Implementing electronic health records (EHRs): health care provider perceptions before and after transition from a local basic EHR to a commercial comprehensive EHR.

Objective: We assessed changes in the percentage of providers with positive perceptions of electronic health record (EHR) benefit before and after transition from a local basic to a commercial comprehensive EHR. Methods: Changes in the percentage of providers with positive perceptions of EHR benefit were captured via a survey of academic health care providers before (baseline) and at 6-12 months (short term) and 12-24 months (long term) after the transition. We analyzed 32 items for the overall group and by practice setting, provider age, and specialty using separate multivariable-adjusted random effects logistic regression models. Results: A total of 223 providers completed all 3 surveys (30% response rate): 85.6% had outpatient practices, 56.5% were >45 years old, and 23.8% were primary care providers. The percentage of providers with positive perceptions significantly increased from baseline to long-term follow-up for patient communication, hospital transitions - access to clinical information, preventive care delivery, preventive care prompt, preventive lab prompt, satisfaction with system reliability, and sharing medical information (P < .05 for each). The percentage of providers with positive perceptions significantly decreased over time for overall satisfaction, productivity, better patient care, clinical decision quality, easy access to patient information, monitoring patients, more time for patients, coordination of care, computer access, adequate resources, and satisfaction with ease of use (P < 0.05 for each). Results varied by subgroup. Conclusion: After a transition to a commercial comprehensive EHR, items with significant increases and significant decreases in the percentage of providers with positive perceptions of EHR benefit were identified, overall and by subgroup.

Diabetes care and its association with glycosylated hemoglobin level.

BACKGROUND: This article examines the associations between patients' source of most help with diabetes care and their glycosylated hemoglobin (A1C) levels. The extent to which differences in A1C by source of most help could be explained by perceived levels of total social support, sociodemographics, and medication adherence were also assessed. METHODS: A cross-sectional study of 205 adults with type 2 diabetes mellitus who completed a clinic survey that included questions about perceived social support, who provides the most support with their diabetes care, and medication adherence. The most recent A1C was abstracted from medical records. RESULTS: The mean (standard deviation) age of participants was 61 (12.3) years, 43.9% were male, 37.1% African American. After adjustment for age, sex, race, marital status, education, diabetes duration, and medication adherence, the means (95% confidence intervals) A1C by source of most help were 9.4 (8.4-10.4) for nonspouse family or friend, 8.2 (7.3-9.1) for health care worker, 8.2 (7.2-9.1) for self-reliant, and 8.1 (7.1-9.0) for spouse. A1C was significantly higher for nonspouse family or friend compared with all other groups (P < 0.01 for each comparison). Differences in A1C by source of most help could not be explained by differences in total social support or medication adherence. CONCLUSIONS: Patients reporting a nonspouse family member or friend as their source of most help with their diabetes management had worse glycemic control than patients reporting all other sources of help.

Primary palliative care for the general internist: integrating goals of care discussions into the outpatient setting.

BACKGROUND: Primary palliative care consists of the palliative care competencies required of all primary care clinicians. Included in these competencies is the ability to assist patients and their families in establishing appropriate goals of care. Goals of care help patients and their families understand the patient's illness and its trajectory and facilitate medical care decisions consistent with the patient's values and goals. General internists and family medicine physicians in primary care are central to getting patients to articulate their goals of care and to have these documented in the medical record. CASE REPORT: Here we present the case of a 71-year-old male patient with chronic obstructive pulmonary disorder, congestive heart failure, and newly diagnosed Alzheimer dementia to model pertinent end-of-life care communication and discuss practical tips on how to incorporate it into practice. CONCLUSION: General internists and family medicine practitioners in primary care are central to eliciting patients' goals of care and achieving optimal end-of-life outcomes for their patients.