician order entry (CPOE), our research team took both a top-down and bottom-up approach and reconciled the results to develop twelveTo identify success factors for implementing computerized physician order entry (CPOE), our research team took both a top-down and bottom-up approach and reconciled the results to develop twelve overarching principles to guide implementation. A consensus panel of experts produced ten Considerations with nearly 150 sub-considerations, and a three year project using qualitative methods at multiple successful sites for a grounded theory approach yielded ten general themes with 24 sub-themes. After reconciliation using a meta-matrix approach, twelve Principles, which cluster into groups forming the mnemonic CPOE emerged. Computer technology principles include: temporal concerns; technology and meeting information needs; multidimensional integration; and costs. Personal principles are: value to users and tradeoffs; essential people; and training and support. Organizational principles include: foundational underpinnings; collaborative project management; terms, concepts and connotations; and improvement through evaluation and learning. Finally, Environmental issues include the motivation and context for implementing such systems.

• Computerized physician order entry and communication: reciprocal impacts.

  Authors: Richard Dykstra

  Proceedings / AMIA ... Annual Symposium. AMIA Symposium. 02/2002;

  Participant observation, focus group and oral history techniques were used to collect data from four distinctly different sites across the U.S. Data were examined initially to identify successParticipant observation, focus group and oral history techniques were used to collect data from four distinctly different sites across the U.S. Data were examined initially to identify success factors for computerized physician order entry (CPOE) implementation. These data, reexamined for communication issues, revealed significant impacts on communication channels and relationships unanticipated by the implementers. Effects on physician-nurse interactions, pharmacy roles, and patient communications that vary by time and location were noted. The importance of robust bi-directional information channels between administration and staff was demonstrated to be potentially "mission-critical." The recommendation for implementers is "Plan to be surprised." Careful planning and pre-work are important but, no matter how much an institution prepares for the upheaval of CPOE, unforeseen consequences are inevitable. The presence of a prepared and capable implementation support group is essential.

• A Rapid Assessment Process for Clinical Informatics Interventions

  Authors: Joan S Ash, Dean F Sittig, Carmit K McMullen, Kenneth Guappone, Richard Dykstra, James Carpenter

  Informatics interventions generally take place in rapidly changing settings where many variables are outside the control of the evaluator. Assessment must be timely so that feedback can instigateInformatics interventions generally take place in rapidly changing settings where many variables are outside the control of the evaluator. Assessment must be timely so that feedback can instigate modification of the intervention. Adapting a methodology from international health and epidemiology, we have developed and refined a Rapid Assessment Process (RAP) for informatics while conducting a study of clinical decision support (CDS) in community hospitals. Using RAP, we have not only been able to provide implementers with actionable feedback, but we have also discovered that users and informaticians conceptualize CDS in vastly different ways. Further understanding of this difference will be needed if we are to improve CDS acceptance by users.