Counseling about medication-induced birth defects with clinical decision support in primary care.

BACKGROUND: We evaluated how computerized clinical decision support (CDS) affects the counseling women receive when primary care physicians (PCPs) prescribe potential teratogens and how this counseling affects women's behavior. METHODS: Between October 2008 and April 2010, all women aged 18-50 years visiting one of three community-based family practice clinics or an academic general internal medicine clinic were invited to complete a survey 5-30 days after their clinic visit. Women who received prescriptions were asked if they were counseled about teratogenic risks or contraception and if they used contraception at last intercourse. RESULTS: Eight hundred one women completed surveys; 27% received a prescription for a potential teratogen. With or without CDS, women prescribed potential teratogens were more likely than women prescribed safer medications to report counseling about teratogenic risks. However, even with CDS 43% of women prescribed potential teratogens reported no counseling. In multivariable models, women were more likely to report counseling if they saw a female PCP (odds ratio: 1.97; 95% confidence interval: 1.26-3.09). Women were least likely to report counseling if they received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Women who were pregnant or trying to conceive were not more likely to report counseling. Nonetheless, women who received counseling about contraception or teratogenic risks were more likely to use contraception after being prescribed potential teratogens than women who received no counseling. CONCLUSIONS: Physician counseling can reduce risk of medication-induced birth defects. However, efforts are needed to ensure that PCPs consistently inform women of teratogenic risks and provide access to highly effective contraception.

Characteristics of patients who seek care via eVisits instead of office visits.

PURPOSE: There is growing recognition that many physician-patient encounters do not require face-to-face contact. The availability of secure Internet portals creates the opportunity for online eVisits. Increasing numbers of health systems provide eVisits, and many health plans reimburse for eVisits. However, little is known on who chooses to seek care via an eVisit. MATERIALS AND METHODS: At four primary care practices, we used the electronic medical record to identify all eVisits and office visits for sinusitis and urinary tract infections (UTIs) between January 2010 and May 2011. From the electronic medical record we abstracted the necessary information on patient demographics. The population studied included 5,165 sinusitis visits (9% of which were eVisits) and 2,954 UTI visits (3% eVisits). RESULTS: In multivariate models controlling for other patient factors, the variables most strongly associated with a patient initiating an eVisit versus an office visit were age (18-44 years of age versus 65 years of age and older: sinusitis, odds ratio 1.65 [0.97-2.81]; UTI, 2.97 [1.03-8.62]) and longer travel distance to clinic (>10 miles from patient home to clinic versus 0-5 miles: sinusitis, odds ratio 6.54 [4.68-9.16]; UTI, odds ratio 3.25 [1.74-6.07]). Higher income was not associated with higher eVisit use. CONCLUSIONS: At these four primary care practices, eVisits accounted for almost 7% of visits for sinusitis and UTI. eVisits attract a younger patient population who might use eVisits for convenience reasons.

Promoting safe prescribing in primary care with a contraceptive vital sign: a cluster-randomized controlled trial.

PURPOSE: Routine assessment of women's pregnancy intentions and contraceptive use-a so-called contraceptive vital sign-may help primary care physicians identify patients who need preconception or contraceptive counseling and be of particular benefit when teratogenic medications are prescribed. METHODS: We conducted a cluster-randomized controlled trial to evaluate the effect of a contraceptive vital sign on primary care documentation of contraceptive use and change in primary care physicians' provision of family planning services. Academic internists in the intervention group (n = 26) were provided with information on their female patients' pregnancy intentions and contraceptive use immediately before visits; internists in the control group (n = 27) received only standard intake information. Data were abstracted from the electronic health record for 5,371 visits by 2,304 women aged 18 to 50 years. RESULTS: Documentation of contraception increased from baseline, from 23% to 57% in the intervention group, but remained 28% in the control group, a change of +77.4 (95% confidence interval [CI], 70.7 to 84.1) adjusted percentage points in the former vs +3.1 (95% CI, 1.2 to 5.0) in the latter (P <.001). For visits involving a teratogenic prescription, documentation increased from 14% to 48% in the intervention group and decreased from 29% to 26% in the control group, a change of +61.5 (95% CI, 35.8 to 87.1) adjusted percentage points in the former vs -0.3 (95% CI, -4.3 to 3.6) in the latter (P <.001). Provision of new family planning services increased only minimally with this intervention, however. When women with documented nonuse of contraception were prescribed potential teratogens, only 7% were provided family planning services. CONCLUSIONS: A contraceptive vital sign improves documentation of contraceptive use; however, ongoing efforts are needed to improve provision of preconception and contraceptive services.

Clinical decision support to promote safe prescribing to women of reproductive age: a cluster-randomized trial.

BACKGROUND: Potentially teratogenic medications are frequently prescribed without provision of contraceptive counseling. OBJECTIVE: To evaluate whether computerized clinical decision support (CDS) can increase primary care providers' (PCPs') provision of family planning services when prescribing potentially teratogenic medications. DESIGN: Cluster-randomized trial conducted in one academic and one community-based practice between October of 2008 and April of 2010. PARTICIPANTS/INTERVENTIONS: Forty-one PCPs were randomized to receive one of two types of CDS which alerted them to risks of medication-induced birth defects when ordering potentially teratogenic medications for women who may become pregnant. The 'simple' CDS provided a cautionary alert; the 'multifaceted' CDS provided tailored information and links to a structured order set designed to facilitate safe prescribing. Both CDS systems alerted PCPs about medication risk only once per encounter. MAIN MEASURES: We assessed change in documented provision of family planning services using data from 35,110 encounters and mixed-effects models. PCPs completed surveys before and after the CDS systems were implemented, allowing assessment of change in PCP-reported counseling about the risks of medication-induced birth defects and contraception. KEY RESULTS: Both CDS systems were associated with slight increases in provision of family planning services when potential teratogens were prescribed, without a significant difference in improvement by CDS complexity (p = 0.87). Because CDS was not repeated, 13% of the times that PCPs received CDS they substituted another potential teratogen. PCPs reported significant improvements in several counseling and prescribing practices. The multifaceted group reported a greater increase in the number of times per month they discussed the risks of medication use during pregnancy (multifaceted: +4.9 ± 7.0 vs. simple: +0.8 ± 3.2, p = 0.03). The simple CDS system was associated with greater clinician satisfaction. CONCLUSIONS: CDS systems hold promise for increasing provision of family planning services when fertile women are prescribed potentially teratogenic medications, but further refinement of these systems is needed.

Internet-based medical visit and diagnosis for common medical problems: experience of first user cohort.

OBJECTIVE: Internet-based medical visits, or "structured e-Visits," allow patients to report symptoms and seek diagnosis and treatment from their doctor over a secure Web site, without calling or visiting the physician's office. While acceptability of e-Visits has been investigated, outcomes associated with e-Visits, that is, whether patients receiving diagnoses receive appropriate care or need to return to the doctor, remain unexplored. MATERIALS AND METHODS: The first 156 e-Visit users from a large family medicine practice were surveyed regarding their experience with the e-Visit and e-Visit outcomes. In addition, medical records for patients making e-Visits were reviewed to examine need for follow-up care within 7 days. RESULTS: Interviews were completed with 121 patients (77.6% participation). The most common type of e-Visit was for "other" symptoms or concerns (37%), followed by sinus/cold symptoms (35%). Back pain, urinary symptoms, cough, diarrhea, conjunctivitis, and vaginal irritation were each less frequent (<10%). A majority, 61% completed e-Visits with their own physician. The majority of patients (57.0%) reported receipt of a diagnosis without need for follow-up beyond a prescription; 75% of patients thought the e-Visit was as good as or better than an in-person visit, and only 11.6% felt that their concerns or questions were incompletely addressed. In a review of medical records, 16.9% had a follow-up visit within 7 days, mostly for the same condition. Four of these were on the same day as the e-Visit, including one emergency department visit. CONCLUSIONS: Outcomes for the e-Visit suggest that it is an appropriate and potentially cost-saving addition to in-person delivery of primary care.

eVisit: a pilot study of a new kind of healthcare delivery.

Patient online eVisits are gaining momentum due to increasing consumer demand for improved access to clinical services, availability of new technologies to deploy such services and development of reimbursement initiatives by major payers. The eVisit service provides patients with an online consultation through a series of structured, secure message exchanges with a physician, providing an alternative for onsite office visits and non-reimbursed phone-based care. In this study, we evaluate a pilot deployment of eVisits in a primary care clinic providing online consultation service for 7 simple health conditions at its three locations. We examine usage data over 3 months and survey and interview results for trends in adoption, demographic and temporal patterns of usage, clinician and patient expectations and experiences, and challenges to sustainability of the service. Based on our analysis, we conclude that the eVisit pilot was a success. Patients valued the new service being offered as demonstrated by a rapid increase in usage. The quality of service was good with fast turnaround times and few exchanges to resolve a request. These positive outcomes combined with a reimbursement model are promising indications of sustainability but several challenges remain.