Observing Provider Utilization of Electronic Health Records to Improve Clinical Quality Metrics.

Introduction: This study compared changes of healthcare quality in a Michigan Medicaid population before and after physician adoption of electronic health records (EHRs) via the Meaningful Use (MU) program for selected Healthcare Effectiveness Data and Information Set (HEDIS) quality of care measures. Methods: Healthcare measures included well-child visits, cancer screening, and chronic illness quality measures. Utilization data were obtained from Medicaid paid claims and encounter data with providers (N=291) receiving their first MU incentive in 2014 and at least one HEDIS-defined outpatient visit with a Michigan Medicaid enrollee. Paired t-tests with a repeated measures design were utilized to analyze the data. Results: Improvements in quality of infant well-child visits (mean difference = 10.2) and colorectal cancer screening (mean difference = 8.0 percent) were observed. We found no change or slight decreases for the other selected measures. Conclusion: These outcomes inform the performance and ability of EHRs to improve quality of healthcare standards particularly as technology continues to evolve under the Centers for Medicare & Medicaid Services (CMS) Interoperability and Patient Access final rule.

New Composite Measure for ADL Limitations: Application to Predicting Nursing Home Placement for Michigan MI Choice Clients.

Functional status measured by activities of daily living (ADL) may be used to predict nursing home placement. Scoring of ADL measures is summarized for convenience, yet this is accompanied by losing detail regarding deficits. We sought to determine whether a revised composite measure tailored to Michigan Medicaid beneficiaries would better identify those at risk for nursing home admission. We compared composite ADL measures created by exploratory factor analysis and additive modeling to Medicaid Enrollment, MI Choice Waiver program, and Nursing Facility claims data from 2013 to 2017. There were moderate to high levels of correlation between ADLs (.4-.82). Exploratory factor analysis extracted two factors, corresponding to domains of mobility or self-care tasks. Application of the self-care-based ADL limitations composite measure provided prediction power equivalent to an additive measure incorporating all ADL limitations for nursing home admission. This approach demonstrated improved interpretability with the need for just five measures.

Current evidence and controversies: advanced practice providers in healthcare.

The authors compare advanced practice providers' education, training, scope of practice, and quality of care with that of physicians. A framework is essential to promote team-based primary care.

Meaningful Use: Does Physician Participation Move the Needle on Quality Metrics?

INTRODUCTION: To determine the association between pattern of participation in the Meaningful Use (MU) initiative and self-reported clinical quality metrics. METHODS: We used state-level Medicaid electronic health record (EHR) incentive program data to categorize physicians based on receipt of MU payments (single year vs. multiple years) and self-reported quality metrics from 2011 to 2016. RESULTS: Among 4,198 participating physicians, only 36% received more than one EHR incentive payment. Physicians participating for a single year had better cancer-screening metrics. By comparison, physicians who participated for multiple years reported better medication-related metrics and chronic disease management metrics. CONCLUSIONS: Nature of participation may have varying degrees of influence on types of clinical quality metrics. Sustained participation may support management of chronic conditions. Administrative claims data will help to elucidate our findings.

Health Information Exchange of Medication Lists: Hospital Discharge to Home Healthcare.

Nurses report significant gaps in communication among patients discharged from the hospital with home healthcare (HHC) services. The aim of this pilot study was to quantify the contents of HHC admission packets used to guide nurses' first home visit after hospital discharge. We evaluated 20 randomly selected charts of older adults admitted to HHC after a hospitalization for heart failure. Admission packets contained nearly 50 pages of material, which frequently included duplicate documents printed from the hospital-based electronic health record (EHR). Despite the plethora of documents, most packets omitted key information, such as patients' cognitive and functional status, and even discharge summaries, which would be relevant and actionable for HHC nurses. Moreover, admission packets contained multiple, often discordant, EHR-generated medication lists, which makes reconciliation challenging for nurses and puts vulnerable patients at risk for adverse drug events. Overall, there is an urgent need to improve health information exchange between hospitals and HHC agencies, which will simultaneously promote nurse efficiency and patient safety.

Eliciting nurses' perspectives to improve health information exchange between hospital and home health care.

Despite patient safety initiatives to improve care transitions, prior research largely neglects to elicit feedback from home health nurses regarding health information exchange. The goal of this quality improvement study was to identify opportunities to facilitate information transfer during hospital-to-home-health-care transitions for older adults with heart failure. We conducted focus groups with 19 nurses employed by a single healthcare system using two commercially available electronic health record (EHR) vendors. We analyzed interview transcripts following an immersion/crystallization approach to identify themes. Average participants were females in their mid-fifties with 15 years of home health experience. Nurses reported challenges with hospital-to-home-health-care information exchange, specifically: 1) poor medication management, 2) ineffective communication, 3) technology issues, and 4) patient factors. Nurses identified several opportunities for improvement, including discordant EHR-generated medication lists, which may be amenable to technological solutions. Local quality improvement efforts should incorporate nurses' suggestions and leverage existing best practices.

Challenges optimizing the after visit summary.

BACKGROUND: The after visit summary (AVS) is a paper or electronic document given to patients after a medical appointment, which is intended to summarize patients' health and guide future care, including self-management tasks. OBJECTIVE: To describe experiences of health systems implementing a redesigned outpatient AVS in commercially available electronic health record (EHR) systems to inform future optimization. MATERIALS AND METHODS: We conducted semi-structured interviews with information technology and clinical leaders at 12 hospital and community-based healthcare institutions across the continental United States focusing on the process of AVS redesign and implementation. We also report our experience implementing a redesigned AVS in the Epic EHR at the Mount Sinai Hospital in New York City, NY. RESULTS: Health systems experienced many challenges implementing the redesigned AVS. While many IT leaders noted that the redesigned AVS is easier to understand and the document is better organized, they claim the effort is time-consuming, Epic system upgrades render AVS modifications non-functional, and primary care and specialty practices have different needs in regards to content and formatting. Our team was able to modify the document by changing the order of print groups, modifying the font size, bolding section headers, and inserting page breaks. Similar to other health systems, our team found that it is difficult to achieve some desired features due to limitations in the EHR platform. CONCLUSION: Health IT leaders view the AVS as a valuable source of information for patients. However, limitations to AVS modifications in EHR systems present challenges to optimizing the tool. EHR vendors should incorporate learning from healthcare systems innovation efforts and consider building more flexibility into their product development.

Delayed Presentation of Isolated Adrenocorticotropin Insufficiency after Nivolumab Therapy for Advanced Non-small-cell lung carcinoma (NSCLC).

We describe a 73-year-old man who developed adrenal insufficiency 7 months after completing nivolumab therapy for advanced non-small cell lung cancer. He presented with non-specific symptoms of malaise and fatigue with an insidious 13.6 kilogram weight loss, prompting an evaluation for disease progression, which was negative. Subsequent evaluation revealed isolated adrenocorticotropin insufficiency as the aetiology, attributed to a delayed side effect of nivolumab therapy.

Expert Witness Training for Geriatric Medicine Fellows Using Courtroom Simulation.

INTRODUCTION: Familiarity with courtroom proceedings is essential for physicians before their first appearance as expert witnesses. Geriatricians who care for vulnerable older adults may be called to testify in guardianship hearings and cases involving elder abuse and contested wills. Coverage of this topic is limited in the medical literature. To enhance this knowledge, the Division of Geriatrics at Michigan State University piloted an expert witness training curriculum for its geriatric medicine fellows. METHODS: An attorney began the training with a didactic lecture to introduce principles of the trial process, evidence, records management, witness testimony, and court procedures. One week later, fellows participated in a mock trial to apply what they learned and gain experience in providing testimony. The simulated cases involved actual patients of the fellows, who were the subjects of a hypothetical contested guardianship matter. A mixed methods approach was used to assess knowledge acquisition, training effectiveness and perceived impact using a pre/post-test and an individualized, semistructured debriefing session. RESULTS: Two fellows participated in the training. Courtroom knowledge as assessed by the pre- and post-tests and qualitative measures improved from baseline. The fellows assessed the mock trial as a valuable experience and both felt more informed and prepared for future service as witnesses. CONCLUSIONS: This pilot study provided geriatric medicine fellows with instruction in courtroom testimony followed by participation in a simulated trial. Fellows rated the experience highly and demonstrated measurable improvement in their knowledge of legal proceedings involving older adults and their role as expert witnesses.

Opportunities to improve clinical summaries for patients at hospital discharge.

BACKGROUND: Clinical summaries are electronic health record (EHR)-generated documents given to hospitalised patients during the discharge process to review their hospital stays and inform postdischarge care. Presently, it is unclear whether clinical summaries include relevant content or whether healthcare organisations configure their EHRs to generate content in a way that promotes patient self-management after hospital discharge. We assessed clinical summaries in three relevant domains: (1) content; (2) organisation; and (3) readability, understandability and actionability. METHODS: Two authors performed independent retrospective chart reviews of 100 clinical summaries generated at two Michigan hospitals using different EHR vendors for patients discharged 1 April -30 June 2014. We developed an audit tool based on the Meaningful Use view-download-transmit objective and the Society of Hospital Medicine Discharge Checklist (content); the Institute of Medicine recommendations for distributing easy-to-understand print material (organisation); and five readability formulas and the Patient Education Materials Assessment Tool (readability, understandability and actionability). RESULTS: Clinical summaries averaged six pages (range 3-12). Several content elements were universally auto-populated into clinical summaries (eg, medication lists); others were not (eg, care team). Eighty-five per cent of clinical summaries contained discharge instructions, more often generated from third-party sources than manually entered by clinicians. Clinical summaries contained an average of 14 unique messages, including non-clinical elements irrelevant to postdischarge care. Medication list organisation reflected reconciliation mandates, and dosing charts, when present, did not carry column headings over to subsequent pages. Summaries were written at the 8th-12th grade reading level and scored poorly on assessments of understandability and actionability. Inter-rater reliability was strong for most elements in our audit tool. CONCLUSIONS: Our study highlights opportunities to improve clinical summaries for guiding patients' postdischarge care.

Beta Testing a Novel Smartphone Application to Improve Medication Adherence.

BACKGROUND: We developed and beta-tested a patient-centered medication management application, PresRx optical character recognition (OCR), a mobile health (m-health) tool that auto-populates drug name and dosing instructions directly from patients' medication labels by OCR. MATERIALS AND METHODS: We employed a single-subject design study to evaluate PresRx OCR for three outcomes: (1) accuracy of auto-populated medication dosing instructions, (2) acceptability of the user interface, and (3) patients' adherence to chronic medications. RESULTS: Eight patients beta-tested PresRx OCR. Five patients used the software for ≥6 months, and four completed exit interviews (n = 4 completers). At baseline, patients used 3.4 chronic prescription medications and exhibited moderate-to-high adherence rates. Accuracy of auto-populated information by OCR was 95% for drug name, 98% for dose, and 96% for frequency. Study completers rated PresRx OCR 74 on the System Usability Scale, where scores ≥70 indicate an acceptable user interface (scale 0-100). Adherence rates measured by PresRx OCR were high during the first month of app use (93%), but waned midway through the 6-month testing period (78%). Compared with pharmacy fill rates, PresRx OCR underestimated adherence among completers by 3%, while it overestimated adherence among noncompleters by 8%. DISCUSSION: Results suggest smartphone applications supporting medication management are feasible and accurately assess adherence compared with objective measures. Future efforts to improve medication-taking behavior using m-health tools should target specific patient populations and leverage common application programming interfaces to promote generalizability. CONCLUSIONS: Our medication management application PresRx OCR is innovative, acceptable for patient use, and accurately tracks medication adherence.

Considerations for using the 'brown bag' strategy to reconcile medications during routine outpatient office visits.

BACKGROUND: Among medication reconciliation studies, varying methods are used to determine which medications patients are actually taking. One recommended approach is to ask patients to "brown bag" their medications for routine office visits. AIMS: To determine if 'brown bag' practices performed during routine office visits improve the accuracy of provider-documented medication lists. METHODS: This cross-sectional pilot study was conducted in a university affiliated community geriatric clinic. Forty-six cognitively intact elders who managed their own medications enrolled. Participants self-selected into two groups: 'brown-baggers' (BBs) and 'non-brown-baggers' (NBBs). Three medication lists were compared for each patient: provider-documented in patient's chart (chart list); researcher-generated by post-appointment semistructured interview (point-of-care [POC] list); post-appointment semi-structured telephone interview (telephone list, reference standard). Accuracy of chart and POC lists were compared with reference lists among BBs and NBBs. RESULTS: Thirty-three (72%) patients brought some of their medications to scheduled appointments (BBs); of these, 39% bagged all of their medications. Excluding route as a variable, 35% of provider-documented chart lists were complete; only 6.5% were accurate. Some 76% of chart-documented medication lists contained inclusion, omission and/or dosing instruction discrepancies, with no differences between BBs and NBBs. However, POC lists obtained using a semi-structured interview included fewer inclusion and omission discrepancies among BBs than NBBs (42% v 77%, P = 0.05). In subset analyses by medication type, over-the-counter (OTC) medication documentation was more accurate among BBs than NBBs. Overall, chart lists contained two to three times more discrepancies than lists generated at POC. CONCLUSION: Most BBs do not bag all their medications for office visits. Chart list accuracy is no better among BBs than NBBs, although patients who 'brown bag' their medications for office visits may prompt providers to conduct a more thorough medication history. Lists generated by semistructured interviewing, regardless of BB status, are more accurate than chart lists. Findings challenge benefits of the 'brown bag' unless coupled with in-depth questioning and processes for transferring information to chart lists.

Association between proton pump inhibitor use and anemia: a retrospective cohort study.

BACKGROUND: Proton pump inhibitors (PPIs) are widely prescribed to treat gastrointestinal diseases. However, concerns have been raised regarding their long-term use. Gastric acid suppression may decrease iron absorption, and it remains uncertain whether iron-deficiency anemia may result from chronic PPI therapy. AIMS: We aimed to explore the association between chronic PPI use and iron-deficiency anemia. METHODS: We conducted a retrospective cohort study of adult patients in an academic outpatient setting who received PPI therapy for at least 1 year between January 1, 2004 and January 1, 2006. We compared the change in hematologic indices among patients receiving PPI therapy for at least 1 year with matched controls. RESULTS: Of the 98 patients on chronic PPI therapy who met inclusion criteria, 35% had no documented indication for such therapy. At baseline, demographics and hematologic indices were similar between PPI-users and controls. Among patients on PPI therapy, all hematologic indices decreased from baseline, including hemoglobin (-0.19 g/dL, P=0.03), hematocrit (-0.63%, P=0.02), and mean corpuscular volume (-0.49 fL, P=0.05). PPI users had significant decreases in mean hemoglobin and hematocrit (P<0.01 for both) compared with matched controls. After adjustment for confounders, including rates of esophagogastroduodenoscopy, colonoscopy and remote cancer status, the odds ratio of decreasing hemoglobin by 1.0 g/dL while on chronic PPI therapy was 5.03 (95% CI, 1.71-14.78, P<0.01), while the odds ratio of decreasing hematocrit by 3% was 5.46 (95% CI, 1.67-17.85, P<0.01). CONCLUSIONS: Among adult patients receiving chronic PPI therapy, there is a significant decrease in hematologic indices from baseline.

Techniques for monitoring cranberry tipworm (Diptera: Cecidomyiidae) in rabbiteye and southern highbush blueberries.

Several monitoring techniques were evaluated for their effectiveness, based on the highest mean captures of cranberry tipworm, Dasineura oxycoccana (Johnson), in detecting D. oxycoccana in rabbiteye, Vaccinium ashei Reade, and southern highbush, V. corymbosum L. x V. darrowi Camp, blueberry plantings. There were no significant differences in captures of D. oxycoccana adults on unbaited sticky board traps, regardless of color (yellow, white, green, or blue). In a separate experiment, three monitoring techniques, yellow unbaited sticky boards, larval/adult emergence from infested buds, and bud dissection, were evaluated for detecting D. oxycoccana, eggs, larvae, and adults. In total, four bud types were examined, including rabbiteye floral, rabbiteye leaf, southern highbush floral, and southern highbush leaf. The emergence monitoring technique detected significantly more D. oxycoccana adults than the other techniques evaluated. Emergence and dissection techniques performed equally well for detecting D. oxycoccana larvae. Dissection was the only technique capable of detecting D. oxycoccana eggs. Overall, the highest numbers of D. oxycoccana eggs were detected in southern highbush leaf buds. However, larval infestation was lower for southern highbush leaf buds compared with other bud types sampled. Hypotheses to explain this phenomenon are discussed. The fewest number of eggs was recorded for southern highbush flower buds, potentially because these buds develop before peak emergence of D. oxycoccana. Managing D. oxycoccana in infested plantings can be improved by incorporating monitoring techniques, specifically bud dissection to search for eggs, that will aid growers in making timely insecticide applications.