Use of electronic health records in U.S. hospitals

Predictors of success for electronic health record implementation in small physician practices

BACKGROUND

The federal government is promoting adoption of electronic health records (EHRs) through financial incentives for EHR use and implementation support provided by regional extension centers. Small practices have been slow to adopt EHRs.

OBJECTIVES

Our objective was to measure time to EHR implementation and identify factors associated with successful implementation in small practices receiving financial incentives and implementation support. This study is unique in exploiting quantitative implementation time data collected prospectively as part of routine project management.

METHODS

This mixed-methods study includes interviews of key informants and a cohort study of 544 practices that had worked with the Primary Care Information Project (PCIP), a publicly funded organization that since 2007 has subsidized EHRs and provided implementation support similar to that supplied by the new regional extension centers. Data from a project management database were used for a cohort study to assess time to implementation and predictors of implementation success.

RESULTS

Four hundred and thirty practices (79%) implemented EHRs within the analysis period, with a median project time of 24.7 weeks (95% CI: 23.3 - 26.4). Factors associated with implementation success were: fewer providers, practice sites, and patients; fewer Medicaid and uninsured patients; having previous experience with scheduling software; enrolling in 2010 rather than earlier; and selecting an integrated EHR plus practice management product rather than two products. Interviews identified positive attitude toward EHRs, resources, and centralized leadership as additional practice-level predictors of success.

CONCLUSIONS

A local initiative similar to current federal programs successfully implemented EHRs in primary care practices by offsetting software costs and providing implementation assistance. Nevertheless, implementation success was affected by practice size and other characteristics, suggesting that the federal programs can reduce barriers to EHR implementation but may not eliminate them.

Investigating and learning lessons from early experiences of implementing ePrescribing systems into NHS hospitals: a questionnaire study

BACKGROUND

ePrescribing systems have significant potential to improve the safety and efficiency of healthcare, but they need to be carefully selected and implemented to maximise benefits. Implementations in English hospitals are in the early stages and there is a lack of standards guiding the procurement, functional specifications, and expected benefits. We sought to provide an updated overview of the current picture in relation to implementation of ePrescribing systems, explore existing strategies, and identify early lessons learned.

METHODS

A descriptive questionnaire-based study, which included closed and free text questions and involved both quantitative and qualitative analysis of the data generated.

RESULTS

We obtained responses from 85 of 108 NHS staff (78.7% response rate). At least 6% (n = 10) of the 168 English NHS Trusts have already implemented ePrescribing systems, 2% (n = 4) have no plans of implementing, and 34% (n = 55) are planning to implement with intended rapid implementation timelines driven by high expectations surrounding improved safety and efficiency of care. The majority are unclear as to which system to choose, but integration with existing systems and sophisticated decision support functionality are important decisive factors. Participants highlighted the need for increased guidance in relation to implementation strategy, system choice and standards, as well as the need for top-level management support to adequately resource the project. Although some early benefits were reported by hospitals that had already implemented, the hoped for benefits relating to improved efficiency and cost-savings remain elusive due to a lack of system maturity.

CONCLUSIONS

Whilst few have begun implementation, there is considerable interest in ePrescribing systems with ambitious timelines amongst those hospitals that are planning implementations. In order to ensure maximum chances of realising benefits, there is a need for increased guidance in relation to implementation strategy, system choice and standards, as well as increased financial resources to fund local activities.

Development of information systems and clinical decision support systems for emergency departments: a long road ahead for Japan

Emergency care services face common challenges worldwide, including the failure to identify emergency illnesses, deviations from standard treatments, deterioration in the quality of medical care, increased costs from unnecessary testing, and insufficient education and training of emergency personnel. These issues are currently being addressed by implementing emergency department information systems (EDIS) and clinical decision support systems (CDSS). Such systems have been shown to increase the efficiency and safety of emergency medical care. In Japan, however, their development is hindered by a shortage of emergency physicians and insufficient funding. In addition, language barriers make it difficult to introduce EDIS and CDSS in Japan that have been created for an English-speaking market. This perspective addresses the key events that motivated a campaign to prioritise these services in Japan and the need to customise EDIS and CDSS for its population.

Hospital IT Sophistication Profiles and Patient Safety Outcomes

Information technology (IT) sophistication of acute care hospitals in Texas was measured to explore the relationships between IT infrastructure and patient outcomes using Donabedian’s framework. The sample was acute care hospitals (n=175) with an IT profile using HIMSS, demographic and operations data. Three dimensions of hospital IT sophistication were measured and related to patient care outcomes using the AHRQ Patient Safety Indicators (PSI). Significant relationships (p < 0.05) using linear regression were found between hospital IT sophistication and three PSI measures. A review of similar studies during the same time period in Iowa, Georgia, and Florida compares findings from two instruments used to profile hospital IT infrastructure. This study adds to and confirms findings of positive relationships between IT sophistication of hospitals and patient care outcomes using the AHRQ safety indicators. Discussion of the conceptual model and the IT sophistication construct provides a theoretical framework for this line of research.

Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition).

SEARCH METHODS

For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. 

SELECTION CRITERIA

We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome.

MAIN RESULTS

In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.

Internal medicine residents' computer use in the inpatient setting

BACKGROUND

Studies have suggested that patient contact time for internal medicine residents is decreasing and being replaced with computer-related activities, yet objective data regarding computer use by residents are lacking.

OBJECTIVE

The aim of this study was to objectively measure time use by internal medicine residents while on duty in the hospital setting using real-time, voice-capture technology.

METHODS

First- and third-year categoric internal medicine residents participated (n  =  25) during a 3-month period in 2010 while rotating on general internal medicine rotations. Portable speech-recognition technology was used to record residents' activities. The residents were prompted every 15 minutes from an earpiece and asked to categorize the activity they had been doing since the last prompt, choosing from a predetermined list of 15 activities.

RESULTS

Of the 1008 duty-time responses, 493 (49%) were classified as computer-related activities, whereas 341 (34%) were classified as direct patient care, 110 (11%) were classified as noncomputer-related education, and 64 (6%) were classified as other activities. Of resident reported computer-use time, 70% was spent on patient notes and order entry.

CONCLUSIONS

The results of our study suggest that computer use is the predominant activity for internal medicine residents while in the inpatient setting. Work redesign because of duty hour regulations should consider how to free up residents' time from computer-based activities to allow residents to engage in more direct patient care and noncomputer-based learning.

Electronic health record adoption and health information exchange among hospitals in New York State

RATIONALE, AIMS AND OBJECTIVES

Unprecedented national and state initiatives are underway to promote adoption and meaningful use of electronic health records (EHRs) with health information exchange (HIE). New York State leads the nation in state initiatives and is conducting ongoing surveillance of its investments. Lessons learned from studying states like New York can inform federal policies and will be essential to evaluate the effectiveness of these initiatives. We undertook this first in a series of planned surveys to assess EHR adoption and HIE activities by New York State hospitals.

METHODS

Between May and December 2009, we surveyed all New York State hospitals to determine rates of EHR adoption, participation in HIE and implementation of functionalities associated with nine core meaningful use criteria.

RESULTS

We received responses from 148 (72.2%) of 205 hospitals surveyed and found that 23 (15.5%) had adopted an EHR and 29 (23.2%) were participating in HIE. Two hospitals (1.4%) reported full implementation of the meaningful use functionalities surveyed. Public hospitals were ahead of private hospitals and notable regional differences were found.

DISCUSSION

EHR adoption rates and participation in HIE are higher among New York hospitals than hospitals nationwide, suggesting that state initiatives funding community EHR implementation may influence these efforts by hospitals. However, overall rates of adoption and preparedness to meet meaningful use remain low. Direct support for hospitals, such as that provided through the national EHR Incentive Program, will likely be critical for rates of EHR adoption and HIE to significantly rise, even in advanced states.

Use of electronic health records and administrative data for public health surveillance of eye health and vision-related conditions in the United States

PURPOSE

To discuss the current trend toward greater use of electronic health records and how these records could enhance public health surveillance of eye health and vision-related conditions.

DESIGN

Perspective, comparing systems.

METHODS

We describe 3 currently available sources of electronic health data (Kaiser Permanente, the Veterans Health Administration, and the Centers for Medicare & Medicaid Services) and how these sources can contribute to a comprehensive vision and eye health surveillance system.

RESULTS

Each of the 3 sources of electronic health data can contribute meaningfully to a comprehensive vision and eye health surveillance system, but none currently provide all the information required. The use of electronic health records for vision and eye health surveillance has both advantages and disadvantages.

CONCLUSIONS

Electronic health records may provide additional information needed to create a comprehensive vision and eye health surveillance system. Recommendations for incorporating electronic health records into such a system are presented.

Patient characteristics associated with venous thromboembolic events: a cohort study using pooled electronic health record data

OBJECTIVE

To demonstrate the potential of de-identified clinical data from multiple healthcare systems using different electronic health records (EHR) to be efficiently used for very large retrospective cohort studies.

MATERIALS AND METHODS

Data of 959 030 patients, pooled from multiple different healthcare systems with distinct EHR, were obtained. Data were standardized and normalized using common ontologies, searchable through a HIPAA-compliant, patient de-identified web application (Explore; Explorys Inc). Patients were 26 years or older seen in multiple healthcare systems from 1999 to 2011 with data from EHR.

RESULTS

Comparing obese, tall subjects with normal body mass index, short subjects, the venous thromboembolic events (VTE) OR was 1.83 (95% CI 1.76 to 1.91) for women and 1.21 (1.10 to 1.32) for men. Weight had more effect then height on VTE. Compared with Caucasian, Hispanic/Latino subjects had a much lower risk of VTE (female OR 0.47, 0.41 to 0.55; male OR 0.24, 0.20 to 0.28) and African-Americans a substantially higher risk (female OR 1.83, 1.76 to 1.91; male OR 1.58, 1.50 to 1.66). This 13-year retrospective study of almost one million patients was performed over approximately 125 h in 11 weeks, part time by the five authors.

DISCUSSION

As research informatics tools develop and more clinical data become available in EHR, it is important to study and understand unique opportunities for clinical research informatics to transform the scale and resources needed to perform certain types of clinical research.

CONCLUSIONS

With the right clinical research informatics tools and EHR data, some types of very large cohort studies can be completed with minimal resources.

An Objective Study of the Impact of the Electronic Medical Record on Outcomes in Trauma Patients

It is commonly believed that the electronic medical record (EMR) will improve patient outcomes. However, there is scant published literature to support this claim and no studies in any surgical population. Our hypothesis was that the EMR would not improve objective outcome measures in patients with traumatic injury. Prospectively collected data from our university-based Level I trauma center was retrospectively reviewed. Demographic, injury severity as well as outcomes and complications data were compared for all patients admitted over a 20-month period before introduction of the EMR and a 20-month period after full, hospital-wide use of the EMR. Implementation of the EMR was associated with a decreased hospital length of stay, P = 0.02; intensive care unit length of stay, P = 0.001; ventilator days, P = 0.002; acute respiratory distress syndrome, P = 0.006, pneumonia, P = 0.008; myocardial infarction, P = 0.001; line infection, P = 0.03; septicemia, P = 0.000; renal failure, P = 0.000; drug complication, P = 0.001; and delay in diagnosis, P = 0.04. There was no difference in mortality, unexpected cardiac arrest, missed injury, pulmonary embolism/deep vein thrombosis, or late urinary tract infection. This is the first study to investigate the impact of the EMR in surgical patients. Although there was an improvement in some complications, the overall impact was inconsistent.

Correlations among risk-standardized mortality rates and among risk-standardized readmission rates within hospitals

BACKGROUND

Hospital-level, 30-day risk-standardized mortality and readmission rates are publicly reported for Medicare patients admitted with acute myocardial infarction (AMI), heart failure (HF), and pneumonia, but the correlations among mortality rates and among readmission rates within US hospitals for these conditions are unknown. Correlation among measures within the same hospital would suggest that there are common hospital-wide quality factors.

METHODS

We designed a cross-sectional study of US hospital 30-day risk-standardized mortality and readmission rates for Medicare fee-for-service beneficiaries from July 2007 to June 2009. We assessed the correlation between pairs of risk-standardized mortality rates and pairs of risk-standardized readmission rates for AMI, HF, and pneumonia.

RESULTS

The mortality cohort included 4559 hospitals, and the readmission cohort included 4468 hospitals. Every mortality measure was significantly correlated with every other mortality measure (range of correlation coefficients, 0.27-0.41, P < 0.0001 for all correlations). Every readmission measure was significantly correlated with every other readmission measure (range of correlation coefficients, 0.32-0.47, P < 0.0001 for all correlations). For each condition pair and outcome, one-third or more of hospitals were in the same quartile of performance. Correlations were highest within large, nonprofit, urban, and/or Council of Teaching Hospitals members. For any given condition pair, the correlation between readmission rates was significantly higher than the correlation between mortality rates (P < 0.01 for all pairs).

CONCLUSION

Risk-standardized readmission rates are moderately correlated with each other within hospitals, as are risk-standardized mortality rates. This suggests that there may be common hospital-wide factors affecting hospital outcomes.

Economic analysis of cloud-based desktop virtualization implementation at a hospital

Background

Cloud-based desktop virtualization infrastructure (VDI) is known as providing simplified management of application and desktop, efficient management of physical resources, and rapid service deployment, as well as connection to the computer environment at anytime, anywhere with anydevice. However, the economic validity of investing in the adoption of the system at a hospital has not been established.

Methods

This study computed the actual investment cost of the hospital-wide VDI implementation at the 910-bed Seoul National University Bundang Hospital in Korea and the resulting effects (i.e., reductions in PC errors and difficulties, application and operating system update time, and account management time). Return on investment (ROI), net present value (NPV), and internal rate of return (IRR) indexes used for corporate investment decision-making were used for the economic analysis of VDI implementation.

Results

The results of five-year cost-benefit analysis given for 400 Virtual Machines (VMs; i.e., 1,100 users in the case of SNUBH) showed that the break-even point was reached in the fourth year of the investment. At that point, the ROI was 122.6%, the NPV was approximately US$192,000, and the IRR showed an investment validity of 10.8%. From our sensitivity analysis to changing the number of VMs (in terms of number of users), the greater the number of adopted VMs was the more investable the system was.

Conclusions

This study confirms that the emerging VDI can have an economic impact on hospital information system (HIS) operation and utilization in a tertiary hospital setting.

From clinical practice guidelines, to clinical guidance in practice - impacts for computerization

This paper presents a case study of clinical guidance within oncology clinics. Close to all patients treated within the observed clinics were treated according to clinical practice guidelines in the form of either a research or a standard treatment protocol. The clinical practice guideline artifacts were however rarely applied in clinical practice. It was first when the guidelines were translated and transformed into second order guiding artifacts (SOGAs) they were applied. The SOGAs applied in clinical practice were activity specific holding space for relevant documentation. The transformation from clinical practice guideline to SOGA was executed according to a standard operating procedure. A wide number of physical features were applied to support quick overview and application in clinical practice. The clinicians were actively participating in the translation and transformation process obtaining ownership to the resulting artifacts. The implications for computerization of clinical practice guidelines are discussed.

Global health business: the production and performativity of statistics in Sierra Leone and Germany

The global push for health statistics and electronic digital health information systems is about more than tracking health incidence and prevalence. It is also experienced on the ground as means to develop and maintain particular norms of health business, knowledge, and decision- and profit-making that are not innocent. Statistics make possible audit and accountability logics that undergird the management of health at a distance and that are increasingly necessary to the business of health. Health statistics are inextricable from their social milieus, yet as business artifacts they operate as if they are freely formed, objectively originated, and accurate. This article explicates health statistics as cultural forms and shows how they have been produced and performed in two very different countries: Sierra Leone and Germany. In both familiar and surprising ways, this article shows how statistics and their pursuit organize and discipline human behavior, constitute subject positions, and reify existing relations of power.

A system for the extraction and representation of summary of product characteristics content

OBJECTIVE

Information about medications is critical in supporting decision-making during the prescription process and thus in improving the safety and quality of care. In this work, we propose a methodology for the automatic recognition of drug-related entities (active ingredient, interaction effects, etc.) in textual drug descriptions, and their further location in a previously developed domain ontology.

METHODS AND MATERIAL

The summary of product characteristics (SPC) represents the basis of information for health professionals on how to use medicines. However, this information is locked in free-text and, as such, cannot be actively accessed and elaborated by computerized applications. Our approach exploits a combination of machine learning and rule-based methods. It consists of two stages. Initially it learns to classify this information in a structured prediction framework, relying on conditional random fields. The classifier is trained and evaluated using a corpus of about a hundred SPCs. They have been hand-annotated with different semantic labels that have been derived from the domain ontology. At a second stage the extracted entities are added in the domain ontology corresponding concepts as new instances, using a set of rules manually-constructed from the corpus.

RESULTS

Our evaluations show that the extraction module exhibits high overall performance, with an average F1-measure of 88% for contraindications and 90% for interactions.

CONCLUSION

SPCs can be exploited to provide structured information for computer-based decision support systems.

The Use of Individualized Pharmacist Performance Reports to Reduce Pharmacist-Related Medication Order Entry Errors following Electronic Medical Record Implementation

Purpose

To measure the impact of an individual pharmacist performance report (IPPR) program on pharmacist-related medication order entry errors (MOEEs) at an academic medical center.

Methods

The number and type of pharmacist-related MOEEs were collected at 2 different times: immediately following implementation of an electronic medical record (baseline) and following completion of the IPPR program. Three different collection methods were utilized to identify and categorize pharmacist-related MOEEs: 1) Patient Safety Net (PSN) incident reporting system, 2) manual event reporting, and 3) a nursing to pharmacy electronic messaging system. The IPPR program consisted of mandatory educational sessions for pharmacist staff. The program content focused on strategies to reduce pharmacist-related MOEEs identified in the baseline data collection period as well as an individualized report generated for each pharmacist having caused an MOEE that showed their performance compared to the department's performance.

Results

The percentage of event reports containing a pharmacist-related MOEE decreased from baseline to post IPPR program (13.7% and 6.3%, respectively; P < .001). In addition, the total number of pharmacist-related MOEEs was halved after the IPPR program (321 vs 148; P < .001). Significant reductions were noted in the following MOEE categories: duplicate orders, missed orders, wrong frequency, wrong dose, and other. Nonsignificant reductions were noted in errors related to no order and wrong drug.

Conclusion

Based on the observations and results of this study, it is proposed that individualized performance feedback can be a successful method to improve MOEE performance by pharmacists.

Impact of automated alerts on follow-up of post-discharge microbiology results: a cluster randomized controlled trial

BACKGROUND

Failure to follow up microbiology results pending at the time of hospital discharge can delay diagnosis and treatment of important infections, harm patients, and increase the risk of litigation. Current systems to track pending tests are often inadequate.

OBJECTIVE

To design, implement, and evaluate an automated system to improve follow-up of microbiology results that return after hospitalized patients are discharged.

DESIGN

Cluster randomized controlled trial.

SUBJECTS

Inpatient and outpatient physicians caring for adult patients hospitalized at a large academic hospital from February 2009 to June 2010 with positive and untreated or undertreated blood, urine, sputum, or cerebral spinal fluid cultures returning post-discharge.

INTERVENTION

An automated e-mail-based system alerting inpatient and outpatient physicians to positive post-discharge culture results not adequately treated with an antibiotic at the time of discharge.

MAIN MEASURES

Our primary outcome was documented follow-up of results within 3 days. Secondary outcomes included physician awareness and assessment of result urgency, impact on clinical assessments and plans, and preferred alerting scenarios.

KEY RESULTS

We evaluated the follow-up of 157 post-discharge microbiology results from patients of 121 physicians. We found documented follow-up in 27/97 (28%) results in the intervention group and 8/60 (13%) in the control group [aOR 3.2, (95% CI 1.3-8.4); p=0.01]. Of all inpatient physician respondents, 32/82 (39%) were previously aware of the results, 45/77 (58%) felt the results changed their assessments and plans, 43/77 (56%) felt the results required urgent action, and 67/70 (96%) preferred alerts for current or broader scenarios.

CONCLUSION

Our alerting system improved the proportion of important post-discharge microbiology results with documented follow-up, though the proportion remained low. The alerts were well received and may be expanded in the future.

Computers in the examination room and the electronic health record: physicians' perceived impact on clinical encounters before and after full installation and implementation

PURPOSE

We compared physicians' self-reported attitudes and behaviours regarding electronic health record (EHR) use before and after installation of computers in patient examination rooms and transition to full implementation of an EHR in a family medicine training practice to identify anticipated and observed effects these changes would have on physicians' practices and clinical encounters.

METHODS

We conducted two individual qualitative interviews with family physicians. The first interview was before and second interview was 8 months later after full implementation of an EHR and computer installation in the examination rooms. Data were analysed through project team discussions and subsequent coding with qualitative analysis software.

RESULTS

At the first interviews, physicians frequently expressed concerns about the potential negative effect of the EHR on quality of care and physician-patient interaction, adequacy of their skills in EHR use and privacy and confidentiality concerns. Nevertheless, most physicians also anticipated multiple benefits, including improved accessibility of patient data and online health information. In the second interviews, physicians reported that their concerns did not persist. Many anticipated benefits were realized, appearing to facilitate collaborative physician-patient relationships. Physicians reported a greater teaching role with patients and sharing online medical information and treatment plan decisions.

CONCLUSIONS

Before computer installation and full EHR implementation, physicians expressed concerns about the impact of computer use on patient care. After installation and implementation, however, many concerns were mitigated. Using computers in the examination rooms to document and access patients' records along with online medical information and decision-making tools appears to contribute to improved physician-patient communication and collaboration.

Method for developing national quality indicators based on manual data extraction from medical records

Developing quality indicators (QI) for national purposes (eg, public disclosure, paying-for-performance) highlights the need to find accessible and reliable data sources for collecting standardised data. The most accurate and reliable data source for collecting clinical and organisational information still remains the medical record. Data collection from electronic medical records (EMR) would be far less burdensome than from paper medical records (PMR). However, the development of EMRs is costly and has suffered from low rates of adoption and barriers of usability even in developed countries. Currently, methods for producing national QIs based on the medical record rely on manual extraction from PMRs.

We propose and illustrate such a method. These QIs display feasibility, reliability and discriminative power, and can be used to compare hospitals. They have been implemented nationwide in France since 2006. The method used to develop these QIs could be adapted for use in large-scale programmes of hospital regulation in other, including developing, countries.

Overcoming challenges to achieving meaningful use: insights from hospitals that successfully received Centers for Medicare and Medicaid Services payments in 2011

OBJECTIVE

In an effort to understand better the federal electronic health record (EHR) incentive programme's challenges, this study compared hospitals that did and did not receive meaningful use (MU) payments in the programme's first year based on the challenges they anticipated a year before.

MATERIALS AND METHODS

This cross-sectional study used 2010 American Hospital Association survey data and 2011 Centers for Medicare and Medicaid Services data that identify hospitals receiving MU payments. Multivariate regression analysis assessed differences in 2010 anticipated challenges to MU for hospitals that were successful in earning 2011 MU payment compared to hospitals that intended to participate in the programme but were not yet successful.

RESULTS

The study sample consisted of 2475 hospitals, 313 of which received MU payments in 2011. Controlling for standard hospital characteristics, hospitals that reported the computerized provider order entry (CPOE) MU criterion as a primary challenge were 18% less likely to receive a 2011 MU payment compared to hospitals that reported other criteria as primary challenges.

DISCUSSION

CPOE was the main challenge among hospitals that failed to achieve MU in the first year of the programme. In order to maximize the incentive programme's effectiveness, policymakers, healthcare organizations, and EHR vendors may benefit from increased attention to hospitals' challenges with CPOE.

CONCLUSION

As the EHR incentive programme matures, policymakers and other stakeholders should consider strategies that maintain the critical elements of MU while adequately supporting hospitals that desire to become MU but are impeded by specific technological, cultural, and organizational adoption and use challenges.

Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review

OBJECTIVE

To systematically review the literature on the implementation of e-health to identify: (i) barriers and facilitators to e-health implementation, and (ii) outstanding gaps in research on the subject.

METHODS

MEDLINE, EMBASE, CINAHL, PSYCINFO and the Cochrane Library were searched for reviews published between 1 January 1995 and 17 March 2009. Studies had to be systematic reviews, narrative reviews, qualitative metasyntheses or meta-ethnographies of e-health implementation. Abstracts and papers were double screened and data were extracted on country of origin; e-health domain; publication date; aims and methods; databases searched; inclusion and exclusion criteria and number of papers included. Data were analysed qualitatively using normalization process theory as an explanatory coding framework.

FINDINGS

Inclusion criteria were met by 37 papers; 20 had been published between 1995 and 2007 and 17 between 2008 and 2009. Methodological quality was poor: 19 papers did not specify the inclusion and exclusion criteria and 13 did not indicate the precise number of articles screened. The use of normalization process theory as a conceptual framework revealed that relatively little attention was paid to: (i) work directed at making sense of e-health systems, specifying their purposes and benefits, establishing their value to users and planning their implementation; (ii) factors promoting or inhibiting engagement and participation; (iii) effects on roles and responsibilities; (iv) risk management, and (v) ways in which implementation processes might be reconfigured by user-produced knowledge.

CONCLUSION

The published literature focused on organizational issues, neglecting the wider social framework that must be considered when introducing new technologies.

Impacts of e-health on the outcomes of care in low- and middle-income countries: where do we go from here?

E-health encompasses a diverse set of informatics tools that have been designed to improve public health and health care. Little information is available on the impacts of e-health programmes, particularly in low- and middle-income countries. We therefore conducted a scoping review of the published and non-published literature to identify data on the effects of e-health on health outcomes and costs. The emphasis was on the identification of unanswered questions for future research, particularly on topics relevant to low- and middle-income countries. Although e-health tools supporting clinical practice have growing penetration globally, there is more evidence of benefits for tools that support clinical decisions and laboratory information systems than for those that support picture archiving and communication systems. Community information systems for disease surveillance have been implemented successfully in several low- and middle-income countries. Although information on outcomes is generally lacking, a large project in Brazil has documented notable impacts on health-system efficiency. Meta-analyses and rigorous trials have documented the benefits of text messaging for improving outcomes such as patients' self-care. Automated telephone monitoring and self-care support calls have been shown to improve some outcomes of chronic disease management, such as glycaemia and blood pressure control, in low- and middle-income countries. Although large programmes for e-health implementation and research are being conducted in many low- and middle-income countries, more information on the impacts of e-health on outcomes and costs in these settings is still needed.

Hospital electronic medical record use and cost of inpatient pediatric care

OBJECTIVE

Electronic medical record (EMR) systems are costly for hospitals to implement and maintain, and the effects of EMR on the cost of care for inpatient pediatrics remain unknown. Our objective was to determine whether delivering care with advanced-stage EMR was associated with a decreased cost per case in a national sample of hospitalized children.

METHODS

The Healthcare Cost and Utilization Project Kids Inpatient Dataset 2009 identified pediatric discharges. The Healthcare Information and Management Systems Society 2009 database identified hospitals' EMR use. EMR was classified into 3 stages, with advanced-stage 3 EMR including automation of ancillary services, automation of nursing workflow, computerized provider order entry, and clinical decision support. Multivariable linear regression was used to determine the independent effect of advanced-stage EMR on cost per case. Propensity score adjustment was included to control for nonrandom assignment of EMR use.

RESULTS

This analysis included 4,605,454 weighted discharges. EMR use by hospitals that care for children was common: 24% for stage 1, 23% stage 2, and 32% advanced stage 3. The multivariable model demonstrated that advanced stage EMR was associated with an average 7% greater cost per case ($146 per discharge).

CONCLUSIONS

The care of children across the United States with EMRs may create a safer health care system but is not associated with inpatient cost savings. In fact our primary analysis shows a 7% additional cost per case. This finding is contrary to predicted savings and may represent an added barrier in the adoption of EMR for inpatient pediatrics.

Multilevel research and the challenges of implementing genomic medicine

Advances in genomics and related fields promise a new era of personalized medicine in the cancer care continuum. Nevertheless, there are fundamental challenges in integrating genomic medicine into cancer practice. We explore how multilevel research can contribute to implementation of genomic medicine. We first review the rapidly developing scientific discoveries in this field and the paucity of current applications that are ready for implementation in clinical and public health programs. We then define a multidisciplinary translational research agenda for successful integration of genomic medicine into policy and practice and consider challenges for successful implementation. We illustrate the agenda using the example of Lynch syndrome testing in newly diagnosed cases of colorectal cancer and cascade testing in relatives. We synthesize existing information in a framework for future multilevel research for integrating genomic medicine into the cancer care continuum.

International medical graduates and health information technology use in the United States

PURPOSE

Health information technology (HIT) holds promise for improving the quality of health care and reducing health care system inefficiencies. Numerous studies have examined HIT availability, specifically electronic health records (EHRs), and utilization among physicians in individual countries. However, no one has examined EHR use among physicians who train in one country and move to practice in another country. In the United States, physicians who complete medical school outside the country but practice within the United States are commonly referred to as International Medical Graduates (IMGs). IMGs have a growing presence in the United States, yet little is known about the availability and use of HIT among these physicians. The purpose of this study is to explore the availability and use of HIT among IMGs practicing in United States.

DESIGN/METHODOLOGY/APPROACH

The Health Tracking Physician Survey (2008) was used to examine the relationship between availability and use of HIT and IMG status controlling for several physician and practice characteristics. Our analysis included responses from 4,720 physicians, 20.7% of whom were IMGs.

FINDINGS

Using logistic regression, controlling for physician gender, specialty, years in practice, practice type, ownership status and geographical location, we found IMGs were significantly less likely to have a comprehensive EHR in their practices (OR = 0.84; p = 0.005). In addition, findings indicate that IMGs are more likely to have and use several so-called first generation HIT capabilities, such as reminders for clinicians about preventive services (OR = 1.31; p = 0.001) and other needed patient follow-up (OR = 1.26; p = 0.007).

ORIGINALITY/VALUE

This study draws attention to the need for further research regarding barriers to HIT adoption and use among IMGs.

Design and development of EMR supporting medical process management

Current EMR system benefits physicians by facilitating order entry and reducing errors. It can improve the safety and effectiveness of medical services, but cannot manage the whole medical process and the quality of medical services. In addition to physicians, EMR should be designed for all medical professionals because medical services cannot be accomplished by physicians alone, but also requires the involvement of other medical professionals. Therefore, we applied PDCA, the famous quality management cycle to design a comprehensive and coherent EMR system which can be used throughout the entire treatment process. EMR with the PDCA Cycle can record every order state and every treatment procedure in order to monitor the whole medical process. This extends the safety from planning the treatment to fulfilling it. By analyzing the records, doctors and hospital managers can perfect the medical process and improve healthcare quality. The EMR we designed with the PDCA Cycle provides a record entry interface for physicians and a worksheet interface for nurses and other professionals. Every treatment procedure and every change of orders or tasks will be fed back to medical professionals. So information generated from the beginning to the end of treatment will link with each other to avoid any information islands. Furthermore, the EMR can display the additional information intuitively and real-timely without increasing the burden of medical professionals' work.

Going digital: adoption of electronic health records in assisted living facilities

This pilot study examines the associations between structural characteristics and the adoption and subsequent use of electronic health records (EHR; resident demographics, clinical notes, medication lists, problem lists, discharge summaries, and advance directives) as a process characteristic in assisted living facilities (ALFs). The study is guided conceptually by Donabedian's Structure-Process-Outcome (SPO) model. Primary survey data were collected from a randomly selected sample (N = 76) in Florida during 2009-2010. Analysis included descriptive and bivariate statistics. Descriptive results indicated that ALFs most frequently used an EHR to record medication lists. Characteristics, including size, profit status, resident case mix, and staffing, were associated at the bivariate level with the use of one or more functional domains of an EHR. Thus, the use of EHRs in ALFs is correlated with facility characteristics.

Use of the internet and an online personal health record system by US veterans: comparison of Veterans Affairs mental health service users and other veterans nationally

OBJECTIVE

The Department of Veterans Affairs (VA) operates one of the largest nationwide healthcare systems and is increasing use of internet technology, including development of an online personal health record system called My HealtheVet. This study examined internet use among veterans in general and particularly use of online health information among VA patients and specifically mental health service users.

METHODS

A nationally representative sample of 7215 veterans from the 2010 National Survey of Veterans was used. Logistic regression was employed to examine background characteristics associated with internet use and My HealtheVet.

RESULTS

71% of veterans reported using the internet and about a fifth reported using My HealtheVet. Veterans who were younger, more educated, white, married, and had higher incomes were more likely to use the internet. There was no association between background characteristics and use of My HealtheVet. Mental health service users were no less likely to use the internet or My HealtheVet than other veterans.

DISCUSSION

Most veterans are willing to access VA information online, although many VA service users do not use My HealtheVet, suggesting more education and research is needed to reduce barriers to its use.

CONCLUSION

Although adoption of My HealtheVet has been slow, the majority of veterans, including mental health service users, use the internet and indicate a willingness to receive and interact with health information online.

Impact of vendor computerized physician order entry in community hospitals

BACKGROUND

It is uncertain if computerized physician order entry (CPOE) systems are effective at reducing adverse drug event (ADE) rates in community hospitals, where mainly vendor-developed applications are used.

OBJECTIVE

To evaluate the impact of vendor CPOE systems on the frequency of ADEs.

DESIGN AND PATIENTS

Prospective before-and-after study conducted from January 2005 to September 2010 at five Massachusetts community hospitals. Participants were adults admitted during the study period. A total of 2,000 charts were reviewed for orders, medication lists, laboratory reports, admission histories, notes, discharge summaries, and flow sheets.

MAIN MEASURES

The primary outcome measure was the rate of preventable ADEs. Rates of potential ADEs and overall ADEs were secondary outcomes.

KEY RESULTS

The rate of preventable ADEs decreased following implementation (10.6/100 vs. 7.0/100 admissions; p = 0.007) with a similar effect observed at each site. However, the associated decrease in preventable ADEs was balanced against an increase in potential ADEs (44.4/100 vs. 57.5/100 admissions; p < 0.001). We observed a reduction of 34.0% for preventable ADEs, but an increase of 29.5% in potential ADEs following implementation. The overall rate of ADEs increased (14.6/100 vs. 18.7/100 admissions; p = 0.03), which was driven by non-preventable events (4.0/100 vs. 11.7/100 admissions; p < 0.001).

CONCLUSIONS

Adoption of vendor CPOE systems was associated with a decrease in the preventable ADE rate by a third, although the rates of potential ADEs and overall ADEs increased. Our findings support the use of vendor CPOE systems as a means to reduce drug-related injury and harm. The potential ADE rate could be reduced by making refinements to the vendor applications and their associated decision support.

Standard practices for computerized clinical decision support in community hospitals: a national survey

Objective

Computerized provider order entry (CPOE) with clinical decision support (CDS) can help hospitals improve care. Little is known about what CDS is presently in use and how it is managed, however, especially in community hospitals. This study sought to address this knowledge gap by identifying standard practices related to CDS in US community hospitals with mature CPOE systems.

Materials and Methods

Representatives of 34 community hospitals, each of which had over 5 years experience with CPOE, were interviewed to identify standard practices related to CDS. Data were analyzed with a mix of descriptive statistics and qualitative approaches to the identification of patterns, themes and trends.

Results

This broad sample of community hospitals had robust levels of CDS despite their small size and the independent nature of many of their physician staff members. The hospitals uniformly used medication alerts and order sets, had sophisticated governance procedures for CDS, and employed staff to customize CDS.

Discussion

The level of customization needed for most CDS before implementation was greater than expected. Customization requires skilled individuals who represent an emerging manpower need at this type of hospital.

Conclusion

These results bode well for robust diffusion of CDS to similar hospitals in the process of adopting CDS and suggest that national policies to promote CDS use may be successful.

The hybrid progress note: semiautomating daily progress notes to achieve high-quality documentation and improve provider efficiency

Health care institutions are moving toward fully functional electronic medical records (EMRs) that promise improved documentation, safety, and quality of care. However, many hospitals do not yet use electronic documentation. Paper charting, including writing daily progress notes, is time-consuming and error prone. To improve the quality of documentation at their hospital, the authors introduced a highly formatted paper note template (hybrid note) that is prepopulated with data from the EMR. Inclusion of vital signs and active medications improved from 75.5% and 60% to 100% (P < .001), respectively. The use of unapproved abbreviations in the medication list decreased from 13.3% to 0% (P < .001). Prepopulating data enhances provider efficiency. Interviews of key clinician leaders also suggest that the initiative is well accepted and that documentation quality is enhanced. The hybrid progress note improves documentation and provider efficiency, promotes quality care, and initiates the development of the forthcoming electronic progress note.

Looking to the future: incorporating genomic information into disparities research to reduce measurement error and selection bias

OBJECTIVE

To extend recent conceptual and methodological advances in disparities research to include the incorporation of genomic information in analyses of racial/ethnic disparities in health care and health outcomes.

DATA SOURCES

Published literature on human genetic variation, the role of genetics in disease and response to treatment, and methodological developments in disparities research.

STUDY DESIGN

We present a conceptual framework for incorporating genomic information into the Institute of Medicine definition of racial/ethnic disparities in health care, identify key concepts used in disparities research that can be informed by genomics research, and illustrate the incorporation of genomic information into current methods using the example of HER-2 mutations guiding care for breast cancer.

PRINCIPAL FINDINGS

Genomic information has not yet been incorporated into disparities research, though it has direct relevance to concepts of race/ethnicity, health status, appropriate care, and socioeconomic status. The HER-2 example demonstrates how available genetic information can be incorporated into current disparities methods to reduce selection bias and measurement error. Advances in health information infrastructure may soon make standardized genetic information more available to health services researchers.

CONCLUSION

Genomic information can refine measurement of racial/ethnic disparities in health care and health outcomes and should be included wherever possible in disparities research.

The effect of health information technology on quality in U.S. hospitals

Health information technology (IT), such as computerized physician order entry and electronic health records, has potential to improve the quality of health care. But the returns from widespread adoption of such technologies remain uncertain. We measured changes in the quality of care following adoption of electronic health records among a national sample of U.S. hospitals from 2004 to 2007. The use of computerized physician order entry and electronic health records resulted in significant improvements in two quality measures, with larger effects in academic than nonacademic hospitals. We conclude that achieving substantive benefits from national implementation of health IT may be a lengthy process. Policies to improve health IT's efficacy in nonacademic hospitals might be more beneficial than adoption subsidies.