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Objective: Investigate the accuracy of 2 different medication reconciliation tools integrated into electronic health record systems (EHRs) using a cognitively demanding scenario and complex medication history., Materials and Methods: Seventeen physicians reconciled medication lists for a polypharmacy patient using 2 EHRs in a simulation study. The lists contained 3 types of discrepancy and were transmitted between the systems via a Continuity of Care Document. Participants updated each EHR and their interactions were recorded and analyzed for the number and type of errors., Results: Participants made 748 drug comparisons that resulted in 53 errors (93% accuracy): 12 using EHR2 (3% rate, 0-3 range) and 41 using EHR1 (11% rate, 0-9 range; P < .0001). Twelve clinicians made completely accurate reconciliations with EHR2 (71%) and 6 with EHR1 (35%). Most errors (28, 53%) occurred in medication entries containing discrepancies: 4 in EHR2 and 24 in EHR1 (P = .008). The order in which participants used the EHRs to complete the task did not affect the results., Discussion: Significantly fewer errors were made with EHR2, which presented lists in a side-by-side view, automatically grouped medications by therapeutic class and more effectively identified duplicates. Participants favored this design and indicated that they routinely used several workarounds in EHR1., Conclusion: Accurate assessment of the safety and effectiveness of electronic reconciliation tools requires rigorous testing and should prioritize complex rather than simpler tasks that are currently used for EHR certification and product demonstration. Higher accuracy of reconciliation is likely when tools are designed to better support cognitively demanding tasks.

This study describes a simulation of diagnostic coding using an EHR. Twenty-three ambulatory clinicians were asked to enter appropriate codes for six standardized scenarios with two different EHRs. Their interactions with the query interface were analyzed for patterns and variations in search strategies and the resulting sets of entered codes for accuracy and completeness. Just over a half of entered codes were appropriate for a given scenario and about a quarter were omitted. Crohn's disease and diabetes scenarios had the highest rate of inappropriate coding and code variation. The omission rate was higher for secondary than for primary visit diagnoses. Codes for immunization, dialysis dependence and nicotine dependence were the most often omitted. We also found a high rate of variation in the search terms used to query the EHR for the same diagnoses. Changes to the training of clinicians and improved design of EHR query modules may lower the rate of inappropriate and omitted codes.

Purpose: To determine the outcome of pulmonary nodules less than 1 cm in diameter detected at chest computed tomography (CT)., Materials and Methods: Reports of chest CT performed during 6 months were reviewed to find patients with pulmonary nodules smaller than 1 cm in long axis for which repeat CT was recommended. Records were studied to determine whether follow-up had been performed, the initial nodules had changed in size, or nodules had been resected., Results: A total of 3,446 chest CT examinations were performed, with 334 patients meeting inclusion criteria. Three patients underwent nodule resection and had pathologic examination results positive for cancer; 185 underwent follow-up, of whom 13 had results excluded as indeterminate. In the remaining 172 patients, 88 had incomplete characterization because of follow-up of less than 2 years, which left 84 with nodule characterization at follow-up. When these 84 patients were combined with the three patients with nodule resection, the number yielded was 87 patients. Seventy-seven of 87 had benign nodules because of resolution or 2-year stability, and 10 of 87 had malignant nodules because of growth or positive histologic examination results. Nine of 10 with malignant nodules had a known primary neoplasm., Conclusion: CT commonly helped identify small nodules. Increase in size occurred infrequently and almost exclusively in patients with a known malignancy.

Purpose: To study factors that may influence pneumothorax and chest tube placement rate, especially needle dwell time and pleural puncture angle., Materials and Methods: In 159 patients, 160 coaxial computed tomography (CT)-guided lung biopsies were performed. Dwell time, the time between pleural puncture and needle removal, was calculated. The smallest angle of the needle with the pleura ("needle-pleural angle") was measured. These and other variables were correlated with pneumothorax and chest tube rates., Results: One hundred fifty biopsies were included. There were 58 (39%) pneumothoraces (14 noted only at CT), with eight (5%) biopsies resulting in chest tube placement. Longer dwell times (mean, 29 minutes; range, 12-66 minutes) did not correlate with pneumothoraces (P =.81). Smaller needle-pleural angles (< 80 degrees) [corrected], decreased forced expiratory volume in 1 second to vital capacity ratio (<50%), lateral pleural puncture, and lesions along fissures were associated with higher [corrected] pneumothorax rates (P <.05). Emphysema along the needle path, pulmonary function tests showing ventilatory obstruction, and lesions along fissures predisposed patients to chest tube placement (P <.05). Pleural thickening and prior surgery were associated with lower pneumothorax rates (P <.05)., Conclusion: Longer dwell times do not correlate with pneumothorax and should not influence the decision to obtain more biopsy samples. A shallow pleural puncture angle may increase the pneumothorax rate.

Purpose: The purpose of our study was to evaluate CT findings during respiratory syncytial virus (RSV) infection in lung transplant recipients and to identify sequelae., Method: Thirty-nine CT scans prior to, during, and following acute infection in 10 lung transplant recipients were reviewed. Abnormalities that were new from baseline observations and occurred within 4 weeks of diagnosis were defined as acute. Chronic findings were defined as those present >4 weeks after diagnosis., Results: Findings in nine patients were ground-glass (seven), air-space (five), and tree-in-bud (four) opacities and acute bronchial dilatation (four) and wall thickening (four). Patients lacked pleural effusions or lymph node enlargement. Five of seven patients with follow-up exams had new air trapping (three), persistent bronchial dilatation (three), and thickening (two). Three and 2 of the 10 patients developed bronchiolitis obliterans syndrome and obliterative bronchiolitis, respectively., Conclusion: During acute infection, patients commonly had ground-glass opacities but lacked pleural effusions and lymph node enlargement. There can be chronic sequelae after infection.

Purpose: To determine the sensitivity and specificity of helical computed tomography (CT) for the diagnosis of acute pulmonary embolism., Materials and Methods: This prospective study included 47 patients who underwent pulmonary arteriography for evaluation for possible acute pulmonary embolism. Tailored helical CT and pulmonary arteriography were performed within 24 hours of each other. Each CT scan was interpreted by two chest radiologists, blinded to arteriographic results, at two institutions. CT scan interpretations were compared with findings on bilateral selective pulmonary arteriograms interpreted by two vascular radiologists at one institution., Results: Fifteen (32%) of 47 patients had angiographically proved pulmonary embolism. For the readers at the first institution, helical CT had 60% sensitivity, 81% specificity, 60% positive predictive value, 81% negative predictive value, and 75% overall accuracy. For the readers at the second institution, helical CT had 53% sensitivity, 97% specificity, 89% positive predictive value, 82% negative predictive value, and 83% accuracy., Conclusion: Detection of pulmonary embolism with helical CT may be less accurate than previously reported. Given its high specificity but relatively low sensitivity, helical CT may not have the ideal attributes of a first-line imaging study for the diagnosis of pulmonary embolism.

Purpose: To study the tolerance of peripherally inserted central catheters (PICCs) of varying sizes and materials to power injection of radiographic contrast agents., Materials and Methods: Eight different models of silicone and five different models of polyurethane single-lumen PICCs were injected with increasing rates of iothalamate 60% with use of a power injector. Tolerated and bursting rates and pressures were recorded., Results: There was a wide range of tolerated rates and pressures, depending on the inner and outer diameters of the catheters and on the catheter material. Silicone PICCs tolerated rates between 0.4 and 7.0 mL/sec and polyurethane PICCs tolerated rates between 0.6 and 10.2 mL/sec, depending on the specific catheter. The 5-F silicone PICCs and the 4-F and 5-F polyurethane PICCs tested all tolerated rates greater than 4 mL/sec. Silicone catheters tolerated pressures between 107 and 184 psi, and polyurethane catheters tolerated pressures between 160 and 314 psi., Conclusions: Larger single-lumen silicone and polyurethane PICCs may be suitable for power injection of contrast agents.

Objective: The purpose of this study was to determine the frequency of system malfunction in patients with nonthoracotomy implantable cardioverter defibrillators and to assess the role of chest radiography in detecting and determining the cause of malfunction., Materials and Methods: The study population consisted of 300 consecutive patients in whom implantable cardioverter defibrillators were implanted using an initial nonthoracotomy approach between September 1990 and October 1994. Transvenous electrodes were placed via the subclavian or cephalic vein under local anesthetic. Intraoperative testing, pulse generator implantation, and, if necessary, subcutaneous patch or extrapericardial patch placement via thoracotomy were done in the operating room under general anesthetic. Follow-up consisted of routine device interrogation every 2-3 months and annual chest radiography. Chest radiographs were obtained more often if patients were symptomatic or if results of device interrogation were abnormal., Results: Patients were followed up for a mean +/- SD of 19 +/- 14 months following implantation. Implantable cardioverter-defibrillator malfunction occurred in 17 patients (6%) during the follow-up period. Of these, 12 (71%) had component abnormalities on chest radiographs. Patients with radiographically apparent implantable cardioverter-defibrillator abnormalities presented in two discrete time periods after device implantation, early (mean, 35 +/- 14 days) and late (mean, 18 +/- 5 months)., Conclusion: Malfunction of nonthoracotomy implantable cardioverter-defibrillator systems develops infrequently after device implantation. In most cases, the cause can be identified on chest radiographs.