Implementing an electronic medical record at a residency site: physicians' perceived effects on quality of care, documentation, and productivity.

BACKGROUND: Electronic Medical Records (EMRs) are quickly becoming a standard component of medical practices. OBJECTIVES: We longitudinally studied the impact of EMR implementation on physician perceptions of quality of care, documentation, and work hours, as well as on measured physician productivity. METHODS: Physicians were surveyed at 3-month intervals regarding perceived impact of the EMR on quality of care, documentation, and productivity. Relative Value Units (RVUs) per clinic hours were used to measure productivity. Paired t-tests were used to compare the mean RVUs per clinic hour in the pre-EMR with the immediate post-EMR time period and the long-term post-EMR time period. RESULTS: RVUs per hour increased significantly from the pre-EMR time period to the immediate post-EMR time period (means 1.49 and 1.82, respectively, P = 0.0007). The long-term post-EMR time period also showed a significant increase over the pre-EMR period (mean 1.79, P = 0.007). Sixty-six percent of physicians perceived that EMR implementation increased their work amount a little or much more. CONCLUSION: Not only did physician production rise immediately, it stayed at the increased level for the duration of our study period. This may be due to improved documentation supporting more appropriate billing. However, physicians also perceived the EMR as taking up more of their time.

Should LSIL with ASC-H (LSIL-H) in cervical smears be an independent category? A study on SurePath specimens with review of literature.

BACKGROUND: Cervical smears exhibiting unequivocal features of 'low grade squamous intraepithelial lesion' (LSIL) are occasionally also admixed with some cells suspicious for, but not diagnostic of, 'high grade squamous intraepithelial lesion' (HSIL). Only a few studies, mostly reported as abstracts, have evaluated this concurrence. In this study, we evaluate the current evidence that favors a distinct category for "LSIL, cannot exclude HSIL" (LSIL-H), and suggest a management algorithm based on combinations of current ASCCP guidelines for related interpretations. METHODS: We studied SurePath preparations of cervical specimens from various institutions during one year period. Cytohisto correlation was performed in cases with cervical biopsies submitted to our institution. The status of HPV DNA testing was also noted in some LSIL-H cases with biopsy results. RESULTS: Out of 77,979 cases 1,970 interpreted as LSIL (1,523), LSIL-H (146), 'atypical squamous cells, cannot exclude HSIL' (ASC-H) (109), and HSIL (192) were selected. Concurrent biopsy results were available in 40% (Total 792 cases: 557 LSIL, 88 LSIL-H, 38 ASCH, and 109 HSIL). Biopsy results were grouped into A. negative for dysplasia (ND), B. low grade (HPV, CIN1, CIN1 with HPV), and C. high grade (CIN 2 and above). The positive predictive values for various biopsy results in relation to initial cytopathologic interpretation were: a. LSIL: (557 cases): ND 32% (179), low grade 58% (323), high grade 10% (55); b. LSIL-H: (88 cases): ND 24% (21), low grade 43% (38), high grade 33% (29); c. ASCH: (38 cases): ND 32% (12), low grade- 37% (14), high grade- 31% (12); d. HSIL (109 cases): ND 5% (6), low grade 26% (28), high grade 69% (75). The patterns of cervical biopsy results in cases reported as LSIL-H were compared with that observed in cases with LSIL, ASC-H, and HSIL. 94% (32 of 34) of LSIL-H were positive for high risk (HR) HPV, 1 was negative for HR HPV but positive for low risk (LR), and 1 LSIL-H was negative for HR and LR both. CONCLUSION: LSIL-H overlapped with LSIL and ASC-H, but was distinct from HSIL. A management algorithm comparable to ASC-H and HSIL appears to be appropriate in LSIL-H cases.

Management of histologic abnormalities of the cervix.

The American Society for Colposcopy and Cervical Pathology sponsored a consensus conference in 2001 to develop evidence-based guidelines for women with histologic abnormalities of the cervix. The options for management of cervical intraepithelial neoplasia 1, 2, and 3 are ranked according to the strength of the recommendation and the quality of the evidence. Follow-up with repeat cytology at six and 12 months or DNA testing for high-risk types of human papillomavirus at 12 months is the preferred management approach for women with cervical intraepithelial neoplasia 1 and satisfactory initial colposcopy. If results from repeat cytology are reported as atypical squamous cells of undetermined significance or greater, or if DNA human papillomavirus testing is positive for oncogenic types of the virus, repeat colposcopy is preferred. When the initial colposcopy is unsatisfactory, a diagnostic excisional procedure is preferred. Follow-up without treatment is acceptable only in women who are pregnant and adolescents with cervical intraepithelial neoplasia 1 who had unsatisfactory colposcopy. Biopsy-confirmed cervical intraepithelial neoplasia 2 and 3 requires treatment except during pregnancy and in compliant adolescents with cervical intraepithelial neoplasia 2 and negative endocervical curettage. When colposcopy is satisfactory, treatment includes ablative or excisional procedures. A diagnostic excisional procedure is recommended in women with biopsy-confirmed cervical intraepithelial neoplasia 2 or 3 and unsatisfactory colposcopy.

Colposcopic proficiency-disease spectrum in a single family practice colposcopists' clinic.

PURPOSE: We sought to assess colposcopic proficiency in a family practice teaching clinic. METHODS: Subjects were a prospective cohort of women age 13 to 68 who were colposcopy clinic attendees from 1991 to 2002. Data recorded on each subject included demographic variables, sexual history, history of sexually transmitted diseases, reason for referral to colposcopy, Pap smear results, colposcopic impression, colposcopic biopsy results, and diagnoses. The Kappa statistic was used to measure agreement between clinical colposcopic assessment and biopsy results. RESULTS: Eight hundred twenty-six patients were enrolled. Compared to biopsy, colposcopic impression overall correctly predicted normal cervical biopsy in 55.8% (95% CI: 45.8%, 65.8%) of cases, and predicted abnormal biopsy 84.9% (95% CI: 81.6%, 88.1%) of the time. Colposcopic impression of low-grade squamous intraepithelial lesion (LSIL) correctly predicted LSIL on biopsy in 64.6% of cases, and correctly predicted the absence of LSIL 74.2% of the time. Colposcopic impression of high-grade squamous intraepithelial lesion (HSIL) correctly predicted biopsy results of HSIL in 70.05% of cases (Kappa = 0.544, P<.0001). There was a 12.7% error rate in discriminating normal from LSIL (Kappa -.258, with P<.0001). CONCLUSION: Family physicians perform colposcopy with good correlation between colposcopic impression and subsequent histology.