No change in physician dictation patterns when visit notes are made available online for patients.

OBJECTIVE: To determine whether physicians document office visits differently when they know their patients have easy, online access to visit notes. PATIENTS AND METHODS: We conducted a natural experiment with a pre-post design and a nonrandomized control group. The setting was a multispecialty group practice in Minnesota. We reviewed a total of 400 visit notes: 100 each for patients seen in a rheumatology department (intervention group) and a pulmonary medicine department (control group) from July 1 to August 30, 2005, before online access to notes, and 100 each for patients seen in these 2 departments 1 year later, from July 1 to August 30, 2006, when only rheumatology patients had online access to visit notes. We measured changes in visit note content related to 9 hypotheses for increased patient understanding and 5 for decreased frank or judgmental language. RESULTS: Changes occurred for 2 of the 9 hypotheses related to patient understanding, both in an unpredicted direction. The proportion of acronyms or abbreviations increased more in the notes of rheumatologists than of pulmonologists (0.6% vs 0.1%; P=.01), whereas the proportion of anatomy understood decreased more in the notes of rheumatologists than of pulmonologists (-5.9% vs -0.8%; P=.02). One change (of 5 possible) occurred related to the use of frank or judgmental terms. Mentions of mental health status decreased in rheumatology notes and increased in pulmonology notes (-8% vs 7%; P=.02). CONCLUSION: Dictation patterns appear relatively stable over time with or without online patient access to visit notes.

Smoking-related attitudes and clinical practices of medical personnel in Minnesota.

CONTEXT: Effective clinic-based, smoking-cessation activities are not widely implemented. OBJECTIVE: To compare and contrast the smoking-cessation attitudes and clinical practices of five types of primary healthcare team members. DESIGN AND SETTING: From July to October 2002, a cross-sectional survey was mailed to randomly selected primary care physicians (MDs), advanced practice nurses (APRNs), registered nurses (RNs), licensed practical nurses (LPNs), and medical assistants (MAs). MAIN OUTCOME MEASURES: Factors associated with limited smoking-cessation service delivery. RESULTS: The overall response rate was 68% (n =3021). Most respondents reported that patients' smoking status was consistently documented at their clinic (79%); other system prompts were less common (30%). Many respondents reported documenting smoking status or recommending quitting; few reported consistently assessing, assisting, or arranging follow-up. The mean rank of smoking cessation as an important preventive service among nine preventive services declined from MDs (1.9) to APRNs (2.5), RNs (3.4), LPNs (4.2), and MAs (4.6). Smoking prevalence increased from 1% in MDs to 3% APRNs, 9% RNs, 17% LPNs, and 22% MAs. Those who reported no consistent smoking-cessation service delivery were more likely to be RNs, LPNs, or MAs, currently smoke, and work more hours. They were less likely to consider patients receptive to cessation messages, to consider themselves qualified to counsel on smoking, or to work in clinics that had smoking-cessation guidelines or system prompts such as chart reminders. CONCLUSIONS: Smoking-cessation service delivery may be enhanced if educational offerings, system changes, and training include all clinical staff members.

Early experience with employee choice of consumer-directed health plans and satisfaction with enrollment.

OBJECTIVE: To assess the initial impact of offering consumer-defined health plan (CDHP) options on employees. DATA SOURCES/STUDY SETTING: A mail survey of 4,680 employees in the corporate offices of Humana Inc. in June 2001. STUDY DESIGN: The study was a cross-sectional mail survey of employees aged 18 and older who were eligible for health care benefits. The survey was conducted following open enrollment. The primary outcome is the choice of consumer-directed health plan or not; the secondary outcome is satisfaction with the enrollment process. Important covariates include sociodemographic characteristics (age, gender, race, educational level, exempt or nonexempt status, type of coverage), health status, health care utilization, and plan design preferences. DATA COLLECTION METHODS: A six-page questionnaire was mailed to the home of each employee, followed by a reminder postcard and two subsequent mailings to nonrespondents. PRINCIPAL FINDINGS: The response rate was 66.2 percent. Seven percent selected one of the two new plan options. Because there were no meaningful differences between employees choosing either of the two new options, these groups were combined in multivariate analysis. A logistic regression modeled the likelihood of choosing the novel plan options. Those selecting the new plans were less likely to be black (odds ratio [OR] 0.46), less likely to have only Humana coverage (OR 0.30), and more likely to have single coverage (OR 1.77). They were less likely to have a chronic health problem (OR 0.56) and more likely to have had no recent medical visits (OR 3.21). They were more likely to believe that lowest premiums were the most important plan attribute (OR 2.89) and to think there were big differences in the premiums of available plans (OR 5.19). Employees in fair or poor health were more likely to have a difficult time during the online enrollment process. They were more likely to find the communications very helpful (OR 0.42) and the benefits information very understandable (OR 0.38). They were less likely to feel that they had enough time to make their enrollment decision (OR 0.47). CONCLUSIONS: Employees who were attracted to the new CDHP plan options valued the attributes that distinguished these plans from other choices. The shift to consumer-defined plans and to the electronic provision of information, however, requires a significant increase in the communication support for all employees, but particularly for those in fair or poor health whose information needs are the most complex and individualized.

Patients' interest in reading their medical record: relation with clinical and sociodemographic characteristics and patients' approach to health care.

BACKGROUND: Although opportunities for patients to review their medical records are increasing, nothing is known about which patients want to take advantage of those opportunities. The objective of this study was to determine the proportion and characteristics of patients who are very interested in examining their clinic medical record and the reasons for their interest. METHODS: Cross-sectional, mailed survey (conducted in May 2001) to a random sample of 4500 adults who had a recent clinic visit. RESULTS: The response rate was 81%; 36% were very interested in reading their medical record (dependent variable). In multivariate logistic regression, the significantly related factors were seeking health information (finding the Internet very important for health information [adjusted odds ratio, 2.09], having a health newsletter subscription [adjusted odds ratio, 1.23], and using a health resource book in last month [adjusted odds ratio, 1.36]); being very concerned about errors in care (adjusted odds ratio, 2.52); and lacking trust in their physician (adjusted odds ratio, 1.55). Health status, use of health care, education, and income were not independently related to patients' interest. The most common reasons for patients wanting to look at their medical record were to see what their physician said about them (74%), to be more involved in their health care (74%), and to understand their condition better (72%). CONCLUSIONS: Patients' interest in reading their medical record is better predicted by their consumer approach to health care than it is by their clinical characteristics. Demographic characteristics of sex and race were related, while socioeconomic factors of education and income were not.

Which enrollees bypass their gatekeepers in a point-of-service plan?

BACKGROUND AND OBJECTIVES: Like Health Maintenance Organizations, point-of-service (POS) health plans use primary care gatekeepers, and they permit self-referral to specialists at increased costs to the enrollee. The main objective of this study was to contrast patients who self-referred with those referred by their primary care physician. RESEARCH DESIGN: We conducted a cross-sectional telephone survey of 606 recent users of specialists in a large Midwestern POS health plan; response rate was 65%. We compared 148 enrollees who self-referred with 458 who had a physician referral. RESULTS: Self-referral was most common among those with a long-term relationship with a specialist (odds ratio [OR] = 2.08) and those dissatisfied with their primary care physician (OR = 3.65), and was rare among those with a long-standing relationship with a primary care physician (OR = 0.46). Most self-referred enrollees (68%) thought paying the additional cost for self-referral was worthwhile, and they were more dissatisfied with the quality and variety of the plan's specialist network. CONCLUSIONS: Continuity with a single physician influences how patients access specialty care. Expanding the panel of specialists in-network and encouraging long-term relationships with primary care physicians are likely to limit self-referral in a POS plan.

Consumer response to a report card comparing healthcare systems.

OBJECTIVE: Report cards to date have focused on quality of care in health plans rather than within healthcare delivery systems. The purpose of this study was to evaluate consumer response to the first healthcare system-level report card. STUDY DESIGN: Qualitative assessment of consumer response. METHODS: We conducted 5 focus groups of community members to evaluate consumer response to the report card; 2 included community club members, 3 included community-dwelling retired persons. Discussions were audiotaped and transcribed; comments were categorized by topic area from the script, and common themes identified. RESULTS: Focus group participants, in general, were unaware of the current emphasis on medical quality improvement initiatives. However, they believed that the opinion that the descriptive clinic information and patient survey data contained in the report card would be most useful mainly for choosing a healthcare system if they were dissatisfied with current medical care, if their healthcare options changed, or if they were in poor health. Personal experience was considered a more trustworthy measure of healthcare quality than were patient survey results. Trustworthiness was perceived to be higher if the report card sponsor was not affiliated with the healthcare systems being evaluated. Participants also believed care system administrators should use the data to enact positive clinic-level and physician-level changes. CONCLUSIONS: Healthcare consumers appreciated the attention to patient experiences and supported healthcare quality improvement initiatives. Report cards were considered important for choosing a healthcare system in certain circumstances and for guiding quality improvement efforts at all levels.

Quality of life after postmastectomy breast reconstruction.

PURPOSE/OBJECTIVES: To explore women's expectations about postmastectomy reconstruction and factors affecting their quality of life after reconstruction. DESIGN: Qualitative focus group study. SETTING: Integrated healthcare system in a midwestern suburban community. SAMPLE: 17 women who had undergone mastectomies with immediate reconstruction between 1.4 and 5 years previously and had participated in a study of women newly diagnosed with breast cancer. METHODS: An experienced focus group moderator conducted two focus group sessions. Comments from the sessions were audiotaped and transcribed verbatim. The sessions involved semistructured, open-ended questions about perceptions of preparation, experience, and satisfaction regarding postmastectomy reconstruction. Thematic content analysis began with open coding at the level of individual comments and proceeded through two levels of higher-order categorization. FINDINGS: Although women felt well informed about breast surgery, they wished they had been more informed about some issues. Ratings of satisfaction generally were high despite some concerns about cosmetic outcome and persistent anxiety about recurrence. CONCLUSIONS: Reconstruction allows women to feel comfortable in clothing, but recovery can be difficult, and reconstruction does not neutralize the biggest emotional challenge of breast cancer: fear of recurrence. IMPLICATIONS FOR PRACTICE: Women appreciate thorough information to prepare them for reconstruction and recovery. For aspects of recovery in which substantial variation exists, the range of experiences should be provided.