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The Next Generation of Medical Informatics for Patient Safety

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rules-based systemIn this article the hospital rules-based system (HRBS) and its subsystems at a major medical center are described. The HRBS was implemented at the Mayo Clinic to rapidly identify and communicate crucial information to the clinician in order to optimize patient care. The system also enhances workload efficiency and improves documentation and communication. The system is used by the infectious-diseases division, pharmacy services, nutritional support services, infection control, and the nursing department. The six HRBS subsystems are Web-based programs that share a common structural design and integrate computerized information from multiple institutional databases. The integrated data are presented in a user-friendly format that improves the efficiency of data retrieval. Information, such as monitoring notes and intervention information, can be entered for specific patients. The subsystems use rules designed to detect suboptimal therapy or monitoring and identify opportunities for cost savings in a timely manner.

Of the more than 700,000 adverse drug events estimated to occur each year in U.S. hospitals, nearly 28% are attributed to a preventable medication error, with most occurring during drug ordering. Others occur at the time of pharmacist processing, drug administration, and monitoring. Deaths from medication errors are estimated to total some 7000 per year. Although physicians, pharmacists, and nurses are diligent about preventing adverse drug events and medication errors, preventable events still occur, often because of inadequate availability of information or institutional information-system failures. Prevention strategies targeting systems rather than individuals are generally most effective in reducing errors.

Computerized information systems are gaining increasing recognition as a tool for reducing medication errors. Strategies used by these systems include improved communication with clinicians, more accessible medical knowledge, better monitoring techniques, automated calculations, and support for clinical decisions.

The Mayo Clinic developed its first rules-based informatics program during the late 1980s to reduce medication errors and improve education of and communication with clinicians. The system predominantly monitored antimicrobial prescribing practices and resulted in improvements in hospital patient care and drug cost savings. The success of this program led to the expansion of a common technological architecture called the hospital rules-based system (HRBS), composed of several subsystems. The rules-based subsystems were developed for more comprehensive, multidisciplinary patient monitoring and cost containment. This article describes the HRBS and each of its subsystems.

The HRBS is Mayo Clinic's rules-based, Web-based, patient care program and comprises six subsystems: computer-based antimicrobial monitoring, computerized patient infectious-diseases data, pharmaceutical care, feeding effectively using electronic data, electronically assisted surveillance of infection, and heparin nomogram system. The goals of the HRBS are to enhance the quality of patient care through (1) more efficient integration and assessment of patient and drug information, (2) reduction of medication errors, (3) reduction of costs, and (4) increased communication with and documentation by health care providers.

Except for the computerized patient infectious diseases data subsystem, all HRBS subsystems use computerized rules. Each rule contains a set of conditions that, when met by a patient, identify situations in which review and intervention by an infectious-diseases physician, pharmacist, nutrition specialist, infection control officer, or nurse may be beneficial. The concepts for the rules are developed by physician and pharmacist specialists and are incorporated into computerized logic by the HRBS programming team. The rules can utilize information from any of the integrated electronic data, including demographic information, calculated values, laboratory and microbiology data, and drug information.

Compilation and integration of patient information from various sources have been estimated to consume up to one third of a physician's time and are no longer feasible at a large medical center. The HRBS significantly decreases this effort by integrating computerized data from hospital admissions, laboratory, microbiology, parenteral nutrition, and pharmacy databases into one place. The integration of these computerized data allows automated calculations to be performed and displayed, including estimated creatinine clearance, body surface area, ideal body weight, body weight for drug dosing, and various nutrition-related calculations (e.g., body mass index, Harris-Benedict equation). In addition, the ability to display data from multiple disparate electronic sources in a specially formatted report for each patient enables the physician, nurse, or pharmacist to make a more rapid clinical assessment. Selected patient information is available from the HRBS subsystems via all computer stations in the Mayo Clinic and its hospitals (Appendix A). The type of patient information shown depends on the subsystem in which the information is viewed.


Hospital information systems are expanding throughout the nation with the goals of reducing medication errors, improving patient care and quality assurance, and saving money. The HRBS enhances the identification of drug-related problems and improves communication and efficiency at the Mayo Clinic.

Get the full text article at Medscape


Last Updated ( Friday, 18 April 2008 22:35 )  

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