Establishing electronic health record competency testing for first-year residents.

BACKGROUND: Despite widespread use of electronic health records (EHRs), it is unclear whether residents possess the EHR skills to perform required tasks. OBJECTIVE: We assessed first-year residents' skills on specific EHR tasks. METHODS: Incoming residents were required to participate in EHR training before starting clinical rotations. The training team developed an assessment tool for 19 EHR tasks. Senior residents used a structured template to assess interns. RESULTS: For ambulatory workflow skills, most participants (range, 70%-100%) demonstrated competence. The 3 skills for which interns needed the most assistance were (1) creating and routing a result note (17 of 68, 25%), (2) deleting a medication or changing a dose in reconciling medications (10 of 68, 15%), and (3) finding results for the past 90 days (10 of 68, 15%). For inpatient workflow skills, most interns (range, 63%-100%) demonstrated competence. The 3 skills in which interns needed the most assistance were (1) placing a referral order at discharge (23 of 68, 34%), (2) finding a temperature on a flow sheet and trending it over time (14 of 68, 21%), and (3) creating a discharge summary, having it reviewed, and forwarding it to the primary care physician (14 of 68, 21%). CONCLUSIONS: Our results should help EHR training teams at other institutions to better understand the strengths and weakness of EHR training approaches and to target training on tasks with the greatest performance deficits as well as toward underperforming individuals or groups.

Using Geographic Information Systems (GIS) to assess outcome disparities in patients with type 2 diabetes and hyperlipidemia.

OBJECTIVES: Geographic information systems (GIS) tools can help expand our understanding of disparities in health outcomes within a community. The purpose of this project was (1) to demonstrate the methods to link a disease management registry with a GIS mapping and analysis program, (2) to address the challenges that occur when performing this link, and (3) to analyze the outcome disparities resulting from this assessment tool in a population of patients with type 2 diabetes mellitus. METHODS: We used registry data derived from the University of California Davis Health System's electronic medical record system to identify patients with diabetes mellitus from a network of 13 primary care clinics in the greater Sacramento area. This information was converted to a database file for use in the GIS software. Geocoding was performed and after excluding those who had unknown home addresses we matched 8528 unique patient records with their respective home addresses. Socioeconomic and demographic data were obtained from the Geolytics, Inc. (East Brunswick, NJ), a provider of US Census Bureau data, with 2008 estimates and projections. Patient, socioeconomic, and demographic data were then joined to a single database. We conducted regression analysis assessing A1c level based on each patient's demographic and laboratory characteristics and their neighborhood characteristics (socioeconomic status [SES] quintile). Similar analysis was done for low-density lipoprotein cholesterol. RESULTS: After excluding ineligible patients, the data from 7288 patients were analyzed. The most notable findings were as follows: There was, there was found an association between neighborhood SES and A1c. SES was not associated with low-density lipoprotein control. CONCLUSION: GIS methodology can assist primary care physicians and provide guidance for disease management programs. It can also help health systems in their mission to improve the health of a community. Our analysis found that neighborhood SES was a barrier to optimal glucose control but not to lipid control. This research provides an example of a useful application of GIS analyses applied to large data sets now available in electronic medical records.

Gender differences in the selection of an action plan for patients with type 2 diabetes mellitus.

OBJECTIVE: : To assess differences between women and men in developing an action plan for the management of their type 2 diabetes mellitus (DM). METHODS: : We chose a convenience sample of the first 153 patients who participated in a four-part educational class focused on the management of type 2 DM. The classes are run by a certified diabetes educator and have a specific format. We use a decision wheel to assist in the development of a patient-generated action plan to address a specific health behavior change. For each patient we documented age, gender, and glycosylated hemoglobin (HbA1c) level. RESULTS: : There was a difference in choice of action plan based on gender (p = 0.014). For women the distribution of action plans was exercise 38%, nutrition 22%, medication 20%, no action plan 13%, and monitoring 7%. For men the distribution of action plans was exercise 26%, nutrition 26%, medication 6%, no action plan 26%, and monitoring 16%. Age did not affect the choice of an action plan (p = 0.964); however, patients with a lower HbA1c level chose exercise more frequently (p < 0.002). CONCLUSIONS: : The results of this study suggest there may be gender-based differences affecting the selection of an action plan for patients with type 2 DM. Further research is needed to determine the relative weight of other important factors on the decision for a particular action plan; e.g. sociodemographic factors, stage of readiness to change, and comorbid conditions.

Interventions to support diabetes self-management: the key role of the patient in diabetes care.

More so than most other diseases, effective control of type 2 diabetes (DM) requires that patients are actively engaged in the self-management of their health. In this paper we define and characterize the elements of self-management and review the published literature for the evidence of the benefit of interventions that support patient self-management.

Walk a mile in my shoes: a chronic illness care workshop for first-year students.

BACKGROUND AND OBJECTIVES: A number of educators and recent medical school graduates have suggested a need to expand predoctoral training in chronic illness care. We developed a workshop to enhance first-year students' self-awareness regarding attitudes toward chronic illness care and to help them communicate effectively around patient self-care. METHODS: Students participated in a two-part workshop incorporating lectures, patient-centered interviewing role-plays, and an assignment requiring students to "have" a chronic illness and perform self-care tasks for 2 weeks. We assessed impact on chronic care knowledge by comparing pre- and post-workshop quiz scores. We also reviewed student evaluations of the experience. RESULTS: Of 96 students, 86 (90%) attended Session 1, and 91 (95%) attended Session 2. The mean (standard deviation) knowledge score improved from 6.4 (1.5) before the workshop to 8.4 (1.2) after the workshop (10 points possible). Of 53 students (55%) who completed an evaluation, most perceived the value of the workshop, including the self-care assignment and role-plays. Some felt more positively about chronic illness care following the workshop, and many indicated additional chronic care training in the clinical years would be welcome. CONCLUSIONS: An introductory workshop for first-year students led to increased knowledge of and improved attitudes toward chronic illness care. Longitudinal training in chronic illness care should be considered in predoctoral education.

Development of a diabetes care management curriculum in a family practice residency program.

Improving the quality of care for patients with chronic illness has become a high priority. Implementing training programs in disease management (DM) so the next generation of physicians can manage chronic illness more effectively is challenging. Residency training programs have no specific mandate to implement DM training. Additional barriers at the training facility include: 1) lack of a population-based perspective for service delivery; 2) weak support for self-management of illness; 3) incomplete implementation due to physician resistance or inertia; and 4) few incentives to change practices and behaviors. In order to overcome these barriers, training programs must take the initiative to implement DM training that addresses each of these issues. We report the implementation of a chronic illness management curriculum based on the Improving Chronic Illness Care (ICIC) Model. Features of this process included both patient care and learner objectives. These were: development of a multidisciplinary diabetes DM team; development of a patient registry; development of diabetes teaching clinics in the family practice center (nutrition, general management classes, and one-on-one teaching); development of a group visit model; and training the residents in the elements of the ICIC Model, ie, the community, the health system, self-management support, delivery system design, decision support, and clinical information systems. Barriers to implementing these curricular changes were: the development of a patient registry; buy-in from faculty, residents, clinic leadership, staff, and patients for the chronic care model; the ability to bill for services and maintain clinical productivity; and support from the health system key stakeholders for sustainability. Unique features of each training site will dictate differences in emphasis and structure; however, the core principles of the ICIC Model in enhancing self-management may be generalized to all sites.