Ermete: A Decision Support System for an Innovative Management of Knowledge and Prescription in Laboratory Medicine: A Trial of Two Italian Local Health Authorities
American Journal of Clinical and Experimental Medicine
Volume 5, Issue 4, July 2017, Pages: 115-122
Received: Jun. 9, 2017;
Accepted: Jun. 9, 2017;
Published: Jun. 22, 2017
Views 1880 Downloads 58
Alessandro Camerotto, Department of Clinical Pathology, Local Health Authority, Rovigo, Italy
Vincenza Truppo, Department of Clinical Pathology, Local Health Authority, Rovigo, Italy
Alessia Pozzato, Department of Obstetrics and Gynecology, Local Health Authority, Rovigo, Italy
Simone Bedendo, Department of Clinical Pathology, Local Health Authority, Rovigo, Italy
Gabriele Angiolelli, Health and Social Care, Local Health Authority, Mirano, Italy
Arianna Lucchiari, Department of Clinical Pathology, Local Health Authority, Rovigo, Italy
Massimo Tosini, Italian Association of Public Health Sociology, Ferrara, Italy
Alessandra Saggin, SDA- Bocconi School of Management, Milan, Italy
Francesco Noce, General Practice, Local Health Authority, Rovigo, Italy
Stefano Rigo, Department of General Medicine, Local Health Authority, Mirano, Italy
Alessio Gasparetto, Information Technology, Local Health Authority, Rovigo, Italy
Roberto Mencarelli, Department of Clinical Pathology, Local Health Authority, Rovigo, Italy
Laboratory tests play an important role in the diagnostic process. Unfortunately, their utility is at present affected by a significant rate of inappropriate prescriptions. The current strategies to solve the problem are not adequate. The aim of this study is to propose a structural solution through the Health Information Technology. Between the years 2008 and 2010, a methodology to prescribe laboratory tests with the aid of a Decision Support System (DSS), denomened Ermete, has been tested in collaboration with General Practitioners of Local Health Authorities of Rovigo and Mirano. The DSS, during the process of prescription, showed indications of appropriateness in real time and the general practitioner might or might not accept the indication. The number of prescriptions processed with DSS was compared with the number of prescriptions issued by the same physicians, in the same period of the previous year, without the assistance of the DSS. Results showed a decrease of the total number of prescriptions when the DSS was used. The reduction rate was 37.2% in Rovigo and 26.1% in Mirano. The achieved results showed that it is possible to perform the governance of prescriptions without political and administrative actions. The DSS was effective in reducing inappropriateness and in managing knowledge.
Ermete: A Decision Support System for an Innovative Management of Knowledge and Prescription in Laboratory Medicine: A Trial of Two Italian Local Health Authorities, American Journal of Clinical and Experimental Medicine.
Vol. 5, No. 4,
2017, pp. 115-122.
Zimmern RL. Testing challenger: evaluation of novel diagnostics and molecular biomarkers. Clin Med 2009; 9: 68-73.
Lundberg GD. The need for an outcomes research agenda for clinical laboratory testing. JAMA 1998; 280: 565-6.
Forsman RW. Why is the laboratory an afterthought for managed care organization? Clin Chem 1996; 42: 813- 6.
ARSS Regione Veneto. Ricognizione del sistema di produzione di prestazioni di Medicina di Laboratorio e Microbiologia del Servizio Socio Sanitario Veneto. 2007.
Plebani M. Exploring the iceberg of errors in laboratory medicine. Clin Chim Alta 2009; 404: 6-23.
Report of the Second Phase of the Review of NHS Pathology Services in England. Chaired by Lord Carter of Coles. Dec 2008. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_091985 (accessed March 2016).
Fryer AA, Hanna FW. Managing demand for pathology tests: financial imperative of duty of care? Ann Clin Biochem 2009; 46: 435–7.
Janssens PMW. Managing the demand for laboratory testing: Options and opportunities. Clin Chim Acta 2010; 411: 1596–602.
Alonso-Cerezo MC, Martín JS, García Montes MA, et al. Appropriate utilization of clinical laboratory tests. Clin Chem Lab Med 2009;47:1461-5.
National Coalition of Public Pathology. Encouraging Quality Pathology Orderingin Australia’s Public Hospitals—Final Report. Feb 2012. http://www.ncopp.org.au/ UserFiles/file/NCOPP%20QUPP%20Project%20Final%20Report%20(web).pdf (accessed March 2016).
Smellie WSA. Demand management and test request rationalization. Ann Clin Biochem 2012; 49: 323–36.
Hauser RG, Shirts BH. Do we now know what inappropriate laboratory utilization is? An expanded systematic review of laboratory clinical audits. Am J Clin Pathol 2014; 141: 774–783.
Hallworth MJ, Epner PL, Ebert C et al. Current evidence and future perspectives on the effective practice of Patient-Centered Laboratory Medicine. Clin Chem 2015; 61: 589–599.
Miyakis S, Karamanof G, Liontos M, et al. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J 2006; 82: 823–9.
Hampton JR, Harrison MJ, Mitchell JR, et al. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J 1975; 2: 486–9.
Sandler G. Do emergency tests help in the management of acute medical admissions? Br Med J (Clin Res Ed) 1984; 289: 973–7.
Fu C, Ji L, Wang W, et al Frequency of HbA1c monitoring was inversely associated with glycemic control of patients with type 2 diabetes mellitus. J Endocrinol Invest 2012; 35: 269–73.
Driskell OJ, Holland D, Hanna FW, et al. Inappropriate requesting of HbA1c is widespread: Assessment of prevalence, impact of national guidance and practice-to-practice variability. Clin Chem 2012; 58: 906–15.
Sandler G. Costs of unnecessary tests. Br Med J 1979; 2: 21–4.
Zhi M, Ding EL, Theisen-Toupal J et al. The landscape of inappropriate laboratory testing: a 15-year meta-analysis. PLoS ONE 2013; 8: e78962.
Cappelletti P. Praticare l' appropriatezza in Medicina di Laboratorio. Un aggiornamento. Riv Ital Med Lab 2016; 12: 65-69.
van Walraven C., Naylor D. Do we know what inappropriate laboratory utilization is? JAMA 1998; 280: 550- 58.
Castelli-Boada JM, Castells-Oliveres X. Appropriateness of physicians' requests of laboratoty examinations in Primary Health Care: an over- and under- utilization study. Clin Chem Lab Med 1999; 37: 65-9.
Plebani M, Laposata M. Translational research involving new biomarkers of disease: a leading role for pathologists. Am J Clin Pathol 2006; 26: 169-71.
Camerotto A, Natali G, Carmignoto F. Aspartato e Alanina Transaminasi: alcune considerazioni su due esami della met?del XX?secolo: la fisiopatologia, il metodo ed il razionale della richiesta. Biochim Clin 2006; 30: 224-32.
Camerotto A, Di Liddo R, Carmignoto F. Il tempo di risposta all’innovazione: un indicatore di efficacia nell’applicazione delle linee guida, procedure e tecnologie innovative. Riv Ital Med Lab 2006; 2: 206-14.
Lewandrowski K. Managing utilization of new diagnostic tests. Clin Leadersh Manag Rev 2003; 17: 318–24.
Wu AH, Lewandrowski K, Gronowski AM, et al. Antiquated tests within the clinical pathology laboratory. Am J Manag Care 2010; 16: e220–7.
Merk’s Manual of the materia medica. New York: Merk’& Co; 1899.
Camerotto A, Formenton F, Ramazzina E. L’inappropriatezza nella richiesta di test di laboratorio per difetto di conoscenza. Errore individuale o errore di sistema? Biochim Clin 2007; 31: 209-15.
Schutz A. Saggi Sociologici. Torino: UTET; 1979.
Fryer AA, Smellie WSA. Managing demand for laboratory tests: a laboratory toolkit. http://jcp.bmjjournals.com/content/early/2012/09/25/jclinpath-2011-200524.full.(accessed march 2016).
Brice CP. Evidence-based Laboratory Medicine: supporting decision-making. Clin Chem 2000; 46: 1041-50.
van Wijk MA, van der Lei J, Mosseveld M, et al. Assessment of decision support for blood test ordering in primary care. a randomized trial., Ann Intern Med. 2001 Feb 20; 134 (4): 274-81.
Camerotto A, Pozzato A., Truppo V, et al. Il 搒oftware?GOELM come innovativa modalit?di gestione della conoscenza e della prescrizione degli esami di laboratorio: l’esperienza di due Unit?Sociosanitarie Locali. Biochim Clin 2012; 36: 98-106.
Seidling HM, Phansalkar S, Seger DL, et al. Factor influencing alert acceptance: a novel approach for predicting the succees of clinical decision support. J Am Med Inform Assoc 2011. http/www.ncbi.nlm.nih.gov/pmc/articles/PMC3128393/ (accessed march 2016).
Heselmans A, Aertgeerts B, Donceel P, et all, Family Physicians’ Perceptions and Use of Electronic Clinical Decision Support During the First Year of Implementation. J Med Syst, Dec; 36(6): 3677-84.
Main C, Moxham T, Wyatt JC, et al, Computerised decision support systems in order communication for diagnostic, screening or monitoring test ordering: systematic reviews of the effects and cost-effectiveness of systems. Health Technology Assessment 2010; Vol. 14: No. 48.
Ohno-Machabo Lucila. Cost- effectiveness of informatics and health IT: impact on finances and quality of care. J. Am. Med Inform Assoc May 2012 Vol 19 n. 3.
van Wijk MA, van der Lei J, Mosseveld M, et al. Assessment of decision support for blood test ordering in primary care. a randomized trial. Ann Intern Med. 2001 Feb 20; 134(4): 274-81.
Poley MJ, Edelenbos KI, Mosseveld M. Cost Consequences of Implementing an Electronic Decision Support System for Ordering Laboratory Tests in Primary Care: Evidence from a Controlled Prospective Study in The Netherlands. Clinical Chemistry 2007; 53: 2213–9.
Mirvis DM, Chang CF. Managed care, managing uncertainty. Arch Int Med 1997; 157: 385-8.
Camerotto A, De Toni S, Carmignoto F. L'adozione di note di prescrivibilit? per i test di laboratorio pu?essere uno strumento di migliore appropriatezza? Mecosan management ed economia sanitaria (Uni Bocconi, Milano) 2004; 51: 71-76.
Camerotto A, Truppo V, Bedendo S, et al. The named Hermes ICT design of Veneto Region for knowledge management in Laboratory Medicine. Riv Ital Lab Med 2014; 10: 125-35.
Popper KR Conjectures and refutations the growth of scientific knowledge. London: Routledge; 1963.
Bianchi A, Di Giovanni P. Psicologia cognitiva. Milano: Mondatori; 2000.
Piattelli Palmarini M. Illusioni di sapere. Che cosa si nasconde dietro i nostri errori. Milano: Mondatori; 1999.
Bara BG. Scienza cognitiva. Un approccio evolutivo alla simulazione della mente. Torino: Bollati Boringhieri; 1990.
Delvecchio G. Decisione ed errore in medicina. Torino: Centro Scientifico Editore; 2005. Bollati Boringhieri; 1990.
Taleb NN, The Black Swan. The impact of the highly improbable. Completed with the second edition including a long essay "On Robustness and Fragility". New York: Random House and Penguin; 2010.
Gewin V. Surreptitious sleep states uncovered. http://nature.com/news/2011/110427/full/news.2011.259.htlm / (accessed march 2016).
Kasper DL, Braunwald E, Fauci AS, et al. Harrison Principi di Medicina Interna XVI?ed. Milano: McGraw-Hill; 2005.
Lombardo Vallauri E. La linguistica. Bologna: Il Mulino; 2007.
De Toni A, Pomello L. Prede o ragni. Torino: UTET; 2005.
Puccini C. Istituzioni di Medicina Legale. Milano: Casa Editrice Ambrosiana; 1984.
Frati P. Responsabilit?professionale. Guida all’esercizio professionale per i medici chirurghi e gli odontoiatri. Torino: Edizioni Medico Scientifiche; 2000. p. 331-5.
Qaseem A, Forland F, Macbeth F et al. Guidelines International network: verso standard internazionali per la produzione di linee guida. www. Evidence.it Ottobre 2012.
Smellie WSA, Finnigan DI, Wilson D et al. Methodology for constructing guidance. J Clin Pathol 2005; 58: 249-53.
Bottari C, Roversi M. La tutela della salute tra garanzie degli utenti ed esigenze di bilancio. Santarcangelo di Romagna; Maggioli: 2012.
Illich Ivan. Medical Nemesis. London; Calder & Boyars: 1974.