A New Contraception Curriculum in the Internal Medicine Residency Primary Care Clinic.

Introduction: Nearly half of all pregnancies in the USA are unintended with a relatively higher proportion occurring in military populations, which can have a large impact on military readiness. Military and civilian internal medicine residency programs do not place an emphasis on contraception in the primary care setting. This intervention sought to elucidate the perceptions of contraception in an internal medicine primary care setting in a military residency and improve confidence in contraceptive counseling and prescribing. Material and Methods: Residents at a military internal residency program were given an hour-long didactic presentation on contraception that was followed 5 weeks later by the implementation of a pocket card for point of care use with key information from the presentation. Residents became certified in the placement and removal of the etonogestrel implant. Pre- and post-intervention surveys were administered to assess for changes in attitudes and confidence in prescribing and counseling. This project was determined to be a quality improvement project by the IRB board of the home institution. Results: Forty-two of 75 (56%) residents responded initially and 40 of 75 (53%) responded after the intervention. There was a significant improvement in resident attitudes towards the applicability of contraception training in internal medicine (p = 0.03) as well as acquiring the skill of etonogestrel implant placement (p = 0.001). There was a trend towards significance in confidence in prescribing oral contraception (p = 0.053). There was no change in residents' confidence in counseling on oral contraception (p = 0.45). Conclusion: A change in the contraception curriculum led to improved residents' skills in etonogestrel placement, and attitudes regarding the applicability of training in contraception to internal medicine, but did not significantly improve confidence in contraceptive counseling. These results suggest that internal medicine residencies should focus on teaching contraception to improve the attitudes in future internists who will need to address contraception in the military population. Future studies could include assessing physician preparedness for addressing contraception during general medical officer tours.

Electronic health records improve clinical note quality.

BACKGROUND AND OBJECTIVE: The clinical note documents the clinician's information collection, problem assessment, clinical management, and its used for administrative purposes. Electronic health records (EHRs) are being implemented in clinical practices throughout the USA yet it is not known whether they improve the quality of clinical notes. The goal in this study was to determine if EHRs improve the quality of outpatient clinical notes. MATERIALS AND METHODS: A five and a half year longitudinal retrospective multicenter quantitative study comparing the quality of handwritten and electronic outpatient clinical visit notes for 100 patients with type 2 diabetes at three time points: 6 months prior to the introduction of the EHR (before-EHR), 6 months after the introduction of the EHR (after-EHR), and 5 years after the introduction of the EHR (5-year-EHR). QNOTE, a validated quantitative instrument, was used to assess the quality of outpatient clinical notes. Its scores can range from a low of 0 to a high of 100. Sixteen primary care physicians with active practices used QNOTE to determine the quality of the 300 patient notes. RESULTS: The before-EHR, after-EHR, and 5-year-EHR grand mean scores (SD) were 52.0 (18.4), 61.2 (16.3), and 80.4 (8.9), respectively, and the change in scores for before-EHR to after-EHR and before-EHR to 5-year-EHR were 18% (p<0.0001) and 55% (p<0.0001), respectively. All the element and grand mean quality scores significantly improved over the 5-year time interval. CONCLUSIONS: The EHR significantly improved the overall quality of the outpatient clinical note and the quality of all its elements, including the core and non-core elements. To our knowledge, this is the first study to demonstrate that the EHR significantly improves the quality of clinical notes.

QNOTE: an instrument for measuring the quality of EHR clinical notes.

BACKGROUND AND OBJECTIVE: The outpatient clinical note documents the clinician's information collection, problem assessment, and patient management, yet there is currently no validated instrument to measure the quality of the electronic clinical note. This study evaluated the validity of the QNOTE instrument, which assesses 12 elements in the clinical note, for measuring the quality of clinical notes. It also compared its performance with a global instrument that assesses the clinical note as a whole. MATERIALS AND METHODS: Retrospective multicenter blinded study of the clinical notes of 100 outpatients with type 2 diabetes mellitus who had been seen in clinic on at least three occasions. The 300 notes were rated by eight general internal medicine and eight family medicine practicing physicians. The QNOTE instrument scored the quality of the note as the sum of a set of 12 note element scores, and its inter-rater agreement was measured by the intraclass correlation coefficient. The Global instrument scored the note in its entirety, and its inter-rater agreement was measured by the Fleiss κ. RESULTS: The overall QNOTE inter-rater agreement was 0.82 (CI 0.80 to 0.84), and its note quality score was 65 (CI 64 to 66). The Global inter-rater agreement was 0.24 (CI 0.19 to 0.29), and its note quality score was 52 (CI 49 to 55). The QNOTE quality scores were consistent, and the overall QNOTE score was significantly higher than the overall Global score (p=0.04). CONCLUSIONS: We found the QNOTE to be a valid instrument for evaluating the quality of electronic clinical notes, and its performance was superior to that of the Global instrument.