Gordon Schiff - Academia.edu (original) (raw)

Papers by Gordon Schiff

Research paper thumbnail of Systems engineering analysis of diagnostic referral closed-loop processes

BMJ Open Quality, 2021

BackgroundClosing loops to complete diagnostic referrals remains a significant patient safety pro... more BackgroundClosing loops to complete diagnostic referrals remains a significant patient safety problem in most health systems, with 65%–73% failure rates and significant delays common despite years of improvement efforts, suggesting new approaches may be useful. Systems engineering (SE) methods increasingly are advocated in healthcare for their value in studying and redesigning complex processes.ObjectiveConduct a formative SE analysis of process logic, variation, reliability and failures for completing diagnostic referrals originating in two primary care practices serving different demographics, using dermatology as an illustrating use case.MethodsAn interdisciplinary team of clinicians, systems engineers, quality improvement specialists, and patient representatives collaborated to understand processes of initiating and completing diagnostic referrals. Cross-functional process maps were developed through iterative group interviews with an urban community-based health centre and a te...

Research paper thumbnail of Table 4, Change ideas for preventing and minimizing diagnostic error

Research paper thumbnail of Health Information Technology Center for Education and Research on Therapeutics (HIT-CERT) - Final Report

Purpose: The purpose of the BWH HIT-CERT was to leverage HIT for pharmacosurveillance, medication... more Purpose: The purpose of the BWH HIT-CERT was to leverage HIT for pharmacosurveillance, medication-related clinical decision support, and to identify new ways to utilize information coming from medication-related decision support. Moreover, we strove to advance our understanding of how providers are responding to medication-related decision support. Scope: Within the three BWH HIT-CERT subprojects, our team examined questions relating to appropriateness, safety, and efficacy across diverse patient populations. The projects covered multiple settings including outpatients, inpatients and recently discharged inpatients. Methods: We completed three research projects over a five-year period, each of which addressed one or more of the programmatic interest areas including patient safety, development and enhancement of tools, health care system interventions, and translation into practice or policy. The three subprojects involved: 1) leveraging new technologies to improve pharmacosurveillan...

Research paper thumbnail of Figure 1, Relationships between diagnostic process errors, misdiagnosis, and adverse events

Research paper thumbnail of Association of Display of Patient Photographs in the Electronic Health Record With Wrong-Patient Order Entry Errors

Research paper thumbnail of Table 1, General medical error studies that reported errors in diagnosis

Research paper thumbnail of Table 2, Illustrative disease-specific studies of diagnosis errors

Research paper thumbnail of Personal Formularies of Primary Care Physicians Across 4 Health Care Systems

Research paper thumbnail of Comparison of a Prototype for Indications-Based Prescribing With 2 Commercial Prescribing Systems

Research paper thumbnail of A Prescription For Enhancing Electronic Prescribing Safety

Research paper thumbnail of What do Australian consumers, pharmacists and prescribers think about documenting indications on prescriptions and dispensed medicines labels?: A qualitative study

BMC health services research, Jan 15, 2017

Documenting the indication on prescriptions and dispensed medicines labels is not standard practi... more Documenting the indication on prescriptions and dispensed medicines labels is not standard practice in Australia. However, previous studies that have focused on the content and design of dispensed medicines labels, have suggested including the indication as a safety measure. The aim of this study was to investigate the perspectives of Australian consumers, pharmacists and prescribers on documenting the indication on prescriptions and dispensed medicines labels. Semi-structured interviews were conducted and mock-up of dispensed medicines labels were designed for participants. Consumers (n = 19) and pharmacists (n = 7) were recruited by convenience sample at community pharmacies in Sydney (Australia) and prescribers (n = 8), including two medical students, were recruited through snowballing. Thirty-four participants were interviewed. Most participants agreed that documenting the indication would be beneficial especially for patients who are forgetful or take multiple medications. Part...

Research paper thumbnail of Using drug knowledgebase information to distinguish between look-alike-sound-alike drugs

Journal of the American Medical Informatics Association : JAMIA, Jan 22, 2018

To extract drug indications from a commercial drug knowledgebase and determine to what extent dru... more To extract drug indications from a commercial drug knowledgebase and determine to what extent drug indications can discriminate between look-alike-sound-alike (LASA) drugs. We extracted drug indications disease concepts from the MedKnowledge Indications module from First Databank Inc. (South San Francisco, CA) and associated them with drugs on the Institute for Safe Medication Practices (ISMP) list of commonly confused drug names. We used high-level concepts (rather than granular concepts) to represent the general indications for each drug. Two pharmacists reviewed each drug's association with its high-level indications concepts for accuracy and clinical relevance. We compared the high-level indications for each commonly confused drug pair and categorized each pair as having a complete overlap, partial overlap or no overlap in high-level indications. Of 278 LASA drug pairs, 165 (59%) had no overlap and 58 (21%) had partial overlap in high-level indications. Fifty-five pairs (20%...

Research paper thumbnail of Reduced Effectiveness of Interruptive Drug-Drug Interaction Alerts after Conversion to a Commercial Electronic Health Record

Journal of general internal medicine, Jan 15, 2018

Drug-drug interaction (DDI) alerts in electronic health records (EHRs) can help prevent adverse d... more Drug-drug interaction (DDI) alerts in electronic health records (EHRs) can help prevent adverse drug events, but such alerts are frequently overridden, raising concerns about their clinical usefulness and contribution to alert fatigue. To study the effect of conversion to a commercial EHR on DDI alert and acceptance rates. Two before-and-after studies. 3277 clinicians who received a DDI alert in the outpatient setting. Introduction of a new, commercial EHR and subsequent adjustment of DDI alerting criteria. Alert burden and proportion of alerts accepted. Overall interruptive DDI alert burden increased by a factor of 6 from the legacy EHR to the commercial EHR. The acceptance rate for the most severe alerts fell from 100 to 8.4%, and from 29.3 to 7.5% for medium severity alerts (P < 0.001). After disabling the least severe alerts, total DDI alert burden fell by 50.5%, and acceptance of Tier 1 alerts rose from 9.1 to 12.7% (P < 0.01). Changing from a highly tailored DDI alerting...

Research paper thumbnail of Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders

BMJ Quality & Safety, 2017

ObjectiveMedication voiding is a computerised provider order entry (CPOE)-based discontinuation m... more ObjectiveMedication voiding is a computerised provider order entry (CPOE)-based discontinuation mechanism that allows clinicians to identify erroneous medication orders. We investigated the accuracy of voiding as an indicator of clinician identification and interception of a medication ordering error, and investigated reasons and root contributors for medication ordering errors.MethodUsing voided orders identified with a void alert, we conducted interviews with ordering and voiding clinicians, followed by patient chart reviews. A structured coding framework was used to qualitatively analyse the reasons for medication ordering errors. We also compared clinician-CPOE-selected (at time of voiding), clinician-reported (interview) and chart review-based reasons for voiding.ResultsWe conducted follow-up interviews on 101 voided orders. The positive predictive value (PPV) of voided orders that were medication ordering errors was 93.1% (95% CI 88.1% to 98.1%, n=94). Using chart review-based...

Research paper thumbnail of Methodologies for evaluating strategies to reduce diagnostic error: report from the research summit at the 7th International Diagnostic Error in Medicine Conference

Diagnosis, 2016

In this article we review current evidence on strategies to evaluate diagnostic error solutions, ... more In this article we review current evidence on strategies to evaluate diagnostic error solutions, discuss the methodological challenges that exist in investigating the value of these strategies in patient care, and provide recommendations for methods that can be applied in investigating potential solutions to diagnostic errors. These recommendations were developed iteratively by the authors based upon initial discussions held during the Research Summit of the 7th Annual Diagnostic Error in Medicine Conference in September 2014. The recommendations include the following elements for designing studies of diagnostic research solutions: (1) Select direct and indirect outcomes measures of importance to patients, while also practical for the particular solution; (2) Develop a clearly-stated logic model for the solution to be tested; (3) Use rapid, iterative prototyping in the early phases of solution testing; (4) Use cluster-randomized clinical trials where feasible; (5) Avoid simple pre-p...

Research paper thumbnail of Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors

Expert Opinion on Drug Safety, 2017

Research paper thumbnail of Learning from errors: analysis of medication order voiding in CPOE systems

Journal of the American Medical Informatics Association, 2017

Objective: Medication order voiding allows clinicians to indicate that an existing order was plac... more Objective: Medication order voiding allows clinicians to indicate that an existing order was placed in error. We explored whether the order voiding function could be used to record and study medication ordering errors. Materials and Methods: We examined medication orders from an academic medical center for a 6-year period (2006–2011; n = 5 804 150). We categorized orders based on status (void, not void) and clinician-provided reasons for voiding. We used multivariable logistic regression to investigate the association between order voiding and clinician, patient, and order characteristics. We conducted chart reviews on a random sample of voided orders (n = 198) to investigate the rate of medication ordering errors among voided orders, and the accuracy of clinician-provided reasons for voiding. Results: We found that 0.49% of all orders were voided. Order voiding was associated with clinician type (physician, pharmacist, nurse, student, other) and order type (inpatient, prescription,...

Research paper thumbnail of Incorporating Indications into Medication Ordering--Time to Enter the Age of Reason

The New England journal of medicine, Jan 28, 2016

Research paper thumbnail of Screening for medication errors using an outlier detection system

Journal of the American Medical Informatics Association : JAMIA, Mar 19, 2017

The study objective was to evaluate the accuracy, validity, and clinical usefulness of medication... more The study objective was to evaluate the accuracy, validity, and clinical usefulness of medication error alerts generated by an alerting system using outlier detection screening. Five years of clinical data were extracted from an electronic health record system for 747 985 patients who had at least one visit during 2012-2013 at practices affiliated with 2 academic medical centers. Data were screened using the system to detect outliers suggestive of potential medication errors. A sample of 300 charts was selected for review from the 15 693 alerts generated. A coding system was developed and codes assigned based on chart review to reflect the accuracy, validity, and clinical value of the alerts. Three-quarters of the chart-reviewed alerts generated by the screening system were found to be valid in which potential medication errors were identified. Of these valid alerts, the majority (75.0%) were found to be clinically useful in flagging potential medication errors or issues. A clinical...

Research paper thumbnail of Addressing Ambulatory Safety and Malpractice: The Massachusetts PROMISES Project

Health Services Research, 2016

Research paper thumbnail of Systems engineering analysis of diagnostic referral closed-loop processes

BMJ Open Quality, 2021

BackgroundClosing loops to complete diagnostic referrals remains a significant patient safety pro... more BackgroundClosing loops to complete diagnostic referrals remains a significant patient safety problem in most health systems, with 65%–73% failure rates and significant delays common despite years of improvement efforts, suggesting new approaches may be useful. Systems engineering (SE) methods increasingly are advocated in healthcare for their value in studying and redesigning complex processes.ObjectiveConduct a formative SE analysis of process logic, variation, reliability and failures for completing diagnostic referrals originating in two primary care practices serving different demographics, using dermatology as an illustrating use case.MethodsAn interdisciplinary team of clinicians, systems engineers, quality improvement specialists, and patient representatives collaborated to understand processes of initiating and completing diagnostic referrals. Cross-functional process maps were developed through iterative group interviews with an urban community-based health centre and a te...

Research paper thumbnail of Table 4, Change ideas for preventing and minimizing diagnostic error

Research paper thumbnail of Health Information Technology Center for Education and Research on Therapeutics (HIT-CERT) - Final Report

Purpose: The purpose of the BWH HIT-CERT was to leverage HIT for pharmacosurveillance, medication... more Purpose: The purpose of the BWH HIT-CERT was to leverage HIT for pharmacosurveillance, medication-related clinical decision support, and to identify new ways to utilize information coming from medication-related decision support. Moreover, we strove to advance our understanding of how providers are responding to medication-related decision support. Scope: Within the three BWH HIT-CERT subprojects, our team examined questions relating to appropriateness, safety, and efficacy across diverse patient populations. The projects covered multiple settings including outpatients, inpatients and recently discharged inpatients. Methods: We completed three research projects over a five-year period, each of which addressed one or more of the programmatic interest areas including patient safety, development and enhancement of tools, health care system interventions, and translation into practice or policy. The three subprojects involved: 1) leveraging new technologies to improve pharmacosurveillan...

Research paper thumbnail of Figure 1, Relationships between diagnostic process errors, misdiagnosis, and adverse events

Research paper thumbnail of Association of Display of Patient Photographs in the Electronic Health Record With Wrong-Patient Order Entry Errors

Research paper thumbnail of Table 1, General medical error studies that reported errors in diagnosis

Research paper thumbnail of Table 2, Illustrative disease-specific studies of diagnosis errors

Research paper thumbnail of Personal Formularies of Primary Care Physicians Across 4 Health Care Systems

Research paper thumbnail of Comparison of a Prototype for Indications-Based Prescribing With 2 Commercial Prescribing Systems

Research paper thumbnail of A Prescription For Enhancing Electronic Prescribing Safety

Research paper thumbnail of What do Australian consumers, pharmacists and prescribers think about documenting indications on prescriptions and dispensed medicines labels?: A qualitative study

BMC health services research, Jan 15, 2017

Documenting the indication on prescriptions and dispensed medicines labels is not standard practi... more Documenting the indication on prescriptions and dispensed medicines labels is not standard practice in Australia. However, previous studies that have focused on the content and design of dispensed medicines labels, have suggested including the indication as a safety measure. The aim of this study was to investigate the perspectives of Australian consumers, pharmacists and prescribers on documenting the indication on prescriptions and dispensed medicines labels. Semi-structured interviews were conducted and mock-up of dispensed medicines labels were designed for participants. Consumers (n = 19) and pharmacists (n = 7) were recruited by convenience sample at community pharmacies in Sydney (Australia) and prescribers (n = 8), including two medical students, were recruited through snowballing. Thirty-four participants were interviewed. Most participants agreed that documenting the indication would be beneficial especially for patients who are forgetful or take multiple medications. Part...

Research paper thumbnail of Using drug knowledgebase information to distinguish between look-alike-sound-alike drugs

Journal of the American Medical Informatics Association : JAMIA, Jan 22, 2018

To extract drug indications from a commercial drug knowledgebase and determine to what extent dru... more To extract drug indications from a commercial drug knowledgebase and determine to what extent drug indications can discriminate between look-alike-sound-alike (LASA) drugs. We extracted drug indications disease concepts from the MedKnowledge Indications module from First Databank Inc. (South San Francisco, CA) and associated them with drugs on the Institute for Safe Medication Practices (ISMP) list of commonly confused drug names. We used high-level concepts (rather than granular concepts) to represent the general indications for each drug. Two pharmacists reviewed each drug's association with its high-level indications concepts for accuracy and clinical relevance. We compared the high-level indications for each commonly confused drug pair and categorized each pair as having a complete overlap, partial overlap or no overlap in high-level indications. Of 278 LASA drug pairs, 165 (59%) had no overlap and 58 (21%) had partial overlap in high-level indications. Fifty-five pairs (20%...

Research paper thumbnail of Reduced Effectiveness of Interruptive Drug-Drug Interaction Alerts after Conversion to a Commercial Electronic Health Record

Journal of general internal medicine, Jan 15, 2018

Drug-drug interaction (DDI) alerts in electronic health records (EHRs) can help prevent adverse d... more Drug-drug interaction (DDI) alerts in electronic health records (EHRs) can help prevent adverse drug events, but such alerts are frequently overridden, raising concerns about their clinical usefulness and contribution to alert fatigue. To study the effect of conversion to a commercial EHR on DDI alert and acceptance rates. Two before-and-after studies. 3277 clinicians who received a DDI alert in the outpatient setting. Introduction of a new, commercial EHR and subsequent adjustment of DDI alerting criteria. Alert burden and proportion of alerts accepted. Overall interruptive DDI alert burden increased by a factor of 6 from the legacy EHR to the commercial EHR. The acceptance rate for the most severe alerts fell from 100 to 8.4%, and from 29.3 to 7.5% for medium severity alerts (P < 0.001). After disabling the least severe alerts, total DDI alert burden fell by 50.5%, and acceptance of Tier 1 alerts rose from 9.1 to 12.7% (P < 0.01). Changing from a highly tailored DDI alerting...

Research paper thumbnail of Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders

BMJ Quality & Safety, 2017

ObjectiveMedication voiding is a computerised provider order entry (CPOE)-based discontinuation m... more ObjectiveMedication voiding is a computerised provider order entry (CPOE)-based discontinuation mechanism that allows clinicians to identify erroneous medication orders. We investigated the accuracy of voiding as an indicator of clinician identification and interception of a medication ordering error, and investigated reasons and root contributors for medication ordering errors.MethodUsing voided orders identified with a void alert, we conducted interviews with ordering and voiding clinicians, followed by patient chart reviews. A structured coding framework was used to qualitatively analyse the reasons for medication ordering errors. We also compared clinician-CPOE-selected (at time of voiding), clinician-reported (interview) and chart review-based reasons for voiding.ResultsWe conducted follow-up interviews on 101 voided orders. The positive predictive value (PPV) of voided orders that were medication ordering errors was 93.1% (95% CI 88.1% to 98.1%, n=94). Using chart review-based...

Research paper thumbnail of Methodologies for evaluating strategies to reduce diagnostic error: report from the research summit at the 7th International Diagnostic Error in Medicine Conference

Diagnosis, 2016

In this article we review current evidence on strategies to evaluate diagnostic error solutions, ... more In this article we review current evidence on strategies to evaluate diagnostic error solutions, discuss the methodological challenges that exist in investigating the value of these strategies in patient care, and provide recommendations for methods that can be applied in investigating potential solutions to diagnostic errors. These recommendations were developed iteratively by the authors based upon initial discussions held during the Research Summit of the 7th Annual Diagnostic Error in Medicine Conference in September 2014. The recommendations include the following elements for designing studies of diagnostic research solutions: (1) Select direct and indirect outcomes measures of importance to patients, while also practical for the particular solution; (2) Develop a clearly-stated logic model for the solution to be tested; (3) Use rapid, iterative prototyping in the early phases of solution testing; (4) Use cluster-randomized clinical trials where feasible; (5) Avoid simple pre-p...

Research paper thumbnail of Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors

Expert Opinion on Drug Safety, 2017

Research paper thumbnail of Learning from errors: analysis of medication order voiding in CPOE systems

Journal of the American Medical Informatics Association, 2017

Objective: Medication order voiding allows clinicians to indicate that an existing order was plac... more Objective: Medication order voiding allows clinicians to indicate that an existing order was placed in error. We explored whether the order voiding function could be used to record and study medication ordering errors. Materials and Methods: We examined medication orders from an academic medical center for a 6-year period (2006–2011; n = 5 804 150). We categorized orders based on status (void, not void) and clinician-provided reasons for voiding. We used multivariable logistic regression to investigate the association between order voiding and clinician, patient, and order characteristics. We conducted chart reviews on a random sample of voided orders (n = 198) to investigate the rate of medication ordering errors among voided orders, and the accuracy of clinician-provided reasons for voiding. Results: We found that 0.49% of all orders were voided. Order voiding was associated with clinician type (physician, pharmacist, nurse, student, other) and order type (inpatient, prescription,...

Research paper thumbnail of Incorporating Indications into Medication Ordering--Time to Enter the Age of Reason

The New England journal of medicine, Jan 28, 2016

Research paper thumbnail of Screening for medication errors using an outlier detection system

Journal of the American Medical Informatics Association : JAMIA, Mar 19, 2017

The study objective was to evaluate the accuracy, validity, and clinical usefulness of medication... more The study objective was to evaluate the accuracy, validity, and clinical usefulness of medication error alerts generated by an alerting system using outlier detection screening. Five years of clinical data were extracted from an electronic health record system for 747 985 patients who had at least one visit during 2012-2013 at practices affiliated with 2 academic medical centers. Data were screened using the system to detect outliers suggestive of potential medication errors. A sample of 300 charts was selected for review from the 15 693 alerts generated. A coding system was developed and codes assigned based on chart review to reflect the accuracy, validity, and clinical value of the alerts. Three-quarters of the chart-reviewed alerts generated by the screening system were found to be valid in which potential medication errors were identified. Of these valid alerts, the majority (75.0%) were found to be clinically useful in flagging potential medication errors or issues. A clinical...

Research paper thumbnail of Addressing Ambulatory Safety and Malpractice: The Massachusetts PROMISES Project

Health Services Research, 2016