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Computer Post-It Notes Aid Docs

Reminder systems boost vaccination rates, other treatments in hospital

THURSDAY, Sept. 27, 2001 (HealthDayNews) -- A computer playing back-seat doctor can greatly increase the odds that patients in the hospital will receive important vaccinations and other preventive therapies, a new study says.

Previous studies have shown that computerized reminder systems boost preventive care in outpatient settings like a doctor's office. But whether they also do so in hospitals, where doctors are more focused on urgent treatments, hadn't been clear.

"Our pitch is that hospitalizations, emergency room visits, any point of contact with the patient serves as an opportunity for vaccinations" and other interventions, says Dr. Paul Dexter, an assistant clinical professor at Indiana University School of Medicine in Indianapolis and lead author of the study. "We understand that that [attitude] is increasingly accepted by the pediatric groups, and we're just adopting that for the internal medicine groups." The study appears this week in The New England Journal of Medicine.

Dexter and his colleagues tested an online reminder system over an 18-month period, during which time it processed the records of almost 6,400 patients who were admitted to their hospital's general medicine service. The program, accessible through computer workstations, prompted doctors to consider four key preventive measures: immunizations against flu and pneumococcal infection, injections of the blood thinner heparin to prevent clotting in the legs and lungs, and prophylactic aspirin upon being sent home.

Throughout the study the system found that there were more than 3,400 patients, or 53 percent of the total, who were eligible for at least one preventive therapy that hadn't been recommended by their admitting physician.

Immunization for patients admitted by doctors not using the system was essentially nil. But using the computer increased the use of pneumococcal vaccine to 35 percent, and the use of the flu shot to 50 percent.

For aspirin and heparin therapy, the gains were somewhat more modest. Use of the blood thinner rose from about 19 percent to almost 33 percent with the reminder system, while prophylactic aspirin orders increased from 28 percent to 36 percent.

Dexter says doctors in the hospital are more likely to consider the two drug therapies, but vaccinations are generally farther from their minds. "Doctors are focused on the problem at hand when it comes to hospitalization: what do I need to do to deal with that problem? [They] weren't as focused on things that were traditionally more the purview of the outpatient physician," he adds.

Dexter says most hospitals are probably already equipped with ample computing power to implement some form of physician reminder. "I don't think that it requires extensive, sophisticated computer systems in order to capture all these patients. You can do a lot with just age data," he says. Being over 65, for example, is a red flag for pneumococcal and flu vaccines.

For hospitals that lack sufficient technology, information already present on daily patient censuses could serve as a prompt to staff doctors, the researchers say.

Dr. Brent James, executive director of the Institute for Health Care Delivery Research in Salt Lake City, Utah, says implementing physician reminders can significantly reduce potentially deadly treatment errors.

"It turns out that the category of errors of omission, where we fail to do what might be beneficial, probably has greater total harm" than the number of more direct blunders, says James, author of an editorial accompanying the journal article.

The Institute of Medicine in 1999 released a report, which James helped prepare, stating that medical errors claimed between 44,000 and 98,000 lives a year in the United States. Errors of omission probably cause at least that many deaths, if not more, James says.

Although doctors are wary about being second-guessed, most welcome computer systems like the one in the latest study, James says. "But there's a trick -- you can't mess up their work. You have to blend them into the flow of care."

If physicians have to call up another system, or walk across the hall to access a terminal, they're much less likely to take advantage of the technology, he adds.

The American Hospital Association declined to comment on the study.

What To Do

For more on how technology can improve medical care delivery, try the National Academy of Sciences. You can also check out the American Medical Informatics Association, or the Agency for Healthcare Research and Quality.

For more on pneumococcal disease, try the National Foundation for Infectious Diseases. And for more on the flu vaccine, visit the Centers for Disease Control and Prevention.

SOURCES: Interviews with Paul Dexter, M.D., assistant clinical professor, Indiana University School of Medicine, Indianapolis; Brent James, M.D., M.Stat., executive director, Institute for Health Care Delivery Research, Salt Lake City, Utah; Sept. 27, 2001, The New England Journal of Medicine
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