Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission.

Methods for categorizing the scale and severity of medication errors corrected by pharmacy staff during admission medication reconciliation using complete medication history continue to evolve. We established a rating scale that is effective for generating error reports to health system quality leadership. These reports are needed to quantify the value of investment in transitions-of-care pharmacy staff. All medication errors that were reported by pharmacy staff in the admission medication reconciliation process during a period of 6 months were eligible for inclusion. Complete medication history data source was utilized by admitting providers and all pharmacist staff and a novel medication error scoring methodology was developed. This methodology included: medication error category, medication error type, potential medication error severity, and medication non-adherence. We determined that 82 medication errors were detected from 72 patients and assessed that 74 of these errors may have harmed patients if they were not corrected through pharmacist intervention. Most of these errors were dosage discrepancies and omissions. With hospital system budgets continually becoming leaner, it is important to measure the effectiveness and value of staff resources to optimize patient care. Pharmacists performing admission medication reconciliation can detect subtle medication discrepancies that may be overlooked by other clinician types. This methodology can serve as a foundation for error reporting and predicting the severity of adverse drug events.

Impact of a mobile integrated healthcare and community paramedicine program on improving medication adherence in patients with heart failure and chronic obstructive pulmonary disease after hospital discharge: A pilot study.

Background: The mobile integrated health-community paramedicine (MIH-CP) program affiliated with the University of Maryland Medical Center focuses on improving patient transitions from hospital to home by addressing both medical and social determinants of health. Until recently, only self-contained health systems could integrate inpatient and outpatient medication data. Without some means to track patients in transition, there is a significant risk of medication-related problems and errors. Objective: To evaluate the impact of the MIH-CP program on medication adherence among patients with congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD). Methods: This is a pilot observational study designed to compare adherence to drug regimens prescribed at hospital discharge (measured by the proportion of days covered [PDC]) between patients enrolled in the MIH-CP program and a propensity-matched control group. Propensity scores were calculated using 11 demographic, diagnostic, third-party payer, and patient care-associated variables. Discharge medication details were obtained from electronic medical records. PDC for each of the medications were calculated from pharmacy claims data. Results: Eighty-three patients were included in the study; forty-three patients were placed in the intervention group and 40 were propensity-matched controls. After adjusting for age, sex, and third-party payer, findings indicated that medication adherence was higher among patients enrolled in the MIH-CP program compared with control during the first 30 days post-discharge, specifically among patients diagnosed with CHF (8% difference in PDC, 95% confidence interval [CI], -0.12-0.28%) and COPD (14% difference, 95% CI, -0.15-0.43%), although neither result achieved statistical significance. The differences in medication adherence between patients who were enrolled and those who were not enrolled in the MIH-CP program diminished after 30 days post-discharge. Conclusion: This pilot study demonstrated a trend toward improved medication adherence among patients enrolled in the MIH-CP program. Future research involving a larger patient cohort will be required to confirm these preliminary findings.

Automating Vancomycin Monitoring to Improve Patient Safety.

INTRODUCTION: Intravenous vancomycin is a frequently used antibiotic and a common cause of medication-related harm because of its narrow therapeutic range. Improving monitoring of drug levels with automation in the electronic health record (EHR) may decrease this harm. METHODS: After examining the existing state of vancomycin ordering, administration, and monitoring, an automated process was created in the EHR that, on initiation of a new vancomycin order, automatically ordered a vancomycin trough level 30 minutes before the fourth dose. In addition, a nursing alert was integrated into the bar coding medication administration process that, if no trough level had been drawn by the time of the administration of the fourth dose, prompted the nurse to draw a trough level. Data from a three-month, post-implementation period was compared to data from a preceding three-month period. RESULTS: The frequency of trough levels drawn between the third and fourth dose increased from 58.6% to 75.8% (p < 0.01). However, the percentage of trough levels drawn within one hour of the fourth dose remained unchanged, possibly because nursing staff waited for the result of the level prior to administering the next dose of vancomycin. A minority of patients in both groups had trough levels that were in range (difference between groups, p = 0.46). CONCLUSION: Automation of vancomycin monitoring was associated with improvement in the frequency of monitoring and only delayed medication dosing by six minutes. Because vancomycin is high risk, this type of process should be broadly implemented, and outcomes should be assessed to identify unexpected outcomes and necessary further refinements.

Measuring electronic communication networks in virtual care teams using electronic health records access-log data.

OBJECTIVE: To develop methods for measuring electronic communication networks in virtual care teams using electronic health records (EHR) access-log data. METHODS: For a convenient sample of 100 surgical colorectal cancer patients, we used time-stamped EHR access-log data extracted from an academic medical center's EHR system to construct communication networks among healthcare professionals (HCPs) in each patient's virtual care team. We measured communication linkages between HCPs using the inverse of the average time between access events in which the source HCPs sent information to and the destination HCPs retrieved information from the EHR system. Social network analysis was used to examine and visualize communication network structures, identify principal care teams, and detect meaningful structural differences across networks. We conducted a non-parametric multivariate analysis of variance (MANOVA) to test the association between care teams' communication network structures and patients' cancer stage and site. RESULTS: The 100 communication networks showed substantial variations in size and structures. Principal care teams, the subset of HCPs who formed the core of the communication networks, had higher proportions of nurses, physicians, and pharmacists and a lower proportion of laboratory medical technologists than the overall networks. The distributions of conditional uniform graph quantiles suggested that our network-construction technique captured meaningful underlying structures that were different from random unstructured networks. MANOVA results found that the networks' topologies were associated with patients' cancer stage and site. CONCLUSIONS: This study demonstrates that it is feasible to use EHR access-log data to measure and examine communication networks in virtual care teams. The proposed methods captured salient communication patterns in care teams that were associated with patients' clinical differences.

Qualitative and Quantitative Analysis of Patients' Perceptions of the Patient Portal Experience with OpenNotes.

BACKGROUND: Access to medical encounter notes (OpenNotes) is believed to empower patients and improve the quality and safety of care. The impact of such access is not well understood beyond select health care systems and notes from primary care providers. OBJECTIVES: This article analyzes patients' perceptions about the patient portal experience with access to primary care and specialist's notes and evaluates free-text comments as an improvement opportunity. MATERIALS AND METHODS: Patients at an academic health care system who accessed the patient portal from February 2016 to May 2016 were provided a link to complete a 15-item online survey. Those who had viewed at least one note were asked about patient characteristics, frequency of note access, note usefulness, note understanding, and if any action was taken after accessing the note. Free-text comments were associated with nine questions which were analyzed using qualitative methods. RESULTS: A total of 23% (1,487/6,439) of patients who viewed the survey in the portal, participated. Seventy-six percent (1,126/1,487) knew that the notes were available on the portal, and of those, 957 had viewed at least one note to continue the survey. Ninety percent of those were older than 30 years of age, and 90% had some college education. The majority (83%) thought OpenNotes helped them take better care of themselves, without increasing worry (94%) or contacting the physician after reading the note (91%). The qualitative analysis of free-text responses demonstrated multiple positive and negative themes, and they were analyzed for potential improvement opportunities. CONCLUSION: Our survey confirms that patients who choose to access their primary care and specialists' online medical records perceive benefits of OpenNotes. Additionally, the qualitative analysis of comments revealed positive benefits and several potential patient portal improvement opportunities which could inform implementation of OpenNotes at other health systems.

Adherence to recommended electronic health record safety practices across eight health care organizations.

Objective: The Safety Assurance Factors for EHR Resilience (SAFER) guides were released in 2014 to help health systems conduct proactive risk assessment of electronic health record (EHR)- safety related policies, processes, procedures, and configurations. The extent to which SAFER recommendations are followed is unknown. Methods: We conducted risk assessments of 8 organizations of varying size, complexity, EHR, and EHR adoption maturity. Each organization self-assessed adherence to all 140 unique SAFER recommendations contained within 9 guides (range 10-29 recommendations per guide). In each guide, recommendations were organized into 3 broad domains: "safe health IT" (total 45 recommendations); "using health IT safely" (total 80 recommendations); and "monitoring health IT" (total 15 recommendations). Results: The 8 sites fully implemented 25 of 140 (18%) SAFER recommendations. Mean number of "fully implemented" recommendations per guide ranged from 94% (System Interfaces-18 recommendations) to 63% (Clinical Communication-12 recommendations). Adherence was higher for "safe health IT" domain (82.1%) vs "using health IT safely" (72.5%) and "monitoring health IT" (67.3%). Conclusions: Despite availability of recommendations on how to improve use of EHRs, most recommendations were not fully implemented. New national policy initiatives are needed to stimulate implementation of these best practices.

Provider and Patient Perceptions of an External Medication History Function.

OBJECTIVES: To determine the awareness and use of an external medication history (EMH) function within an electronic health record and its impact on patient perception of medication adherence. METHODS: Two self-administered surveys were given: one to providers and one to patients. Participants included providers from an academic medical center and patients from 2 general internal medicine clinics. RESULTS: Of 154 completed provider surveys, 61% were aware the EMH existed. More of the respondents aware of the EMH were primary care and medicine subspecialty providers (79.1%) when compared with surgical providers (20.9%, P < 0.0001). The most common reasons chosen for looking at the EMH included checking for medication adherence (44%), questions about a specific medication (40%), and checking controlled substance prescription history (37%). Of those aware of the EMH, 65% found medications on the EMH that they were not aware their patient was getting filled. Of the 94 patient surveys, 34% felt the EMH feature might change their medication taking behavior, and 48% responded that it already had. Patients with a history of depression and/or anxiety were less likely to report the intent to change their medication taking behavior, OR, 0.34 [95% CI, 0.13-0.87]. CONCLUSION: An external medication history function can provide further insight about a patient's medication profile and prescription filling. Knowledge attained from the EMH may improve patient safety by helping to uncover nonadherence, dosing discrepancies, and medications prescribed by other providers. Additionally, patient knowledge of this feature might improve medication adherence. Although further studies are needed to obtain objective data, the external medication history function may have significant impact on both providers and patients, and its benefit should be widely publicized.

Correlation of venous thromboembolism prophylaxis and electronic medical record alerts with incidence among surgical patients.

BACKGROUND: Venous thromboembolism events are potentially preventable adverse events. We investigated the effect of interruptions and delays in pharmacologic prophylaxis on venous thromboembolism incidence. Additionally, we evaluated the utility of electronic medical record alerts for venous thromboembolism prophylaxis. METHODS: Venous thromboembolisms were identified in surgical patients retrospectively through Core Measure Venous ThromboEmbolism-6-6 and Patient Safety Indicator 12 between November 2013 and March 2015. Venous thromboembolism pharmacologic prophylaxis and prescriber response to electronic medical record alerts were recorded prospectively. Prophylaxis was categorized as continuous, delayed, interrupted, other, and none. RESULTS: Among 10,318 surgical admissions, there were 131 venous thromboembolisms; 23.7% of the venous thromboembolisms occurred with optimal continuous prophylaxis. Prophylaxis, length of stay, age, and transfer from another hospital were associated with increased venous thromboembolism incidence. Compared with continuous prophylaxis, interruptions were associated with 3 times greater odds of venous thromboembolism. Delays were associated with 2 times greater odds of venous thromboembolism. Electronic medical record alerts occurred in 45.7% of the encounters and were associated with a 2-fold increased venous thromboembolism incidence. Focus groups revealed procedures as the main contributor to interruptions, and workflow disruption as the main limitation of the electronic medical record alerts. CONCLUSION: Multidisciplinary strategies to decrease delays and interruptions in venous thromboembolism prophylaxis and optimization of electronic medical record tools for prophylaxis may help decrease rates of preventable venous thromboembolism.

Phased implementation of electronic health records through an office of clinical transformation.

Evidence suggests that when carefully implemented, health information technologies (HIT) have a positive impact on behavior, as well as operational, process, and clinical outcomes. Recent economic stimulus initiatives have prompted unprecedented federal investment in HIT. Despite strong interest from the healthcare delivery community to achieve 'meaningful use' of HIT within a relatively short time frame, few best-practice implementation methodologies have been described. Herein we outline HIT implementation strategies at an academic health center with an office of clinical transformation. Seven percent of the medical center's information technology budget was dedicated to the Office of Clinical Transformation, and successful conversion of 1491 physicians to electronic-based documentation was accomplished. This paper outlines the process re-design, end-user adoption, and practice transformation strategies that resulted in a 99.7% adoption rate within 6 months of the introduction of digital documentation.

Similarities and differences in outcomes of cirrhosis due to nonalcoholic steatohepatitis and hepatitis C.

The objective of this study was to prospectively define outcomes of cirrhosis due to nonalcoholic steatohepatitis (NASH) and compare them with those associated with hepatitis C virus (HCV) infection. We compared 152 patients with cirrhosis due to NASH with 150 matched patients with cirrhosis due to HCV. Over 10 years, 29/152 patients with cirrhosis due to NASH died compared with 44/150 patients with HCV (P < .04). This was mainly due to the lower mortality rate in patients with Child class A cirrhosis due to NASH versus HCV (3/74 vs. 15/75; P < .004). There were no significant across-group differences in mortality in patients with Child class B or C cirrhosis. Sepsis was the most common cause of death in both groups; patients with NASH had a higher cardiac mortality (8/152 vs. 1/150; P < .03). Patients with Child class A cirrhosis due to NASH also had a significantly lower risk of decompensation, defined by a 2-point increase in Child-Turcotte-Pugh score (P < .007). Cirrhosis due to NASH was associated with a lower rate of development of ascites (14/101 vs. 40/97 patients at risk; P < .006). NASH also had a significantly lower risk of development of hepatocellular carcinoma (10/149 vs. 25/147 patients at risk; P < .01). In conclusion, compensated cirrhosis due to NASH is associated with a lower mortality rate compared with that due to HCV. It is also associated with a lower rate of development of ascites, hyperbilirubinemia, and hepatocellular carcinoma. However, cardiovascular mortality is greater in patients with NASH.