Prevalence and functionality of electronic health records in internal medicine continuity clinics

Electronic health record-based triggers to detect potential delays in cancer diagnosis

BACKGROUND

Delayed diagnosis of cancer can lead to patient harm, and strategies are needed to proactively and efficiently detect such delays in care. We aimed to develop and evaluate 'trigger' algorithms to electronically flag medical records of patients with potential delays in prostate and colorectal cancer (CRC) diagnosis.

METHODS

We mined retrospective data from two large integrated health systems with comprehensive electronic health records (EHR) to iteratively develop triggers. Data mining algorithms identified all patient records with specific demographics and a lack of appropriate and timely follow-up actions on four diagnostic clues that were newly documented in the EHR: abnormal prostate-specific antigen (PSA), positive faecal occult blood test (FOBT), iron-deficiency anaemia (IDA), and haematochezia. Triggers subsequently excluded patients not needing follow-up (eg, terminal illness) or who had already received appropriate and timely care. Each of the four final triggers was applied to a test cohort, and chart reviews of randomly selected records identified by the triggers were used to calculate positive predictive values (PPV).

RESULTS

The PSA trigger was applied to records of 292 587 patients seen between 1 January 2009 and 31 December 2009, and the CRC triggers were applied to 291 773 patients seen between 1 March 2009 and 28 February 2010. Overall, 1564 trigger positive patients were identified (426 PSA, 355 FOBT, 610 IDA and 173 haematochezia). Record reviews revealed PPVs of 70.2%, 66.7%, 67.5%, and 58.3% for the PSA, FOBT, IDA and haematochezia triggers, respectively. Use of all four triggers at the study sites could detect an estimated 1048 instances of delayed or missed follow-up of abnormal findings annually and 47 high-grade cancers.

CONCLUSIONS

EHR-based triggers can be used successfully to flag patient records lacking follow-up of abnormal clinical findings suspicious for cancer.

Ambulatory office organization for internal medicine resident medical education

PURPOSE

Residents will most effectively learn about ambulatory, systems-based practice by working in highly functional ambulatory practices; however, systems experiences in ambulatory training are thought to be highly variable. The authors sought to determine the prevalence of functional-practice characteristics at clinics where residents learn.

METHOD

In 2007, the authors conducted a national survey of medical directors of resident continuity clinics using a comprehensive, Web-based instrument that included both a residency clinic assessment and a practice system assessment (PSA). The authors designed the PSA to estimate the Physician Practice Connections (PPC) score, indicating the readiness of a practice to function as a patient-centered medical home (PCMH).

RESULTS

Of 356 clinic directors or physician representatives responding to an initial inquiry, 221 completed the survey (62%)--representing 185 programs (49% of accredited programs). The majority of clinics were hospital based (139/220; 63%) or hospital supported (41/220; 19%) and were located in urban settings (151/217; 70%). Estimated payer mix categories included Medicare or managed Medicare (169; 29%), Medicaid or managed Medicaid (161; 34%), and self-pay (156; 25%). The mean estimated PPC score was 53 points (of 100; SD = 17.6). Suburban and rural clinics, Veterans Affairs' clinics, federally qualified health centers, and clinics with a higher proportion of patients with commercial insurance or managed Medicare earned higher scores.

CONCLUSIONS

A substantial portion of residency clinics have elements needed for PCMH recognition. However, clinics struggled with connecting these elements with coordination-of-care processes, suggesting areas for improvement to support better functioning of ambulatory training practices.