Medication prescribing and monitoring errors in primary care: a report from the Practice Partner Research Network.

INTRODUCTION: Medication errors have been associated with poor patient outcomes and pose significant public health consequences. Establishing medication safety quality indicators is crucial to capturing the pervasiveness of preventable errors and is a fundamental first step in the process of improvement. In this article, a study is presented in which a set of medication prescribing and monitoring quality indicators were developed, and adherence to them was assessed among a group of US primary care practices. METHODS: Twenty Practice Partner Research Network practices in 14 US states with 94 clinicians and 52,246 active adult patients participated in the study. All practices use a common electronic medical record with dosing, interaction and monitoring decision support features. A consensus development process was used to select indicators in the categories of inappropriate treatment, dosing, drug-drug and drug-disease interactions, and monitoring of potential adverse events. Data extracted electronically from practices' electronic medical record were used to assess practice-level adherence with the indicator set as of 1 July 2008. RESULTS: Thirty medication safety indicators were selected. Across all practices, inappropriate treatment, dosing, drug-drug and drug-disease interactions were avoided in 75%, 84%, 98% and 86% of eligible patients, respectively; monitoring of preventable adverse drug events occurred in 75% of patients. There was wide variability in practice adherence with the indicators. DISCUSSION: The consensus development process was successful in selecting a broad set of primary care medication safety quality indicators. Although aggregate adherence was relatively high in this group of practices, opportunities exist to improve potential errors in treatment selection, dosing and monitoring.

Translating research into practice using electronic medical records the PPRNet-TRIP project: primary and secondary prevention of coronary heart disease and stroke.

This paper describes the background and methods of an Agency for Healthcare Research and Quality-funded study designed to evaluate the impact of a quality improvement model using academic detailing and electronic medical records (EMRs) on adherence with 22 clinical practice guidelines for prevention of cardiovascular disease and stroke. The study is being conducted in 23 primary care practices in 14 states that use a common EMR and pool data for research. Control practices receive copies of the clinical practice guidelines and quarterly updates of their adherence with them. Intervention practices receive similar information and participate in regular site visits and investigator meetings designed to catalyze their quality improvement efforts. The intervention began January 1, 2001 and will be completed on June 30, 2003.

Quality improvement using electronic medical records: a case study of a high-performing practice.

Electronic medical record (EMR) systems are useful tools that can help primary care practices improve clinical care; however, the successful implementation of an EMR system depends on dedicated users who optimize the system to suit their practice needs. This case study describes the strategies a solo, family physician practice has adopted to improve care as part of a national cardiovascular disease prevention study.

System supports for chronic illness care and their relationship to clinical outcomes.

The Chronic Care Model proposes that organizational system changes improve the quality of chronic care. This cross-sectional study explores the relationship between system supports for chronic care and clinical outcomes for two major chronic illnesses: diabetes and cardiovascular disease. Nine community-based primary care practices from the Practice Partner Research Network (PPRNet) are studied using practice group interviews and clinical data from the PPRNet database. As overall system support increases, providers' achievement of recommended care and desirable patient outcomes improves (r = .828, p = .006). Enhanced systems for provider decision support had the strongest positive correlation with clinical outcomes (r = .907, p = .001).

Impact of an electronic medical record system on community-based primary care practices.

BACKGROUND: Although primary care physicians are increasingly interested in adopting electronic medical record (EMR) systems, few use such systems in practice. This study explores the organizational impact of an EMR system on community-based practices that have overcome the initial barriers and are experienced EMR users. METHODS: Five primary care practices that are members of a national research network participated in this study. Using qualitative methods, including semistructured interviews and observations, we assessed the impact of an EMR system on the work lives of various user groups. RESULTS: Physicians and staff indicated that the EMR system has changed not only how they manage patient records but also how they communicate with each other, provide patient care services, and perform job responsibilities. The EMR is also perceived by its users to have an impact on practice costs. Although in most practices physicians and staff were unaware of actual expenses and cost savings associated with the EMR, those in practices that have eliminated duplicate paper-based systems believe they have realized cost savings. CONCLUSIONS: Several important themes emerged. The organizational context in which the system is implemented is important. Effective leadership, the presence of a system champion, availability of technical training and support, and adequate resources are essential elements to the success of the EMR.

Preventive services in the primary care practices of the Practice Partner Research Network.

Despite the emphasis of primary care on preventive services over the past decade, and the reminder systems that are available to promote the provision of these services, many patients still do not receive needed services. This study describes the preventive services that the primary care practices of the Practice Partner Research Network (PPRNet) monitors, and documents adherence to them. Preventive services monitored in PPRNet practices and the levels of adherence to them vary by practice and service. The lower-than-desired levels of adherence offer opportunities for improvement interventions.

Quality of care for chronic illness in primary care: opportunity for improvement in process and outcome measures.

OBJECTIVE: To describe adherence to a number of quality indicators and clinical outcomes for asthma, diabetes mellitus, hypertension, coronary heart disease, atrial fibrillation, and cerebrovascular disease in the primary care practices of the Practice Partner Research Network (PPRNet). STUDY DESIGN: Cross-sectional epidemiologic design. PATIENTS AND METHODS: PPRNet is a national research network of ambulatory, mostly primary care practices that use the Practice Partner Patient Records electronic medical records. Participating practices send anonymous clinical data on patients to the PPRNet data center monthly. Standard database management and statistical software are used to compile practice reports. These reports include measures of adherence to process and outcome measures for chronic illnesses, the subject of this report. RESULTS: Forty-eight PPRNet practices provided data for the first quarter of 1998. A total of 336,401 patients were active in these practices during this quarter. At least 2000 active patients had each of the conditions studied. Wide variation in guideline adherence among PPRNet practices was present for each of the performance measures. Better performance was present for physical examination measures and laboratory monitoring than for treatment interventions. Overall performance was excellent for blood pressure monitoring, poor for lipid monitoring in patients with CHD, and intermediate for glycosylated hemoglobin monitoring in patients with diabetes mellitus. CONCLUSION: The findings of this study are comparable to others in documenting that most clinical practice guidelines for chronic illness are not followed for a majority of patients and that large majorities do not reach desired clinical outcomes.

Medication cost information in a computer-based patient record system. Impact on prescribing in a family medicine clinical practice.

BACKGROUND: Medications account for 8% of national health care expenditures, and prescription drugs are a focus of cost containment measures. Physicians have limited knowledge about drug costs, and no method of providing this information has demonstrated sustained cost reductions. OBJECTIVE: To determine the impact of cost information in a computer-based patient record system on prescribing by family physicians. METHODS: A yearlong, controlled clinical trial was conducted at the Family Medicine Center, Medical University of South Carolina, Charleston, a group practice staffed by attending physicians and residents. Prescription cost information was included in the computer-based patient record system used at the center. During a 6-month period, cost information was not displayed; during the subsequent 6-month intervention period, costs were displayed at the time of prescribing. An intention-to-treat analysis was used to compare prescription costs between the control and intervention periods for all medications prescribed, and stratified analyses for several medication and physician factors were performed. RESULTS: A total of 22,883 prescriptions were written during the 1-year study period. The mean +/- SD cost per prescription in the control period was $21.83 +/- $27.00 (range, $0.01-$510.00), and in the intervention period was $22.03 +/- $28.12 (range, $0.01-$435.96) (P = .61, Student t test). Increases in mean prescription cost and proportion of total costs were identified in 4 medication classes: antibiotics, cardiovascular agents, headache therapies, and antithrombotic agents. Decreases in mean prescription cost and proportion of total costs were identified in 5 medication classes: nonsteroidal anti-inflammatory drugs, histamine type 2-receptor antagonists and proton pump inhibitors, ophthalmic preparations, vaginal preparations, and otic preparations. CONCLUSIONS: In this setting, the provision of real-time computerized drug cost information did not affect overall prescription drug costs to patients, although differences in individual medication classes were observed. The negative results of this study may reflect confounding due to the use of historical controls, suboptimal timing of the intervention in the prescribing process, susceptibility bias at the study site, or the insensitivity of prescribing habits to cost information.

Electronic medical records as tools for quality improvement in ambulatory practice: theory and a case study.

Information management is critical in today's health care environment. Traditional paper-based medical records are inadequate information management tools. Electronic medical records (EMRs) overcome many problems with paper records and are ideally suited to help physicians increase productivity and improve the quality of care they provide. The Department of Family Medicine at the Medical University of South Carolina uses the Practice Partner Patient Record EMR system. Department members have developed a quality improvement model based on this EMR system. The model has been used to improve care for acute bronchitis, diabetes mellitus, tobacco abuse, asthma, and postmenopausal osteoporosis.

The computer-based patient record as a CQI tool in a family medicine center.

BACKGROUND: In 1994 the Department of Family Medicine (DFM) at the Medical University of South Carolina (MUSC) developed an innovative infrastructure for continuous quality improvement (CQI) which capitalized on its existing computer-based patient record (CPR) system. CQI PROGRAM: The CPR is a key element in all components of the DFM patient care CQI activities. Computerized record reviews, online queries, and special reports provide the background information needed to establish CQI projects and, in some cases, diagnose the cause. Any data entered into the CPR, including progress notes text, is searchable for use by the quality improvement teams. The most compelling aspect of DFM's CPR-based CQI system is the use of quality control charts that are regularly generated by the research division from CPR data. These charts allow the CQI teams to determine whether any changes in the process measurements are due to chance causes or are caused by specific interventions introduced to improve the process. ONGOING IMPROVEMENT PROJECTS: Four ongoing improvement projects that rely on CPR data and use electronically created control charts are discussed--optimizing the treatment of acute bronchitis, improving adherence to practice guidelines for patients with adult onset diabetes mellitus, improving the recognition and treatment of tobacco abuse, and improving blood pressure control in patients with hypertension. Each improvement project has a unique set of goals and objectives, against which the project's success is measured. CONCLUSION: A CPR system can be used to provide fast, organized access to large amounts of patient information to support structured quality improvement activities.

Family practice educators' perceptions of computer-based patient records.

BACKGROUND: Despite the National Institute of Medicine's endorsement of computer-based patient records (CPRs), the majority of family practice residency programs continue to use paper records. This study examined the perceptions of family medicine educators about CPRs to understand their limited use of computerized patient record systems. METHODS: A survey was mailed to the directors of 247 family practice residency programs; 199 were completed and returned (response rate 81%). Respondents were asked to identify their concerns about CPRs, what they perceived as the advantages and disadvantages of CPRs compared with paper records, and the likelihood that their program will implement a CPR within the next year and within the next 5 years. RESULTS: The perceived benefits of CPR were greater efficiency, accuracy, and quality in patient care. However, many respondents were concerned about cost, mechanical breakdowns, conversion hardships, training needs, and physicians' attitudes. Despite these objections, the majority of respondents reported it is ¿somewhat¿ or ¿very¿ likely that their program will implement a CPR system within the next 5 years. CONCLUSIONS: Although the surveyed family medicine educators believed that CPRs offer significant benefits, they also perceived several disadvantages of converting from paper to computer-based patient records. Widespread use of CPRs among family practice programs in the near future depends on the extent to which vendors and others heighten awareness and knowledge about the benefits of CPRs and address concerns about cost, mechanical breakdowns, and transition difficulties.

Implementation and evaluation of a computer-based preventive services system.

BACKGROUND AND OBJECTIVES: Insufficient attention has been paid to the role that modern information systems can play in improving the delivery of and education about preventive services in family medicine training and practice sites. From September 1990-September 1993, the Department of Family Medicine at the Medical University of South Carolina conducted a demonstration project designed to develop, implement, and evaluate a comprehensive, computer-based preventive services delivery and educational system, based on the recommendations in the US Preventive Services Task Force (USPSTF) Report. METHODS: A computer-based patient record (CPR) system was implemented. The system had sophisticated preventive services tracking and reminder, physician, and patient education features. Twenty-nine basic USPSTF recommendations were incorporated in the system. An extensive physician education series was also implemented. A multi-method evaluation system, including patient exit surveys, physician interviews, and practice audits was used to evaluate and design improvements to the CPR and education systems. RESULTS: Although the system initially had no effect on patient perceptions about the frequency of preventive services delivery, there was reasonable concordance between patient desires and physician behavior for the discussion of preventive services (Kappa = .5 to .6). Physician acceptance of the system was good--in 1992, 30% of physicians used the preventive services reminders in most of their patient visits, and in 1993, 88% of physicians reported more frequent use. Practice audits from February 1992-July 1993 showed increased adherence with all seven counseling services, 10 of 15 screening services, and one of five immunization services. CONCLUSIONS: A CPR-based preventive services system coupled with an adaptable physician education about and delivery of preventive services. an ideal solution to improving the education about and delivery of preventive services.

Improving a preventive services reminder system using feedback from focus groups.

OBJECTIVE: To improve the computer-generated preventive services patient reminder letter used by a department of family medicine at a medical university in South Carolina. DESIGN: A qualitative method chosen because of its demonstrated efficacy in generating in-depth attitude and opinion data was used for 12 focus groups (111 participants) in which participants were asked to evaluate the reminder letter and other preventive services reminder materials. Information from these groups was used to design a revised patient reminder system that was tested in six additional focus groups (50 participants). SETTING: University-based family medicine center. PARTICIPANTS: Adults 19 years of age or older of whom approximately one half were selected from a random sample of family medicine center patients and the remainder from volunteers recruited from the general community by newspaper advertisement. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Participants' perceptions and attitudes about the reminder letter and other materials as well as suggestions for improving the preventive services reminder system. RESULTS: The revised patient reminder materials resulted in a warmer, more personal letter sent to patients at the time of their birthdays in an envelope containing a prevention message. A leaflet describing the rationale for preventive services and answering common questions about prevention and a booklet describing the preventive services available at the family medicine center were also developed. CONCLUSION: This study illustrated the benefits of incorporating patients' perspectives in the design of preventive services reminders.

Barriers to adherence to preventive services reminder letters: the patient's perspective.

BACKGROUND: Despite an emerging consensus as to which preventive services are appropriate, a minority of patients receive them. Although adherence to recommendations for some interventions has increased, research studies have shown that adherence rates can be further improved through a better understanding of patient attitudes and motivations regarding preventive services. METHODS: Using components of the Patient Path Model, this study examined the response to patient reminder letters for cholesterol screening sent to 1077 adult patients between August and October 1990. The research strategy incorporated both quantitative and qualitative methods, including a telephone survey and focus group interviews of nonresponders to the reminder letter. RESULTS: Three hundred seven patients were surveyed by telephone to ascertain their reasons for nonresponse. One hundred fifty-four (50.2%) did not recall receiving the reminder letter, 84 (27.4%) recalled receiving the letter but did not recall its content, and 69 (22.5%) recalled both receiving the letter and its content. No consistent reason for nonadherence emerged among the 69 nonresponders who recalled the reminder. Twenty-seven of the nonresponders who did not recall receiving the cholesterol reminder participated in the focus groups. The participants stressed the importance of distinguishing the reminder letter from a bill, conveying a personally relevant message, and addressing logistical barriers to preventive services. CONCLUSIONS: Careful attention to the format and content of patient reminder letters is necessary to improve adherence to preventive services recommendations.

A comprehensive microcomputer-based medical records system with sophisticated preventive services features for the family physician.

BACKGROUND: Computer-based medical records systems improve the provision of preventive services in the offices of family physicians. Until recently, these systems were either not commercially available for use by practicing physicians or were very expensive. METHODS: A commercially available, microcomputer-based medical records system is currently used at the Department of Family Medicine at the Medical University of South Carolina. This system is used as a fully electronic medical record and has sophisticated health maintenance tracking and reminder features. These features track the provision of preventive services, provide physician reminders at the time of patient visits, permit generation of mailed patient reminders, and provide reference to relevant patient education resources. RESULTS AND CONCLUSION: The system described in this paper can be used by practicing physicians to improve their delivery of preventive services.