R Scott Evans

Intermountain Medical Center, Salt Lake City, Utah, United States

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Publications (75)233.81 Total impact

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    ABSTRACT: An explicit approach to warfarin dose adjustment using computerized clinical decision support (CDS) improves warfarin management. We report metrics of quality for warfarin management before and after implementation of CDS in a large health care system.
    09/2014;
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    ABSTRACT: Develop and evaluate an automated case detection and response triggering system to monitor patients every 5 min and identify early signs of physiologic deterioration.
    Journal of the American Medical Informatics Association : JAMIA. 08/2014;
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    AHRQ Publication No 14-0003. 06/2014;
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    ABSTRACT: Although the rate of bleeding among patients with atrial fibrillation (AF) taking novel oral anticoagulants in randomized controlled trials is described, the rate of bleeding with "real-world" use is uncertain.
    05/2014;
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    ABSTRACT: D-dimer increases with age, and recent research suggests that the use of an age-adjusted d-dimer threshold may improve diagnostic efficiency without compromising safety. To assess the safety of using an age-adjusted d-dimer threshold in the work-up of patients with suspected pulmonary embolism (PE). We report the outcomes of 923 patients age > 50 years who presented to our emergency department with suspected PE, a Revised Geneva Score (RGS) calculated, and a d-dimer performed. All patients underwent computed tomography pulmonary angiography (CTPA). We compare the false negative rate for PE of a conventional d-dimer threshold with an age-adjusted d-dimer threshold. We report the proportion of patients for whom an age adjusted d-dimer would obviate the need for CTPA. Among 104 patients with a negative conventional d-dimer and an RGS ≤ 10, no PE was observed within 90 days (false negative rate 0%; 95% CI 0-2.8%). Among 273 patients with a negative age-adjusted d-dimer and an RGS ≤ 10, 4 PE were observed within 90 days (false negative rate 1.5%; 95% CI 0.4-3.7%). We observed an 18.3% (95% CI 15.9-21.0) absolute reduction in the proportion of patients age > 50 years who would merit CTPA using an age-adjusted d-dimer threshold compared with a conventional d-dimer threshold. Use of an age-adjusted d-dimer threshold reduces imaging among patients age > 50 years with an RGS ≤ 10. While the adoption of an age-adjusted d-dimer threshold is probably safe, the confidence intervals surrounding the additional 1.5% of PE that was missed using an age-adjusted threshold necessitate prospective study before this practice can be adopted into routine clinical care.
    Chest 05/2014; · 7.13 Impact Factor
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    ABSTRACT: Incidental pulmonary nodules that require follow-up are often noted on chest CT. Evidence-based guidelines regarding appropriate follow-up have been published, but the rate of adherence to guideline recommendations is unknown. Furthermore, it is unknown whether the radiology report affects the nodule follow-up rate. A review of 1,000 CT pulmonary angiographic studies ordered in the emergency department was performed to determine the presence of an incidental pulmonary nodule. Fleischner Society guidelines were applied to ascertain if follow-up was recommended. Radiology reports were classified on the basis of whether nodules were listed in the findings section only, were noted in the impression section, or had explicit recommendations for follow-up. Whether the rate of nodule follow-up was affected by the radiology report was determined according to these 3 groups. Incidental pulmonary nodules that required follow-up were noted on 9.9% (95% confidence interval, 8%-12%) of CT pulmonary angiographic studies. Follow-up for nodules was poor overall (29% [28 of 96]; 95% confidence interval, 20%-38%) and decreased significantly when the nodules were mentioned in the findings section only (0% [0 of 12]). Specific instructions to follow up nodules in radiology reports still resulted in a low follow-up rate of 29% (19 of 65; 95% confidence interval, 18%-40%). Incidental pulmonary nodules detected on CT pulmonary angiography are common and are frequently not followed up appropriately. Although the inclusion of a pulmonary nodule in the impression section of a radiology report is helpful, it does not ensure follow-up. Better systems for appropriate identification and follow-up of incidental findings are needed.
    Journal of the American College of Radiology: JACR 12/2013;
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    ABSTRACT: Obstructive sleep apnea (OSA) is a worldwide problem affecting 2-14% of the general population and most patients remain undiagnosed. OSA patients are at elevated risk for hypoxemia, cardiac arrhythmias, cardiorespiratory arrest, hypoxic encephalopathy, stroke and death during hospitalization. Clinical screening questionnaires are used to identify hospitalized patients with OSA; especially before surgery. However, current screening questionnaires miss a significant number of patients and require more definitive testing before specific therapy can be started. Moreover, many patients are admitted to the hospital with a previous diagnosis of OSA that is not reported. Thus, many patients with OSA do not receive appropriate therapy during hospitalization due to the lack of information from previous inpatient and outpatient encounters. Large enterprise data warehouses provide the ability to monitor patient encounters over wide geographical areas. This study found that previously diagnosed OSA is highly prevalent and undertreated in hospitalized patients and the use of early computer alerts by respiratory therapists resulted in significantly more OSA patients receiving appropriate medical care (P < 0.002) which resulted in significantly fewer experiencing hypoxemia (P < 0.006). The impact was greater for non-surgery patients compared to surgery patients.
    Studies in health technology and informatics 01/2013; 192:505-9.
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    ABSTRACT: BACKGROUND: Computed tomography (CT) pulmonary angiography use has increased dramatically, raising concerns for patient safety. Adherence to recommendations and guidelines may protect patients. We measured adherence to the recommendations of Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED II) investigators for evaluation of suspected pulmonary embolism and the rate of potential false-positive pulmonary embolism diagnoses when recommendations of PIOPED II investigators were not followed. METHODS: We used a structured record review to identify 3500 consecutive CT pulmonary angiograms performed to investigate suspected pulmonary embolism in 2 urban emergency departments, calculating the revised Geneva score (RGS) to classify patients as "pulmonary embolism unlikely" (RGS≤10) or "pulmonary embolism likely" (RGS>10). CT pulmonary angiograms were concordant with PIOPED II investigator recommendations if pulmonary embolism was likely or pulmonary embolism was unlikely and a highly sensitive D-dimer test result was positive. We independently reviewed 482 CT pulmonary angiograms to measure the rate of potential false-positive pulmonary embolism diagnoses. RESULTS: A total of 1592 of 3500 CT pulmonary angiograms (45.5%) followed the recommendations of PIOPED II investigators. The remaining 1908 CT pulmonary angiograms were performed on patients with an RGS≤10 without a D-dimer test (n=1588) or after a negative D-dimer test result (n=320). The overall rate of pulmonary embolism was 9.7%. Potential false-positive diagnoses of pulmonary embolism occurred in 2 of 3 patients with an RGS≤10 and a negative D-dimer test result. CONCLUSIONS: Nonadherence to recommendations for CT pulmonary angiography is common and exposes patients to increased risks, including potential false-positive diagnoses of pulmonary embolism.
    The American journal of medicine 11/2012; · 5.30 Impact Factor
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    ABSTRACT: OBJECTIVES:: The subjectivity and complexity of surveillance definitions for ventilator-associated pneumonia preclude meaningful internal or external benchmarking and therefore hamper quality improvement initiatives for ventilated patients. We explored the feasibility of creating objective surveillance definitions for ventilator-associated pneumonia. DESIGN:: We identified clinical signs suitable for inclusion in objective definitions, proposed candidate definitions incorporating these objective signs, and then applied these definitions to retrospective clinical data to measure their frequencies and associations with adverse outcomes using multivariate regression models for cases and matched controls. SETTING:: Medical and surgical intensive care units in eight U.S. hospitals (four tertiary centers, three community hospitals, and one Veterans Affairs institution). PATIENTS:: Eight thousand seven hundred thirty-five consecutive episodes of mechanical ventilation for adult patients. INTERVENTIONS:: We evaluated 32 different candidate definitions composed of different combinations of the following signs: three thresholds for respiratory deterioration defined by sustained increases in daily minimum positive end-expiratory pressure or FIO2 after either 2 or 3 days of stable or decreasing ventilator settings, abnormal temperature, abnormal white blood cell count, purulent pulmonary secretions defined by neutrophils on Gram stain, and positive cultures for pathogenic organisms. MEASUREMENTS AND MAIN RESULTS:: Ventilator-associated pneumonia incidence, attributable ventilator days, hospital days, and hospital mortality. All candidate definitions were significantly associated with increased ventilator days and hospital days, but only definitions requiring objective evidence of respiratory deterioration were significantly associated with increased hospital mortality. Significant odds ratios for hospital mortality ranged from 1.9 (95% confidence interval 1.2-2.9) to 6.1 (95% confidence interval 2.2-17). Requiring additional clinical signs beyond respiratory deterioration alone decreased event rates, had little impact on attributable lengths of stay, and diminished sensitivity and positive predictive values for hospital mortality. CONCLUSIONS:: Objective surveillance definitions that include quantitative evidence of respiratory deterioration after a period of stability strongly predict increased length of stay and hospital mortality. These definitions merit further evaluation of their utility for hospital quality and safety improvement programs.
    Critical care medicine 09/2012; · 6.37 Impact Factor
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    ABSTRACT: ABSTRACT BACKGROUND: As peripherally inserted central catheter (PICC) use has increased, so has the upper extremity deep venous thrombosis (DVT) rate. PICC diameter may pose the most modifiable risk for PICC-associated DVT. METHODS: A three year prospective observational study of all PICC insertions by a specially trained and certified team using a consistent and replicable approach was conducted at a 456-bed, level-one trauma and tertiary referral hospital during January 1, 2008 through December 31, 2010. An intensified effort by the PICC team in 2010 was introduced to discuss and reach interdisciplinary consensus on the need for each lumen of the PICC and a change to smaller diameter 5F triple-lumen PICC. RESULTS: Significantly more 4F single-lumen PICC were used during 2010 (n = 470) compared to 2008 and 2009 (n = 338, 382; p < 0.0001). 5F triple-lumen PICC used in 2010 were found to have similar DVT rates as 5F double-lumen and lower rates than 6F triple-lumen catheters used in 2008 and 2009. The PICC-associated DVT rate was significantly lower (1.9% vs. 3.0%,; p < 0.04) in 2010 compared to 2008 and 2009. The cost and length of stay attributable to PICC-associated DVT was $15,973 and 4.6 days. CONCLUSIONS: A significant increase in the use of single lumen PICC in addition to the institutional adoption of smaller 5F triple lumen PICC was associated with a significant decrease in the rate of PICC-associated DVT.1Medical Informatics, Intermountain Healthcare;2Biomedical Informatics, University of Utah School of Medicine;3Nutrition Support Service/PICC Team, Intermountain Medical Center;4Department of Medicine, Intermountain Medical Center;5Department of Medicine, University of Utah School of Medicine;6RAND,7Hyperbaric Medicine, Intermountain Medical Center and LDS Hospital; Salt Lake City, UTCorresponding author: R. Scott Evans, Medical Informatics, LDS Hospital, 8th Avenue and C Street, Salt Lake City, Utah 84143, rscott.evans@imail.org.
    Chest 08/2012; · 7.13 Impact Factor
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    ABSTRACT: The complexity and subjectivity of ventilator-associated pneumonia (VAP) surveillance limit its value in assessing and comparing quality of care for ventilated patients. A simpler, more quantitative VAP definition may increase utility. We streamlined the Centers for Disease Control and Prevention definition of VAP to increase objectivity and efficiency. Qualitative criteria were replaced with quantitative criteria, and changes in ventilator settings were used to screen patients for worsening oxygenation. We retrospectively compared surveillance time, reproducibility, and outcomes for streamlined versus conventional surveillance among medical and surgical patients on mechanical ventilation in 3 university hospitals. Application of the streamlined definition was faster (mean 3.5 minutes vs 39.0 minutes per patient) and more objective (interrater reliability κ 0.79 vs 0.45) than the conventional definition. On multivariate analysis, the streamlined definition predicted increases in ventilator days (6.5 days [95% CI, 4.1-10.0] vs 6.4 days [95% CI, 4.7-8.6]), intensive care days (5.6 days [95% CI, 3.2-8.9] vs 6.2 days [95% CI, 4.6-8.2]), and hospital mortality (odds ratio [OR] 0.84 [95% CI, 0.31-2.29] vs OR 0.69 [95% CI, 0.30-1.55]) as effectively as conventional surveillance. The conventional definition was a marginally superior predictor of increased hospital days (5.2 days [95% CI, 3.4-7.6] vs 2.1 days [95% CI, -0.5-5.6]). A streamlined version of the VAP definition was faster, more objective, and predicted patients' outcomes almost as effectively as the conventional definition. VAP surveillance using the streamlined method may facilitate more objective and efficient quality assessment for ventilated patients.
    Clinical Infectious Diseases 02/2012; 54(3):370-7. · 9.37 Impact Factor
  • R Scott Evans, James F Lloyd, Lee A Pierce
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    ABSTRACT: The enormous amount of data being collected by electronic medical records (EMR) has found additional value when integrated and stored in data warehouses. The enterprise data warehouse (EDW) allows all data from an organization with numerous inpatient and outpatient facilities to be integrated and analyzed. We have found the EDW at Intermountain Healthcare to not only be an essential tool for management and strategic decision making, but also for patient specific clinical decision support. This paper presents the structure and two case studies of a framework that has provided us the ability to create a number of decision support applications that are dependent on the integration of previous enterprise-wide data in addition to a patient's current information in the EMR.
    AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium 01/2012; 2012:189-98.
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    ABSTRACT: Fewer than half of eligible hospitalized medical patients receive appropriate venous thromboembolism (VTE) prophylaxis. One reason for this low rate is the complexity of existing risk assessment models. A simple set of easily identifiable risk factors that are highly predictive of VTE among hospitalized medical patients may enhance appropriate thromboprophylaxis. Electronic medical record interrogation was performed to identify medical admissions from January 1, 2000-December 31, 2007 (n=143,000), and those patients with objectively confirmed VTE during hospitalization or within 90 days following discharge. Putative risk factors most predictive of VTE were identified, and a risk assessment model (RAM) was derived; 46,000 medicine admissions from January 1, 2008-December 31, 2009 served as a validation cohort to test the predictive ability of the RAM. The newly derived RAM was compared with a published VTE assessment tool (Kucher Score). Four risk factors: previous VTE; an order for bed rest; peripherally inserted central venous catheterization line; and a cancer diagnosis, were the minimal set most predictive of hospital-associated VTE (area under the receiver operating characteristic curve [AUC]=0.874; 95% confidence interval [CI], 0.869-0.880). These risk factors upon validation in a separate population (validation cohort) retained an AUC=0.843; 95% CI, 0.833-0.852. The ability of the 4-element RAM to identify patients at risk of developing VTE within 90 days was superior to the Kucher Score. The 4-element RAM identified in this study may be used to identify patients at risk for VTE and improve rates of thromboprophylaxis. This simple and accurate RAM is an alternative to more complicated published VTE risk assessment tools that currently exist.
    The American journal of medicine 10/2011; 124(10):947-954.e2. · 5.30 Impact Factor
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    ABSTRACT: To understand how the source of information affects different adverse event (AE) surveillance methods. Retrospective analysis of inpatient adverse drug events (ADEs) and hospital-associated infections (HAIs) detected by either a computerized surveillance system (CSS) or manual chart review (MCR). Descriptive analysis of events detected using the two methods by type of AE, type of information about the AE, and sources of the information. CSS detected more HAIs than MCR (92% vs 34%); however, a similar number of ADEs was detected by both systems (52% vs 51%). The agreement between systems was greater for HAIs than ADEs (26% vs 3%). The CSS missed events that did not have information in coded format or that were described only in physician narratives. The MCR detected events missed by CSS using information in physician narratives. Discharge summaries were more likely to contain information about AEs than any other type of physician narrative, followed by emergency department reports for HAIs and general consult notes for ADEs. Some ADEs found by MCR were detected by CSS but not verified by a clinician. Inability to distinguish between CSS false positives and suspected AEs for cases in which the clinician did not document their assessment in the CSS. The effect that information source has on different surveillance methods depends on the type of AE. Integrating information from physician narratives with CSS using natural language processing would improve the detection of ADEs more than HAIs.
    Journal of the American Medical Informatics Association 07/2011; 18(4):491-7. · 3.57 Impact Factor
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    ABSTRACT: To evaluate the medical professionals and medical students perceived usefulness of an emergency medical card (EMC) and a continuity of care (CoC) report, in enhancing CoC. The study reviewers included medical professionals from outpatient clinics at Intermountain Healthcare and fourth-year medical students from the University of Utah. Three cases we randomly extracted from a database of patients who had added new care information at the time. EMCs and CoC reports were populated for the cases, and information then de-identified. Using patient information in the electronic medical record (EMR), reviewers evaluated if the EMR information was adequate to support medical decisions made on the patient's diagnosis, medications, laboratory tests, and disposition. The reviewer assessed if the EMC and CoC report information would influence the medical decisions made. An online survey was used to assess the reviewers' perception on the usefulness of the two documents. On average, 94% of the reviewers perceived the EMC to be useful in enhancing medical decision making at the point of care, and 74% found the CoC report to be useful. More specifically, the two documents were found to be useful in decreasing encounter time (100% each), increasing overall knowledge of healthcare providers (100% each), influencing decision on the treatment (94% each), and new laboratory test orders (87% and 90%, respectively). The EMC and CoC report were found to be useful methods for transporting patient healthcare information across the healthcare continuum. The documents were found more specifically to be useful for effective decision making, improving efficiency and quality of care, at the point of care.
    International Journal of Medical Informatics 06/2011; 80(6):412-20. · 2.06 Impact Factor
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    ABSTRACT: To outline methods for deriving and validating intensive care unit (ICU) antimicrobial utilization (AU) measures from computerized data and to describe programming problems that emerged. Retrospective evaluation of computerized pharmacy and administrative data. ICUs from 4 academic medical centers over 36 months. Investigators separately developed and validated programming code to report AU measures in selected ICUs. Use of antibacterial and antifungal drugs for systemic administration was categorized and expressed as antimicrobial-days (each day that each antimicrobial drug was given to each patient) and patient-days receiving antimicrobials (each day that any antimicrobial drug was given to each patient). Monthly rates were compiled and analyzed centrally, with ICU patient-days as the denominator. Results were validated against data collected from manual review of medical records. Frequent discussion among investigators aided identification and correction of programming problems. AU data were successfully programmed though a reiterative process of computer code revision. After identifying and resolving major programming errors, comparison of computerized patient-level data with data collected by manual review of medical records revealed discrepancies in antimicrobial-days and patient-days receiving antimicrobials that ranged from less than 1% to 17.7%. The hospital from which numerator data were derived from electronic records of medication administration had the least discrepant results. Computerized AU measures can be derived feasibly, but threats to validity must be sought out and corrected. The magnitude of discrepancies between computerized AU data and a gold standard based on manual review of medical records varies, with electronic records of medication administration providing maximal accuracy.
    Infection Control and Hospital Epidemiology 05/2011; 32(5):472-80. · 4.02 Impact Factor
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    ABSTRACT: 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 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.
    Journal of the American Medical Informatics Association 03/2011; 18(3):232-42. · 3.57 Impact Factor
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    ABSTRACT: 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 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.
    BMC Medical Informatics and Decision Making 02/2011; 11:13. · 1.60 Impact Factor
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    ABSTRACT: Public health surveillance is necessary to prevent and control communicable and non-communicable diseases. An electronic reporting system using HL7 v2.5.1 was implemented between Intermountain Healthcare and the Utah Department of Health. We conducted prospective and retrospective studies to evaluate the timeliness, completeness of content information, and completeness of the electronic reporting process, and compared these metrics against other reporting entities. The electronic reporting system was more timely than other clinical reporting facilities and included more complete information in initial case reports. During a four month period, the electronic reporting system captured 8% of the cases not reported by the paper-based reporting system but missed 5% of the cases reported by the paper-based reporting system. We believe it would be more efficient for Infection Preventionists at hospitals to use their resources to detect cases not captured by the electronic reporting system instead of manually re-reporting cases already transmitted to public health electronically.
    AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium 01/2011; 2011:1144-52.
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    ABSTRACT: Collaborate, translate, and impact are key concepts describing the roles and purposes of the research Centers of Excellence (COE) in Public Health Informatics (PHI). Rocky Mountain COE integrated these concepts into a framework of PHI Innovation Space and Stage to guide their collaboration between the University of Utah, Intermountain Healthcare, and Utah Department of Health. Seven research projects are introduced that illustrate the framework and demonstrate how to effectively manage multiple innovations among multiple organizations over a five-year period. A COE is more than an aggregation of distinct research projects over a short time period. The people, partnership, shared vision, and mutual understanding and appreciation developed over a long period of time form the core and foundation for ongoing collaborative innovations and its successes.
    Online journal of public health informatics. 01/2011; 3(3).

Publication Stats

1k Citations
233.81 Total Impact Points

Institutions

  • 2004–2013
    • Intermountain Medical Center
      Salt Lake City, Utah, United States
  • 2011–2012
    • Harvard Medical School
      • Department of Population Medicine
      Boston, MA, United States
  • 1985–2012
    • University of Utah
      • • Department of Biomedical Informatics
      • • Division of Infectious Diseases
      Salt Lake City, UT, United States
  • 2006
    • Columbia University
      • Department of Biomedical Informatics
      New York City, NY, United States