Physician Perceptions and Beliefs about Generating and Providing a Clinical Summary of the Office Visit.

BACKGROUND: A core measure of the meaningful use of EHR incentive program is the generation and provision of the clinical summary of the office visit, or the after visit summary (AVS), to patients. However, little research has been conducted on physician perceptions and beliefs about the AVS. OBJECTIVES: Evaluate physician perceptions and beliefs about the AVS and the effect of the AVS on workload, patient outcomes, and the care the physician delivers. METHODS: A cross-sectional online survey of physicians at two academic medical centers (AMCs) in the northeast who are participating in the meaningful use EHR incentive program. RESULTS: Of the 1 795 physicians at both AMCs participating in the incentive program, 853 completed the survey for a response rate of 47.5%. Eighty percent of the respondents reported that the AVS was easy (very easy or quite easy or somewhat easy) to generate and provide to patients. Nonetheless, more than three-fourths of the respondents reported a negative effect of generating and providing the AVS on workload of office staff (78%) and workload of physicians (76%). Primary care physicians had more positive beliefs about the effect of the AVS on patient outcomes than specialists (p<0.001) and also had more positive beliefs about the effect of the AVS on the care they delivered than specialists (p<0.001). CONCLUSIONS: Achieving the core meaningful use measure of generating and providing the AVS was easy for physicians but it did not necessarily translate into positive beliefs about the effect of the AVS on patient outcomes or the care the physician delivered. Physicians also had negative beliefs about the effect of the AVS on workload. To promote positive beliefs among physicians around the AVS, organizations should obtain physician input into the design and implementation of the AVS and develop strategies to mitigate its negative impacts on workload.

Effect of EHR user interface changes on internal prescription discrepancies.

OBJECTIVE: To determine whether specific design interventions (changes in the user interface (UI)) of an electronic health record (EHR) medication module are associated with an increase or decrease in the incidence of contradictions between the structured and narrative components of electronic prescriptions (internal prescription discrepancies). MATERIALS AND METHODS: We performed a retrospective analysis of 960,000 randomly selected electronic prescriptions generated in a single EHR between 01/2004 and 12/2011. Internal prescription discrepancies were identified using a validated natural language processing tool with recall of 76% and precision of 84%. A multivariable autoregressive integrated moving average (ARIMA) model was used to evaluate the effect of five UI changes in the EHR medication module on incidence of internal prescription discrepancies. RESULTS: Over the study period 175,725 (18.4%) prescriptions were found to have internal discrepancies. The highest rate of prescription discrepancies was observed in March 2006 (22.5%) and the lowest in March 2009 (15.0%). Addition of "as directed" option to the dropdown decreased prescription discrepancies by 195 / month (p = 0.0004). An non-interruptive alert that reminded providers to ensure that structured and narrative components did not contradict each other decreased prescription discrepancies by 145 / month (p = 0.03). Addition of a "Renew / Sign" button to the Medication module (a negative control) did not have an effect in prescription discrepancies. CONCLUSIONS: Several UI changes in the electronic medication module were effective in reducing the incidence of internal prescription discrepancies. Further research is needed to identify interventions that can completely eliminate this type of prescription error and their effects on patient outcomes.

Relationship between documentation method and quality of chronic disease visit notes.

OBJECTIVE: To assses the relationship between methods of documenting visit notes and note quality for primary care providers (PCPs) and specialists, and to determine the factors that contribute to higher quality notes for two chronic diseases. METHODS: Retrospective chart review of visit notes at two academic medical centers. Two physicians rated the subjective quality of content areas of the note (vital signs, medications, lifestyle, labs, symptoms, assessment & plan), overall quality, and completed the 9 item Physician Documentation Quality Instrument (PDQI-9). We evaluated quality ratings in relation to the primary method of documentation (templates, free-form or dictation) for both PCPs and specialists. A one factor analysis of variance test was used to examine differences in mean quality scores among the methods. RESULTS: A total of 112 physicians, 71 primary care physicians (PCP) and 41 specialists, wrote 240 notes. For specialists, templated notes had the highest overall quality scores (p≤0.001) while for PCPs, there was no statistically significant difference in overall quality score. For PCPs, free form received higher quality ratings on vital signs (p = 0.01), labs (p = 0.002), and lifestyle (p = 0.002) than other methods; templated notes had a higher rating on medications (p≤0.001). For specialists, templated notes received higher ratings on vital signs, labs, lifestyle and medications (p = 0.001). DISCUSSION: There was no significant difference in subjective quality of visit notes written using free-form documentation, dictation or templates for PCPs. The subjective quality rating of templated notes was higher than that of dictated notes for specialists. CONCLUSION: As there is wide variation in physician documentation methods, and no significant difference in note quality between methods, recommending one approach for all physicians may not deliver optimal results.

Increasing patient engagement: patients' responses to viewing problem lists online.

OBJECTIVE: To characterize the opinions, emotions, and actions taken by patients who viewed their electronic problem list via an online personal health record (PHR). MATERIALS AND METHODS: An online survey of patients who viewed their problem lists, as maintained by their healthcare provider, in a web-based PHR linked to an electronic health record for the first time. RESULTS: A total 3,649 patients completed the survey, yielding a response rate of 42.1%. Patient attitudes towards the problem list function were positive overall, with 90.4% rating it at least somewhat useful and 86.7% reporting they would probably or definitely use it again. Nearly half (45.6%) of patients identified at least one major or minor problem missing from their list. After viewing the list, 56.1% of patients reported taking at least one action in response, with 32.4% of patients reporting that they researched a condition on the Internet, 18.3% reported that they contacted their healthcare provider and 16.7% reported changing or planning to change a health behavior (patients could report multiple actions). 64.7% of patients reported feeling at least somewhat happy while viewing their problem list, though others reported feeling sad (30.4%), worried (35.7%) or scared (23.8%) (patients could report multiple emotions). A smaller number of patients reported feeling angry (16.6%) or ashamed (14.3%). Patients who experienced an emotional response were more likely to take action. CONCLUSION: Overall, patients found the ability to view their problem lists very useful and took action in response to the information. However, some had negative emotions. More research is needed into optimal strategies for supporting patients receiving this information.

Provider use of and attitudes towards an active clinical alert: a case study in decision support.

BACKGROUND: In a previous study, we reported on a successful clinical decision support (CDS) intervention designed to improve electronic problem list accuracy, but did not study variability of provider response to the intervention or provider attitudes towards it. The alert system accurately predicted missing problem list items based on health data captured in a patient's electronic medical record. OBJECTIVE: To assess provider attitudes towards a rule-based CDS alert system as well as heterogeneity of acceptance rates across providers. METHODS: We conducted a by-provider analysis of alert logs from the previous study. In addition, we assessed provider opinions of the intervention via an email survey of providers who received the alerts (n = 140). RESULTS: Although the alert acceptance rate was 38.1%, individual provider acceptance rates varied widely, with an interquartile range (IQR) of 14.8%-54.4%, and many outliers accepting none or nearly all of the alerts they received. No demographic variables, including degree, gender, age, assigned clinic, medical school or graduation year predicted acceptance rates. Providers' self-reported acceptance rate and perceived alert frequency were only moderately correlated with actual acceptance rates and alert frequency. CONCLUSIONS: Acceptance of this CDS intervention among providers was highly variable but this heterogeneity is not explained by measured demographic factors, suggesting that alert acceptance is a complex and individual phenomenon. Furthermore, providers' self-reports of their use of the CDS alerting system correlated only modestly with logged usage.

An automated telephone-based smoking cessation education and counseling system.

Automated patient education and counseling over the telephone is a convenient and inexpensive method for modifying health-related behaviors. A computer-controlled, telecommunications technology called Telephone-Linked Care (TLC) was used to develop a behavioral intervention to assist smokers to quit and to prevent relapse. The education and counseling is offered through a series of interactive telephone conversations which can take place in the smoker's home. The system's automated dialogues are driven by an expert system that controls the logic. The content is derived from the Transtheoretical Model of behavioral change, principles of Social Cognitive Theory, strategies of patient-centered counseling and recommendations of clinical experts in smoking cessation. The system asks questions, provides information, gives positive reinforcement and feedback, and makes suggestions for behavioral change. Information that the patient communicates is stored and is used to influence the content of subsequent conversations.

Human hybridoma lupus anticoagulants distinguish between lamellar and hexagonal phase lipid systems.

Antibodies to phospholipids may have important physiological and biological functions. Lupus anticoagulants represent a subclass of anti-phospholipid antibodies which are characterized by their ability to prolong the clotting time in in vitro coagulation assays measuring partial thromboplastin time (PTT) (Thiagarajan, P., Shapiro, S. S., and DeMarco, L. (1980) J. Clin. Invest. 66, 397-405). In the present study, we produced hybridomas by fusing lymphocytes from 13 systemic lupus erythematosus patients with the GM 4672 lymphoblastoid line. Of the resulting 67 hybridoma autoantibodies, 14 (21%) were found to prolong a modified PTT assay, and 11 of these antibodies were analyzed further. Competition experiments, using a modified PTT assay, demonstrated that hexagonal phase phospholipids, including natural and synthetic forms of phosphatidylethanolamine, were able to neutralize the lupus anticoagulant activity of all 11 hybridoma antibodies. In contrast, lamellar phospholipids, such as phosphatidylcholine and synthetic lamellar forms of phosphatidylethanolamine, had no effect on the anticoagulant activity. Thus, these antibodies are capable of recognizing phospholipids on purely structural criteria. The demonstration that anti-phospholipid antibodies are able to distinguish between different structural arrangements of phospholipid may have important implications regarding the immunoregulation of autoimmunity.

Quantitative joint imaging using 67gallium citrate in a rabbit model of zymosan induced arthritis.

The intensity of synovitis induced by the intraarticular injection of 70 mg of zymosan into rabbit knee joints was assessed using the radiopharmaceutical 67gallium citrate (67Ga). Maximal uptake of 67Ga was observed 5 days after zymosan administration. The distribution of 67Ga in the intraarticular and paraarticular structures was quantitated and highest concentrations were found in the synovial membrane. The short term quantitative evaluation of zymosan induced arthritis is possible using scintigraphic technique.