User interface accelerators for clinical documentation in Smart Form

We have deployed a number of user interface accelerators within the text editor of a documentation-based clinical decision support application. These accelerators enhance the process of documenting a visit and promote closer integration of actionable decision support into the documentation workflow.

The Acute Respiratory Infection Quality Dashboard: a performance measurement reporting tool in an electronic health record

Quality reporting tools, integrated with electronic health records, can help clinicians understand performance, manage populations, and improve quality. The Acute Respiratory Infection Quality Dashboard (ARI QD) for LMR users is a secure web report for performance measurement of an acute condition delivered through a central data warehouse and custom-built reporting tool. Pilot evaluation of the ARI QD indicates that clinicians prefer a quality report that combines not only structured data regarding diagnosis and antibiotic prescribing rates entered into EHRs but one that also shows billing data. The ARI QD has the potential to reduce inappropriate antibiotic prescribing for ARIs.

Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists

The period following discharge from the hospital is a vulnerable time for patients. About half of adults experience a medical error after hospital discharge, and 19%-23% suffer an adverse event, most commonly an adverse drug event. This article reviews several important challenges to providing high-quality care as patients leave the hospital. These include the discontinuity between hospitalists and primary care physicians, changes to the medication regimen, new self-care responsibilities that may stress available resources, and complex discharge instructions. We also discuss approaches to promoting more effective transitions of care, including improvements in communication between inpatient and outpatient physicians, effective reconciliation of prescribed medication regimens, adequate education of patients about medication use, closer medical follow-up, engagement with social support systems, and greater clarity in physician-patient communication. By understanding the key challenges and adopting strategies to improve patient care in the transition from hospital to home, hospitalists could significantly reduce medical errors in the postdischarge period.

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network

Confusion about patients' medication regimens during the hospital admission and discharge process accounts for many preventable and serious medication errors. Many organizations have begun to redesign their clinical processes to address this patient safety concern. Partners HealthCare, an integrated delivery network in Boston, Massachusetts, has answered this interdisciplinary challenge by leveraging its multiple outpatient electronic medical records (EMR) and inpatient computerized provider order entry (CPOE) systems to facilitate the process of medication reconciliation. This manuscript describes the design of a novel application and the associated services that aggregate medication data from EMR and CPOE systems so that clinicians can efficiently generate an accurate pre-admission medication list. Information collected with the use of this application subsequently supports the writing of admission and discharge orders by physicians, performance of admission assessment by nurses, and reconciliation of inpatient orders by pharmacists. Results from early pilot testing suggest that this new medication reconciliation process is well accepted by clinicians and has significant potential to prevent medication errors during transitions of care.

Empowering patients to improve the quality of their care: design and implementation of a shared health maintenance module in a US integrated healthcare delivery network

We describe a health maintenance module within a personal health record designed to improve the quality of routine preventive care for patients in a large integrated healthcare delivery network. This module allows patients and their providers to share an online medical record and decision support tools. Our preliminary results indicate that this approach is well-accepted by patients and their providers and has significant potential to facilitate patient-provider communication and improve the quality of routine health maintenance care. Further research will determine the long term impact and sustainability of this approach.

Accuracy of ICD-9 coding for Clostridium difficile infections: a retrospective cohort

Clostridium difficile (C. diff) is a major nosocomial problem. Epidemiological surveillance of the disease can be accomplished by microbiological or administrative data. Microbiological tracking is problematic since it does not always translate into clinical disease, and it is not always available. Tracking by administrative data is attractive, but ICD-9 code accuracy for C. diff is unknown. By using a large administrative database of hospitalized patients with C. diff (by ICD-9 code or cytotoxic assay), this study found that the sensitivity, specificity, positive, and negative predictive values of ICD-9 coding were 71%, 99%, 87%, and 96% respectively (using micro data as the gold standard). When only using symptomatic patients the sensitivity increased to 82% and when only using symptomatic patients whose test results were available at discharge, the sensitivity increased to 88%. C. diff ICD-9 codes closely approximate true C. diff infection, especially in symptomatic patients whose test results are available at the time of discharge, and can therefore be used as a reasonable alternative to microbiological data for tracking purposes.

Design and implementation of a web-based patient portal linked to an ambulatory care electronic health record: patient gateway for diabetes collaborative care

BACKGROUND

Despite the availability of expert guidelines and widespread diabetes quality improvement efforts, care of patients with diabetes remains suboptimal. Two key barriers to care that may be amenable to informatics-based interventions include (1) lack of patient engagement with therapeutic care plans and (2) lack of medication adjustment by physicians ("clinical inertia") during clinical encounters.

METHODS

The authors describe the conceptual framework, design, implementation, and analysis plan for a diabetes patient web-portal linked directly to the electronic health record (EHR) of a large academic medical center via secure Internet access designed to overcome barriers to effective diabetes care.

RESULTS

Partners HealthCare System (Boston, MA), a multi-hospital health care network comprising several thousand physicians caring for over 1 million individual patients, has developed a comprehensive patient web-portal called Patient Gateway that allows patients to interact directly with their EHR via secure Internet access. Using this portal, a specific diabetes interface was designed to maximize patient engagement by importing the patient's current clinical data in an educational format, providing patient-tailored decision support, and enabling the patient to author a "Diabetes Care Plan." The physician view of the patient's Diabetes Care Plan was designed to be concise and to fit into typical EHR clinical workflow.

CONCLUSIONS

We successfully designed and implemented a Diabetes Patient portal that allows direct interaction with our system's EHR. We are assessing the impact of this advanced informatics tool for collaborative diabetes care in a clinic-randomized controlled trial among 14 primary care practices within our integrated health care system.

Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out

BACKGROUND

Restrictions in the hours residents can be on duty have resulted in increased sign-outs, that is, transfer of patient care information and responsibility from one physician to a cross-coverage physician, leading to discontinuity in patient care. This sign-out process, which occurs primarily in the inpatient setting, traditionally has been informal, unstructured, and idiosyncratic. Although studies show that discontinuity may be harmful to patients, this is little data to assist residency programs in redesigning systems to improve sign-out and manage the discontinuity.

PURPOSE

This article reviews the relevant medical literature, current practices in non-health professions in managing discontinuity, and summarizes the existing practice and experiences at 3 academic internal medicine hospitalist-based programs.

CONCLUSIONS

We provide recommendations and strategies for best practices to design safe and effective sign-out systems for residents that may also be useful to hospitalists working in academic and community settings.

Clinical pharmacists and inpatient medical care: a systematic review

BACKGROUND

The role of clinical pharmacists in the care of hospitalized patients has evolved over time, with increased emphasis on collaborative care and patient interaction. The purpose of this review was to evaluate the published literature on the effects of interventions by clinical pharmacists on processes and outcomes of care in hospitalized adults.

METHODS

Peer-reviewed, English-language articles were identified from January 1, 1985, through April 30, 2005. Three independent assessors evaluated 343 citations. Inpatient pharmacist interventions were selected if they included a control group and objective patient-specific health outcomes; type of intervention, study design, and outcomes such as adverse drug events, medication appropriateness, and resource use were abstracted.

RESULTS

Thirty-six studies met inclusion criteria, including 10 evaluating pharmacists' participation on rounds, 11 medication reconciliation studies, and 15 on drug-specific pharmacist services. Adverse drug events, adverse drug reactions, or medication errors were reduced in 7 of 12 trials that included these outcomes. Medication adherence, knowledge, and appropriateness improved in 7 of 11 studies, while there was shortened hospital length of stay in 9 of 17 trials. No intervention led to worse clinical outcomes and only 1 reported higher health care use. Improvements in both inpatient and outpatient outcome measurements were observed.

CONCLUSIONS

The addition of clinical pharmacist services in the care of inpatients generally resulted in improved care, with no evidence of harm. Interacting with the health care team on patient rounds, interviewing patients, reconciling medications, and providing patient discharge counseling and follow-up all resulted in improved outcomes. Future studies should include multiple sites, larger sample sizes, reproducible interventions, and identification of patient-specific factors that lead to improved outcomes.

Inpatient management of diabetes and hyperglycemia among general medicine patients at a large teaching hospital

BACKGROUND

Because of the relationship between inpatient hyperglycemia and adverse patient outcomes, current guidelines recommend glucose levels less than 180 mg/dL in the non-ICU inpatient setting and the use of effective insulin protocols for appropriate patients.

OBJECTIVE

To determine the current state of glucose management on an academic hospitalist service and the relationship between insulin-ordering practices and glycemic control.

DESIGN

Prospective cohort study.

SETTING

Hospitalist-run general medicine service of an academic teaching hospital.

PATIENTS

107 consecutive patients with diabetes mellitus or inpatient hyperglycemia.

MEASUREMENTS

We collected data on up to 4 bedside glucose measurements per day, detailed clinical information, and all orders related to glucose management. The primary outcomes were rate of hyperglycemia (glucose > 180 mg/dL) per patient and mean glucose level per patient-day.

RESULTS

The mean rate of hyperglycemia was 31% of measurements per patient. Basal insulin was ordered for 43% of patients, and scheduled rapid- or short-acting insulin was ordered for 4% of patients. Sixty-five percent of patients who had at least 1 episode of hyper- or hypoglycemia had no change made to any insulin order during the first 5 days of the hospitalization. When adjusted for clinical factors, the use of sliding-scale insulin by itself was associated with a 20 mg/dL higher mean glucose level per patient-day.

CONCLUSIONS

Management of diabetes and hyperglycemia on a general medicine service showed several deficiencies in process and outcome. Possible targets for improvement include increased use of basal and nutritional insulin and daily insulin adjustment in response to hyperglycemia.

Effect of the inpatient general medicine rotation on student pursuit of a generalist career

BACKGROUND

Entry into general internal medicine (GIM) has declined. The effect of the inpatient general medicine rotation on medical student career choices is uncertain.

OBJECTIVE

To assess the effect of student satisfaction with the inpatient general medicine rotation on pursuit of a career in GIM.

DESIGN

Multicenter cohort study.

PARTICIPANTS

Third-year medical students between July 2001 and June 2003.

MEASUREMENTS

End-of-internal medicine clerkship survey assessed satisfaction with the rotation using a 5-point Likert scale. Pursuit of a career in GIM defined as: (1) response of "Very Likely" or "Certain" to the question "How likely are you to pursue a career in GIM?"; and (2) entry into an internal medicine residency using institutional match data.

RESULTS

Four hundred and two of 751 (54%) students responded. Of the student respondents, 307 (75%) matched in the 2 years following their rotations. Twenty-eight percent (87) of those that matched chose an internal medicine residency. Of these, 8% (25/307) were pursuing a career in GIM. Adjusting for site and preclerkship interest, overall satisfaction with the rotation predicted pursuit of a career in GIM (odds ratio [OR] 3.91, P<.001). Although satisfaction with individual items did not predict pursuit of a generalist career, factor analysis revealed 3 components of satisfaction (attending, resident, and teaching). Adjusting for preclerkship interest, 2 factors (attending and teaching) were associated with student pursuit of a career in GIM (P<.01).

CONCLUSIONS

Increased satisfaction with the inpatient general medicine rotation promotes pursuit of a career in GIM.

Role of pharmacist counseling in preventing adverse drug events after hospitalization

BACKGROUND

Hospitalization and subsequent discharge home often involve discontinuity of care, multiple changes in medication regimens, and inadequate patient education, which can lead to adverse drug events (ADEs) and avoidable health care utilization. Our objectives were to identify drug-related problems during and after hospitalization and to determine the effect of patient counseling and follow-up by pharmacists on preventable ADEs.

METHODS

We conducted a randomized trial of 178 patients being discharged home from the general medicine service at a large teaching hospital. Patients in the intervention group received pharmacist counseling at discharge and a follow-up telephone call 3 to 5 days later. Interventions focused on clarifying medication regimens; reviewing indications, directions, and potential side effects of medications; screening for barriers to adherence and early side effects; and providing patient counseling and/or physician feedback when appropriate. The primary outcome was rate of preventable ADEs.

RESULTS

Pharmacists observed the following drug-related problems in the intervention group: unexplained discrepancies between patients' preadmission medication regimens and discharge medication orders in 49% of patients, unexplained discrepancies between discharge medication lists and postdischarge regimens in 29% of patients, and medication nonadherence in 23%. Comparing trial outcomes 30 days after discharge, preventable ADEs were detected in 11% of patients in the control group and 1% of patients in the intervention group (P = .01). No differences were found between groups in total ADEs or total health care utilization.

CONCLUSIONS

Pharmacist medication review, patient counseling, and telephone follow-up were associated with a lower rate of preventable ADEs 30 days after hospital discharge. Medication discrepancies before and after discharge were common targets of intervention.

Decision support for acute problems: the role of the standardized patient in usability testing

For applications that require clinician use while interacting with patients, usability testing with standardized patients has the potential to approximate actual patient care in a controlled setting. We used hypothetical scenarios and a standardized patient to collect quantitative and qualitative results in testing an early prototype of a new application, the Acute Respiratory Infection (ARI) Smart Form. The standardized patient fit well into the usability testing sessions. Clinicians had a positive response to the standardized patients and behaved as they normally would during a clinical encounter. Positive findings of the ARI Smart Form included that users thought it had impressive functionality and the potential to save time. Criticism focused on the visual design, which could be streamlined, and navigation, which was difficult in some areas. Based on these results, we are modifying the ARI Smart Form in preparation for use in actual patient care. Standardized patients should be considered for usability testing, especially if an application is to be used during the patient interview.

Quality Dashboards: technical and architectural considerations of an actionable reporting tool for population management

Quality Dashboards (QD) is a condition-specific, actionable web-based application for quality reporting and population management that is integrated into the Electronic Health Record (EHR). Using server-based graphic web controls in a .Net environment to construct Quality Dashboards allows customization of the reporting tool without the need to rely on commercial business intelligence tool. Quality Dashboards will improve patient care and quality outcomes as clinicians utilize the reporting tool for population management.

Barriers to electronic health record use during patient visits

The effectiveness of electronic health record (EHR)-based clinical decision support is limited when clinicians do not interact with the EHR during patient visits. To assess EHR use during ambulatory visits and determine barriers to such use, we performed a cross-sectional survey of 501 primary care clinicians. Of 225 respondents, 53 (24%) never or only sometimes used any EHR functionality during patient visits. Non-physician clinicians (e.g., nurse practitioners) were marginally more likely to be EHR non-users than physicians (39% versus 21%, respectively; p = .05). The most commonly reported barriers to using the EHR during patient visits were loss of eye contact with patients (62%), falling behind schedule (52%), computers being too slow (49%), inability to type quickly enough (32%), feeling that using the computer in front of the patient is rude (31%), and preferring to write long prose notes (28%). EHR developers and healthcare system leaders must address social, workflow, technical, and professional barriers if clinicians are to use EHRs in the presence of patients and realize the full potential of ambulatory clinical decision support.

Smart Form framework as a foundation for clinical documentation platform

Smart Form--a condition-driven documentation tool with integrated advanced decision support--is built on a flexible framework and is evolving into a platform for a variety of Web-based clinical documentation systems.

Using qualitative studies to improve the usability of an EMR

The adoption of electronic medical records (EMRs) and user satisfaction are closely associated with the system's usability. To improve the usability of a results management module of a widely deployed web-based EMR, we conducted two qualitative studies that included multiple focus group and field study sessions. Qualitative research can help focus attention on user tasks and goals and identify patterns of care that can be visualized through task modeling exercises. Findings from both studies raised issues with the amount and organization of information in the display, interference with workflow patterns of primary care physicians, and the availability of visual cues and feedback. We used the findings of these studies to recommend design changes to the user interface of the results management module.

Diagnostic yield and utility of neurovascular ultrasonography in the evaluation of patients with syncope

OBJECTIVE

To determine the diagnostic utility of neurovascular ultrasonography (transcranial Doppler and carotid ultrasonography) in patients with syncope.

PATIENTS AND METHODS

We retrospectively identified consecutive patients who underwent neurovascular ultrasonography for the diagnosis of syncope or presyncope at an academic hospital in 1997 and 1998. From medical records we abstracted patient demographic and clinical information, results and consequences of testing, and follow-up data for 3 years.

RESULTS

A total of 140 patients participated in the study. The median age of the study patients was 74 years (interquartile range, 66-80 years), and 49% were male. Severe extracranial or Intracranial cerebrovascular disease was found on neurovascular ultrasonography in 20 patients (14%; 95% confidence interval [CI], 9.5%-21%). Focal neurologic signs or symptoms or carotid bruits were found in 19 (95%) of 20 patients with positive test results compared with 46 (38%) of 120 patients without severe disease (P<.001). Ultrasonography identified cerebrovascular lesions that may have contributed to the syncopal process in only 2 (1.4%) of 140 patients (95% CI, 0.39%-5.1%), but the lesions were unlikely to have been the primary cause of syncope in either patient.

CONCLUSION

In this predominantly stroke-age population, neurovascular ultrasonography had a low yield for diagnosing vascular lesions that contributed to the pathophysiology of syncope. However, in patients with focal signs or symptoms or carotid bruits, it detected incidental lesions that typically require treatment or follow-up. In patients with syncope, neurovascular ultrasonography should be reserved for this subset. The data suggest enhancements to the American College of Physicians guideline for the use of neurovascular ultrasonography in patients with syncope.

Smart Forms: building condition-specific documentation and decision support tools for ambulatory EHR

Smart Forms are condition-specific documentation tools that integrate pertinent data review, guideline-based decision support, ambulatory order entry, patient education and coded data capture capabilities. Smart Forms are being developed as Web applications in a service oriented architecture and employ a rules engine for dynamic content generation.

Diagnostic evaluation and management of patients with syncope

This article focuses on the evaluation of patients with syncope, a symptom not a disease. Syncope is a transient loss of consciousness associated with loss of postural tone with spontaneous recovery. The authors discuss the utility of an indications for different diagnostic tests, the indications for hospital admission, and the management of patients with certain known causes of syncope, including vasovagal and arrhythmic.