Physicians' use of key functions in electronic health records from 2005 to 2007: a statewide survey

A model to measure self-assessed proficiency in electronic medical records: Validation using maturity survey data from Canadian community-based physicians

OBJECTIVE

Adoption of electronic medical records (EMRs) does not necessarily translate to proficiency -referred to here as EMR maturity. To realize the full benefit of wide scale EMR adoption, the focus must shift from adoption to advancing mature use. This calls for validated assessment models so that researchers, health system planners and digital health developers can better understand what contributes to maturity among physicians. This research aims to validate a measurement model for self-assessed EMR maturity among community-based physicians.

METHODS

As part of an Ontario government-funded EMR adoption program, the EMR Maturity Model for community-based practices was adapted from a hospital-based EMR maturity model. A survey instrument was developed on the foundation of the new model and revised by experts and stakeholders. Content validity, face validity and user acceptance were established before survey administration. Internal consistency and construct validity of the model were tested after survey data were collected. Finally, physicians' comments collected via the survey were qualitatively analyzed to provide additional insights that can be applied to refinement of the model and survey.

RESULTS

As of August 1, 2019, 1588 physicians completed the survey. Ordinal alpha tests for reliability and content validity yielded an alpha value of 0.86 across all key measures specifically associated with maturity. Among most of these, there was a pattern of weak to moderate significant (p < .0001) positive Spearman inter-correlations. One factor was extracted for items measuring dimensions of maturity and all factor loadings of the key measures were greater than 0.40. The fit of the one-factor model was moderately adequate. This indicates the model is valid and reliable, with consistency across key measures for measuring one factor: maturity.

CONCLUSIONS

This is the first known validated model published in English that measures EMR maturity among community-based physicians. While the model is shown to be valid and reliable statistically and qualitative analysis supports this, there is room for improvement. Both the statistical analysis and portions of the qualitative analysis suggest areas of exploration to strengthen the model and survey. Future efforts will include refining the survey to improve user interface and accrue further data, as the sample to date is insufficient for generalizability.

Medication-related clinical decision support alert overrides in inpatients

Objective

To define the types and numbers of inpatient clinical decision support alerts, measure the frequency with which they are overridden, and describe providers' reasons for overriding them and the appropriateness of those reasons.

Materials and Methods

We conducted a cross-sectional study of medication-related clinical decision support alerts over a 3-year period at a 793-bed tertiary-care teaching institution. We measured the rate of alert overrides, the rate of overrides by alert type, the reasons cited for overrides, and the appropriateness of those reasons.

Results

Overall, 73.3% of patient allergy, drug-drug interaction, and duplicate drug alerts were overridden, though the rate of overrides varied by alert type (P < .0001). About 60% of overrides were appropriate, and that proportion also varied by alert type (P < .0001). Few overrides of renal- (2.2%) or age-based (26.4%) medication substitutions were appropriate, while most duplicate drug (98%), patient allergy (96.5%), and formulary substitution (82.5%) alerts were appropriate.

Discussion

Despite warnings of potential significant harm, certain categories of alert overrides were inappropriate >75% of the time. The vast majority of duplicate drug, patient allergy, and formulary substitution alerts were appropriate, suggesting that these categories of alerts might be good targets for refinement to reduce alert fatigue.

Conclusion

Almost three-quarters of alerts were overridden, and 40% of the overrides were not appropriate. Future research should optimize alert types and frequencies to increase their clinical relevance, reducing alert fatigue so that important alerts are not inappropriately overridden.

Psychometric validation of a new measurement instrument for time-oriented patient information in electronic medical records: A questionnaire survey of physicians

RATIONALE, AIMS, AND OBJECTIVES

Time is an important element in medical data. Physicians record and store information about patients' disease progress and treatment response in electronic medical records (EMRs). Because EMRs use timestamps, physicians can identify patterns over time regarding a patient's disease and treatment (eg, laboratory values and medications). However, analyses of physicians' use and satisfaction with EMRs have focused on functionality, storage, and system operation rather than the use of time-oriented information. This study aimed to understand physicians' needs regarding time-oriented patient information in EMRs in clinical practice.

METHODS

The reliability and validity of the items in the questionnaire were evaluated in 87 physicians at a national university hospital. Internal consistency was satisfactory (Cronbach alpha coefficient, 0.87).

RESULTS

Four dimensions were identified in exploratory factor analysis. Correlations between the 4 dimensions supported the construct validity of the items. Scores of time-oriented patients' medical history in the 4 dimensions showed a significant association with physician age. Based on confirmatory factor analysis, associations were significant and positive (P < .001). In terms of the needs of physicians regarding time-oriented patient information in EMRs, both time-oriented treatment results followed by time-oriented team information had significant positive associations.

CONCLUSION

Our study suggests that 4 specific time-oriented patient information factors in EMRs are needed by physicians. Exploring physicians' needs regarding patient-specific time-oriented information may provide a better understanding of the barriers facing the adoption and use of EMRs (eg, decision-making and practice safety concerns) and lead to better acceptance of EMRs in physicians' clinical practices.

Infinicare framework for integrated understanding of health-related activities in clinical and daily-living contexts

Clinical and consumer health informatics interventions promise to transform health care, yielding higher quality, more accessible care at a lower cost. However, the potential of these interventions cannot be achieved if they are developed and rolled out in a disconnected way: clinic-based systems typically do not interface with home-based systems that capture patient-generated health-related data. The fragmentation between these interventions severely limits the benefits of all interventions; given that health care is a continuum between clinical and daily-living settings. We introduce the Infinicare framework, which posits that clinical health-related activities "shape" daily-living-based health-related activities and, conversely, that daily-living-based health-related activities "inform" activities in clinics. Non-alignment of activities across these diverse contexts yields systemic gaps. Workflow studies that capture health-related activities and characterise gaps between clinical and daily-living contexts can inform the design and implementation of gap-filling, collaborative health information technologies. To inform these technologies, workflow studies should be patient-oriented, include both clinical and daily-living settings and subsume both process and structure variables. Novel methodologies are needed to effectively and efficiently capture health-related activities across both clinical and daily-living settings and their contexts. Guidelines for applying these recommendations in developing collaborative health information technologies are provided.

Nurses' perceptions, acceptance, and use of a novel in-room pediatric ICU technology: testing an expanded technology acceptance model

BACKGROUND

The value of health information technology (IT) ultimately depends on end users accepting and appropriately using it for patient care. This study examined pediatric intensive care unit nurses' perceptions, acceptance, and use of a novel health IT, the Large Customizable Interactive Monitor.

METHODS

An expanded technology acceptance model was tested by applying stepwise linear regression to data from a standardized survey of 167 nurses.

RESULTS

Nurses reported low-moderate ratings of the novel IT's ease of use and low to very low ratings of usefulness, social influence, and training. Perceived ease of use, usefulness for patient/family involvement, and usefulness for care delivery were associated with system satisfaction (R2 = 70%). Perceived usefulness for care delivery and patient/family social influence were associated with intention to use the system (R2 = 65%). Satisfaction and intention were associated with actual system use (R2 = 51%).

CONCLUSIONS

The findings have implications for research, design, implementation, and policies for nursing informatics, particularly novel nursing IT. Several changes are recommended to improve the design and implementation of the studied IT.

Electronic health records implementation: an evaluation of information system impact and contingency factors

OBJECTIVE

This paper provides a review of EHR (electronic health record) implementations around the world and reports on findings including benefits and issues associated with EHR implementation.

MATERIALS AND METHODS

A systematic literature review was conducted from peer-reviewed scholarly journal publications from the last 10 years (2001-2011). The search was conducted using various publication collections including: Scopus, Embase, Informit, Medline, Proquest Health and Medical Complete. This paper reports on our analysis of previous empirical studies of EHR implementations. We analysed data based on an extension of DeLone and McLean's information system (IS) evaluation framework. The extended framework integrates DeLone and McLean's dimensions, including information quality, system quality, service quality, intention of use and usage, user satisfaction and net benefits, together with contingent dimensions, including systems development, implementation attributes and organisational aspects, as identified by Van der Meijden and colleagues.

RESULTS

A mix of evidence-based positive and negative impacts of EHR was found across different evaluation dimensions. In addition, a number of contingent factors were found to contribute to successful implementation of EHR.

LIMITATIONS

This review does not include white papers or industry surveys, non-English papers, or those published outside the review time period.

CONCLUSION

This review confirms the potential of this technology to aid patient care and clinical documentation; for example, in improved documentation quality, increased administration efficiency, as well as better quality, safety and coordination of care. Common negative impacts include changes to workflow and work disruption. Mixed observations were found on EHR quality, adoption and satisfaction. The review warns future implementers of EHR to carefully undertake the technology implementation exercise. The review also informs healthcare providers of contingent factors that potentially affect EHR development and implementation in an organisational setting. Our findings suggest a lack of socio-technical connectives between the clinician, the patient and the technology in developing and implementing EHR and future developments in patient-accessible EHR. In addition, a synthesis of DeLone and McLean's framework and Van der Meijden and colleagues' contingent factors has been found useful in comprehensively understanding and evaluating EHR implementations.

A survey aimed at general citizens of the US and Japan about their attitudes toward electronic medical data handling

Objectives: To clarify the views of the general population of two countries (US and Japan), concerning the handling of their medical records electronically. Methods: We contacted people nationwide in the United States at random via Random Digit Dialing (RDD) to obtain 200 eligible responders. The questionnaire was for obtaining the information on their attitudes towards handling of their medical records, disclosure of the name of disease, secondary usage of information, compiling their records into a lifelong medical record, and access to their medical records on the Internet. We had also surveyed people of Shizuoka prefecture in Japan using same questionnaires sent by mail, for which we obtained 457 valid answers. Results: Even in an unidentifiable manner, US people feel profit-oriented usage of medical data without specific consent is not acceptable. There is a significant difference between usage of unidentifiable medical data for profit (about 50% feel negatively) and for official/research purposes (about 30% feel negatively). About 60% of the US responders have a negative view on the proposal that unidentifiable medical information be utilized for profit by private companies to attain healthcare cost savings. As regards compiling a lifelong medical record, positive answers and negative answers are almost equally divided in the US (46% vs. 38%) while more positive attitudes are seen in Japan (74% vs. 12%). However, any incentive measures aimed at changing attitudes to such a compiling including the discount of healthcare costs or insurance fees are unwelcomed by people regardless of their age or health condition in both surveys. Regarding the access to their own medical record via the Internet, 38% of the US responders feel this is unacceptable while 50.5% were willing to accept it. Conclusions: Participants from the US think that the extent of the sharing their identifiable medical records should be limited to the doctors-in-charge and specified doctors referred to by their own doctors. On the other hand, Japanese people find it acceptable for doctors of the same hospital to share their medical records. Even in unidentifiable manner, people in both countries think the profits resulting from the secondary use of medical records should be returned to the public or patients. With regard to compiling a lifelong medical record, participants from the US provided both positive answers and negative answers, while more positive attitudes were observed in Japan. However, any incentives or measures aimed at changing attitudes towards such a compilation, including provision of a discount on healthcare costs or insurance fees, were not welcomed by participants from US as well as those from Japan, regardless of their age or health condition.

User-driven prioritization of features for a prospective InterPersonal Health Record: perceptions from the Italian context

In this paper we present two large user studies in which we gather evidence about the adoption and satisfaction level of users in regard to electronic records that manage health related information from two distinct but complementary perspectives: that of General Practitioners (GPs) about their Electronic Medical Records (EMRs); and that of citizens/patients about their Personal Health Records (PHRs). In these user studies we also probe the user attitudes towards innovative functionalities from these two perspectives and, on the basis of the collected perceptions, we apply an original ranking method to infer what features are valued most and hence could inspire design to make PHRs more situated into the users' lives and drive a higher adoption of these tools. On the basis of the perceived shortcomings of current records, we envision an InterPersonal Health Record (IPHR) that is a sort of hybrid electronic record that merges together typical EMR- and PHR-related features and is endowed with specific functionalities aimed at enhancing interpersonal relationships, communication and collaboration between citizens/patients and their GPs through the record and about its contents. This study is then a contribution in understanding the current attitudes and expectations of potential users towards full-fledged prospective PHRs, as well as a first step in identifying those requirements and priority areas on which to focus further for the design and deployment of more community- and communication-oriented tools in the primary health care domain.

Overrides of medication-related clinical decision support alerts in outpatients

BACKGROUND

Electronic prescribing is increasingly used, in part because of government incentives for its use. Many of its benefits come from clinical decision support (CDS), but often too many alerts are displayed, resulting in alert fatigue.

OBJECTIVE

To characterize the override rates for medication-related CDS alerts in the outpatient setting, the reasons cited for overrides at the time of prescribing, and the appropriateness of overrides.

METHODS

We measured CDS alert override rates and the coded reasons for overrides cited by providers at the time of prescribing. Our primary outcome was the rate of CDS alert overrides; our secondary outcomes were the rate of overrides by alert type, reasons cited for overrides at the time of prescribing, and override appropriateness for a subset of 600 alert overrides. Through detailed chart reviews of alert override cases, and selective literature review, we developed appropriateness criteria for each alert type, which were modified iteratively as necessary until consensus was reached on all criteria.

RESULTS

We reviewed 157,483 CDS alerts (7.9% alert rate) on 2,004,069 medication orders during the study period. 82,889 (52.6%) of alerts were overridden. The most common alerts were duplicate drug (33.1%), patient allergy (16.8%), and drug-drug interactions (15.8%). The most likely alerts to be overridden were formulary substitutions (85.0%), age-based recommendations (79.0%), renal recommendations (78.0%), and patient allergies (77.4%). An average of 53% of overrides were classified as appropriate, and rates of appropriateness varied by alert type (p<0.0001) from 12% for renal recommendations to 92% for patient allergies.

DISCUSSION

About half of CDS alerts were overridden by providers and about half of the overrides were classified as appropriate, but the likelihood of overriding an alert varied widely by alert type. Refinement of these alerts has the potential to improve the relevance of alerts and reduce alert fatigue.

Provider-to-provider electronic communication in the era of meaningful use: a review of the evidence

BACKGROUND

Electronic communication between providers occurs daily in clinical practice but has not been well studied.

PURPOSE

To assess the impact of provider-to-provider electronic communication tools on communication and healthcare outcomes through literature review.

DATA SOURCES

Ovid MEDLINE, PubMed, Google Scholar, Cumulative Index to Nursing and Allied Health Literature, and Academic Search Premier.

STUDY SELECTION

Publication in English-language peer-reviewed journals. Studies provided quantitative provider-to-provider communication data, provider satisfaction statistics, or electronic health record (EHR) communication data.

DATA EXTRACTION

Literature review.

DATA SYNTHESIS

Two reviewers conducted the title review to determine eligible studies from initial search results. Three reviewers independently reviewed titles, abstracts, and full text (where appropriate) against inclusion and exclusion criteria.

LIMITATIONS

Small number of eligible studies; few described trial design (20%). Homogeneous provider type (physicians). English-only studies.

CONCLUSIONS

Of 25 included studies, all focused on physicians; most were observational (68%). Most (60%) described electronic specialist referral tools. Although overall use has been measured, there were no studies of the effectiveness of intra-EHR messaging. Literature describing the effectiveness of provider-to-provider electronic communications is sparse and narrow in scope. Complex care, such as that envisioned for the Patient Centered Medical Home, necessitates further research.

Use and satisfaction with key functions of a common commercial electronic health record: a survey of primary care providers

BACKGROUND

Despite considerable financial incentives for adoption, there is little evidence available about providers' use and satisfaction with key functions of electronic health records (EHRs) that meet "meaningful use" criteria.

METHODS

We surveyed primary care providers (PCPs) in 11 general internal medicine and family medicine practices affiliated with 3 health systems in Texas about their use and satisfaction with performing common tasks (documentation, medication prescribing, preventive services, problem list) in the Epic EHR, a common commercial system. Most practices had greater than 5 years of experience with the Epic EHR. We used multivariate logistic regression to model predictors of being a structured documenter, defined as using electronic templates or prepopulated dot phrases to document at least two of the three note sections (history, physical, assessment and plan).

RESULTS

146 PCPs responded (70%). The majority used free text to document the history (51%) and assessment and plan (54%) and electronic templates to document the physical exam (57%). Half of PCPs were structured documenters (55%) with family medicine specialty (adjusted OR 3.3, 95% CI, 1.4-7.8) and years since graduation (nonlinear relationship with youngest and oldest having lowest probabilities) being significant predictors. Nearly half (43%) reported spending at least one extra hour beyond each scheduled half-day clinic completing EHR documentation. Three-quarters were satisfied with documenting completion of pneumococcal vaccinations and half were satisfied with documenting cancer screening (57% for breast, 45% for colorectal, and 46% for cervical). Fewer were satisfied with reminders for overdue pneumococcal vaccination (48%) and cancer screening (38% for breast, 37% for colorectal, and 31% for cervical). While most believed the problem list was helpful (70%) and kept an up-to-date list for their patients (68%), half thought they were unreliable and inaccurate (51%).

CONCLUSIONS

Dissatisfaction with and suboptimal use of key functions of the EHR may mitigate the potential for EHR use to improve preventive health and chronic disease management. Future work should optimize use of key functions and improve providers' time efficiency.

A typology of electronic health record workarounds in small-to-medium size primary care practices

OBJECTIVE

Electronic health record (EHR) use in ambulatory care can improve safety and quality; however, problems with design, implementation, and poor interface with other systems lead users to develop 'workarounds', or behaviors users adopt to overcome perceived limitations in a technical system. We documented workarounds used in independent, community-based primary care practices, and developed a typology of their key features.

MATERIALS AND METHODS

Comparative case study of EHR use in seven independent primary care practices. Field researchers spent approximately 1 month in each practice to observe EHR use, conduct patient pathways, and interview clinicians and staff.

RESULTS

We observed workarounds addressing a wide range of EHR-related problems, including: user interface issues (eg, insufficient data fields, limited templates), barriers to electronic health information exchange with external organizations, and struggles incorporating new technologies into existing office space. We analyzed the observed workarounds inductively to develop a typology that cuts across specific clinical or administrative processes to highlight the following key formal features of workarounds in general: temporary/routinized, which captures whether the workaround is taken for granted as part of daily workflow or is understood as a short-term solution; avoidable/unavoidable, referring to the extent to which the workaround is within the practice's power to eliminate; and deliberately chosen/unplanned, which differentiates strategically chosen adaptations from less thoughtful workarounds.

CONCLUSIONS

This workaround typology provides a framework for EHR users to identify and address workarounds in their own practices, and for researchers to examine the effect of different types of EHR workarounds on patient safety, care quality, and efficiency.

Development and evaluation of CAHPS questions to assess the impact of health information technology on patient experiences with ambulatory care

BACKGROUND

Little is known about whether health information technology (HIT) affects patient experiences with health care.

OBJECTIVE

To develop HIT questions that assess patients care experiences not evaluated by existing ambulatory Consumer Assessment of Health Plans and Systems (CAHPS) measures.

RESEARCH DESIGN

We reviewed published articles and conducted focus groups and cognitive testing to develop survey questions. We collected data, using mail and the internet, from patients of 69 physicians receiving care at an academic medical center and 2 regional integrated delivery systems in late 2009 and 2010. We evaluated questions and scales about HIT using factor analysis, item-scale correlations, and reliability (internal consistency and physician-level) estimates.

RESULTS

We found support for 3 HIT composites: doctor use of computer (2 items), e-mail (2 items), and helpfulness of provider's website (4 items). Corrected item-scale correlations were 0.37 for the 2 doctor use of computer items and 0.71 for the 2 e-mail items, and ranged from 0.50 to 0.60 for the provider's website items. Cronbach α was high for e-mail (0.83) and provider's website (0.75), but only 0.54 for doctor use of computer. As few as 50 responses per physician would yield reliability of 0.70 for e-mail and provider's website. Two HIT composites, doctor use of computer (P<0.001) and provider's website (P=0.02), were independent predictors of overall ratings of doctors.

CONCLUSIONS

New CAHPS HIT items were identified that measure aspects of patient experiences not assessed by the CAHPS C&G 1.0 survey.

Primary care practitioners' views on test result management in EHR-enabled health systems: a national survey

Context

Failure to notify patients of test results is common even when electronic health records (EHRs) are used to report results to practitioners. We sought to understand the broad range of social and technical factors that affect test result management in an integrated EHR-based health system.

Methods

Between June and November 2010, we conducted a cross-sectional, web-based survey of all primary care practitioners (PCPs) within the Department of Veterans Affairs nationwide. Survey development was guided by a socio-technical model describing multiple inter-related dimensions of EHR use.

Findings

Of 5001 PCPs invited, 2590 (51.8%) responded. 55.5% believed that the EHRs did not have convenient features for notifying patients of test results. Over a third (37.9%) reported having staff support needed for notifying patients of test results. Many relied on the patient's next visit to notify them for normal (46.1%) and abnormal results (20.1%). Only 45.7% reported receiving adequate training on using the EHR notification system and 35.1% reported having an assigned contact for technical assistance with the EHR; most received help from colleagues (60.4%). A majority (85.6%) stayed after hours or came in on weekends to address notifications; less than a third reported receiving protected time (30.1%). PCPs strongly endorsed several new features to improve test result management, including better tracking and visualization of result notifications.

Conclusions

Despite an advanced EHR, both social and technical challenges exist in ensuring notification of test results to practitioners and patients. Current EHR technology requires significant improvement in order to avoid similar challenges elsewhere.

The integration of information and communication technology into community pharmacists practice in Barcelona

The study aims to identify community pharmacists' (CPs) utilization of information and communication technology (ICT); to develop and characterize a typology of CPs' utilization of ICT and to identify factors that can enhance or inhibit the use of these technologies. An online survey of the 7649 members of the Pharmacist Association of Barcelona who had a registered email account in 2006 was carried out. Factor analysis, cluster analysis and binomial logit modelling were undertaken. Multivariate analysis of the CPs' responses to the survey (648) revealed two profiles of adoption of ICT. The first profile (40.75%) represents those CPs who place high emphasis on ICT within their practice. This group is therefore referred to as 'integrated CPs'. The second profile (59.25%) represents those CPs who make less use of ICT and so are consequently labelled 'non-integrated CPs'. Statistical modelling was used to identify variables that were important in predisposing CPs to integrate ICT with their work. From the analysis it is evident that responses to questions relating to 'recommend patients going on line for health information'; 'patients discuss or share their Internet health information findings'; 'emphasis on the Internet for communication and dissemination' and 'Pharmacists Professional Association information' play a positive and significant role in the probability of being an 'integrated CP'. The integration of ICT within CPs' practices cannot be adequately understood and appreciated without examining how CPs are making use of ICT within their own practice, their organizational context and the nature of the pharmacists-client relationship.

Trends in biomedical informatics: most cited topics from recent years

Biomedical informatics is a young, highly interdisciplinary field that is evolving quickly. It is important to know which published topics in generalist biomedical informatics journals elicit the most interest from the scientific community, and whether this interest changes over time, so that journals can better serve their readers. It is also important to understand whether free access to biomedical informatics articles impacts their citation rates in a significant way, so authors can make informed decisions about unlock fees, and journal owners and publishers understand the implications of open access. The topics and JAMIA articles from years 2009 and 2010 that have been most cited according to the Web of Science are described. To better understand the effects of free access in article dissemination, the number of citations per month after publication for articles published in 2009 versus 2010 was compared, since there was a significant change in free access to JAMIA articles between those years. Results suggest that there is a positive association between free access and citation rate for JAMIA articles.

Modeling nurses' acceptance of bar coded medication administration technology at a pediatric hospital

OBJECTIVE

To identify predictors of nurses' acceptance of bar coded medication administration (BCMA).

DESIGN

Cross-sectional survey of registered nurses (N=83) at an academic pediatric hospital that recently implemented BCMA.

METHODS

Surveys assessed seven BCMA-related perceptions: ease of use; usefulness for the job; social influence from non-specific others to use BCMA; training; technical support; usefulness for patient care; and social influence from patients/families. An all possible subset regression procedure with five goodness-of-fit indicators was used to identify which set of perceptions best predicted BCMA acceptance (intention to use, satisfaction).

RESULTS

Nurses reported a moderate perceived ease of use and low perceived usefulness of BCMA. Nurses perceived moderate-or-higher social influence to use BCMA and had moderately positive perceptions of BCMA-related training and technical support. Behavioral intention to use BCMA was high, but satisfaction was low. Behavioral intention to use was best predicted by perceived ease of use, perceived social influence from non-specific others, and perceived usefulness for patient care (56% of variance explained). Satisfaction was best predicted by perceived ease of use, perceived usefulness for patient care, and perceived social influence from patients/families (76% of variance explained).

DISCUSSION

Variation in and low scores on ease of use and usefulness are concerning, especially as these variables often correlate with acceptance, as found in this study. Predicting acceptance benefited from using a broad set of perceptions and adapting variables to the healthcare context.

CONCLUSION

Success with BCMA and other technologies can benefit from assessing end-user acceptance and elucidating the factors promoting acceptance and use.

Measuring meaningful use

To qualify for new federal funds intended to promote the widespread adoption and use of electronic health records, U.S. physician practices must meet the government's "meaningful use" benchmarks. Our analysis indicates that among physicians who have electronic health records, between 75-85 percent are already using functions that meet some of the proposed criteria for demonstrating meaningful use. But gaps remain. We provide a new analysis of baseline use of specific electronic health record functions among primary care physicians and medical and surgical specialists. The analysis can help researchers and policy makers measure more accurately the success of ongoing efforts to expand effective use of health information technology.

Typical electronic health record use in primary care practices and the quality of diabetes care

PURPOSE

Recent efforts to encourage meaningful use of electronic health records (EHRs) assume that widespread adoption will improve the quality of ambulatory care, especially for complex clinical conditions such as diabetes. Cross-sectional studies of typical uses of commercially available ambulatory EHRs provide conflicting evidence for an association between EHR use and improved care, and effects of longer-term EHR use in community-based primary care settings on the quality of care are not well understood.

METHODS

We analyzed data from 16 EHR-using and 26 non-EHR-using practices in 2 northeastern states participating in a group-randomized quality improvement trial. Measures of care were assessed for 798 patients with diabetes. We used hierarchical linear models to examine the relationship between EHR use and adherence to evidence-based diabetes care guidelines, and hierarchical logistic models to compare rates of improvement over 3 years.

RESULTS

EHR use was not associated with better adherence to care guidelines or a more rapid improvement in adherence. In fact, patients in practices that did not use an EHR were more likely than those in practices that used an EHR to meet all of 3 intermediate outcomes targets for hemoglobin A(1c), low-density lipoprotein cholesterol, and blood pressure at the 2-year follow-up (odds ratio = 1.67; 95% CI, 1.12-2.51). Although the quality of care improved across all practices, rates of improvement did not differ between the 2 groups.

CONCLUSIONS

Consistent use of an EHR over 3 years does not ensure successful use for improving the quality of diabetes care. Ongoing efforts to encourage adoption and meaningful use of EHRs in primary care should focus on ensuring that use succeeds in improving care. These efforts will need to include provision of assistance to longer-term EHR users.

Pharmacy workers' perceptions and acceptance of bar-coded medication technology in a pediatric hospital

BACKGROUND

The safety benefits of bar-coded medication-dispensing and administration (BCMA) technology depend on its intended users favorably perceiving, accepting, and ultimately using the technology.

OBJECTIVES

(1) To describe pharmacy workers' perceptions and acceptance of a recently implemented BCMA system and (2) to model the relationship between perceptions and acceptance of BCMA.

METHODS

Pharmacists and pharmacy technicians at a Midwest U.S. pediatric hospital were surveyed following the hospital's implementation of a BCMA system. Twenty-nine pharmacists' and 10 technicians' self-reported perceptions and acceptance of the BCMA system were analyzed, supplemented by qualitative observational and free-response survey data. Perception-acceptance associations were analyzed using structural models.

RESULTS

The BCMA system's perceived ease of use was rated low by pharmacists and moderate by pharmacy technicians. Both pharmacists and technicians perceived that the BCMA system was not useful for improving either personal job performance or patient care. Pharmacy workers perceived that individuals important to them encouraged BMCA use. Pharmacy workers generally intended to use BCMA but reported low satisfaction with the system. Perceptions explained 72% of the variance in intention to use BCMA and 79% of variance in satisfaction with BCMA.

CONCLUSIONS

To promote their acceptance and use, BCMA and other technologies must be better designed and integrated into the clinical work system. Key steps to achieving better design and integration include measuring clinicians' acceptance and elucidating perceptions and other factors that shape acceptance.

Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use?

BACKGROUND

Electronic health record (EHR) adoption is a national priority in the USA, and well-designed EHRs have the potential to improve quality and safety. However, physicians are reluctant to implement EHRs due to financial constraints, usability concerns, and apprehension about unintended consequences, including the introduction of medical errors related to EHR use. The goal of this study was to characterize and describe physicians' attitudes towards three consequences of EHR implementation: (1) the potential for EHRs to introduce new errors; (2) improvements in healthcare quality; and (3) changes in overall physician satisfaction.

METHODS

Using data from a 2007 statewide survey of Massachusetts physicians, we conducted multivariate regression analysis to examine relationships between practice characteristics, perceptions of EHR-related errors, perceptions of healthcare quality, and overall physician satisfaction.

RESULTS

30% of physicians agreed that EHRs create new opportunities for error, but only 2% believed their EHR has created more errors than it prevented. With respect to perceptions of quality, there was no significant association between perceptions of EHR-associated errors and perceptions of EHR-associated changes in healthcare quality. Finally, physicians who believed that EHRs created new opportunities for error were less likely be satisfied with their practice situation (adjusted OR 0.49, p=0.001).

CONCLUSIONS

Almost one third of physicians perceived that EHRs create new opportunities for error. This perception was associated with lower levels of physician satisfaction.

What stands in the way of technology-mediated patient safety improvements?: a study of facilitators and barriers to physicians' use of electronic health records

OBJECTIVES

For electronic health record (EHR) systems to have a positive impact on patient safety, clinicians must be able to use these systems effectively after they are made available. This study's objective is to identify and describe facilitators and barriers to physicians' use of EHR systems.

METHODS

Twenty research interviews were conducted with attending physicians who were using EHR at 1 of 2 Midwest community hospitals and/or at their respective outpatient clinics.

RESULTS

Analyses yielded more than 200 perceived facilitators and barriers, comprising 19 distinct categories. Categories of facilitators/barriers related to user attribute included learning, typing proficiency, understanding the EHR system, motivation/initiative, and strategies/workarounds. Categories related to system attributes were supporting hardware/software and system speed, functionality, and usability. Categories related to support from others were formal technical support, formal training, and informal support from colleagues. Categories of organizational facilitators/barriers were time allowance and interinstitutional integration. Categories of environmental facilitators/barriers were physical space, electricity, wireless connectivity, and the social environment.

CONCLUSIONS

Together, the broad set of discovered facilitators and barriers confirms and expands prior research on the facilitators and barriers to health information technology use. The depth of reported information on each facilitator and barrier made possible by qualitative interview methods contributes to the theoretical understanding of facilitators and barriers to EHR use. Equally as important, this study provides an information base from which relevant policy and design interventions can be launched to improve the use of EHR systems and, thus, patient safety.

Implementation of an electronic referral system for outpatient specialty care

Poor communication between primary care and specialists often leads to delays, inefficiencies and suboptimal patient outcomes. This study examined implementation of an electronic referral system (eReferral) that creates direct communication between primary care providers and specialist reviewers. Semi-structured interviews were conducted to assess factors affecting the success of eReferral implementation; transcripts were analyzed using qualitative methods. Primary and specialty care providers were enthusiastic about the system. Primary care providers had favorable attitudes despite a number of challenges including increased workload due to a shift in tasks from specialists and administrative personnel, poor connectivity, and insufficient hardware. System acceptance was driven by perceptions of improved access to specialty care, better appointment tracking, and improved communication between primary and specialty care providers. Synergy among development processes, implementation practices, and technical factors, including human-centered design, iterative development, a phased rollout, and an intuitive user interface, also fostered uptake of the system.

Clinician characteristics and use of novel electronic health record functionality in primary care

BACKGROUND

Conventional wisdom holds that older, busier clinicians who see complex patients are less likely to adopt and use novel electronic health record (EHR) functionality.

METHODS

To compare the characteristics of clinicians who did and did not use novel EHR functionality, we conducted a retrospective analysis of the intervention arm of a randomized trial of new EHR-based tobacco treatment functionality.

RESULTS

The novel functionality was used by 103 of 207 (50%) clinicians. Staff physicians were more likely than trainees to use the functionality (64% vs 37%; p<0.001). Clinicians who graduated more than 10 years previously were more likely to use the functionality than those who graduated less than 10 years previously (64% vs 42%; p<0.01). Clinicians with higher patient volumes were more likely to use the functionality (lowest quartile of number of patient visits, 25%; 2nd quartile, 38%; 3rd quartile, 65%; highest quartile, 71%; p<0.001). Clinicians who saw patients with more documented problems were more likely to use the functionality (lowest tertile of documented patient problems, 38%; 2nd tertile, 58%; highest tertile, 54%; p=0.04). In multivariable modeling, independent predictors of use were the number of patient visits (OR 1.2 per 100 additional patients; 95% CI 1.1 to 1.4) and number of documented problems (OR 2.9 per average additional problem; 95% CI 1.4 to 6.1).

CONCLUSIONS

Contrary to conventional wisdom, clinically busier physicians seeing patients with more documented problems were more likely to use novel EHR functionality.

Transitioning between ambulatory EHRs: a study of practitioners' perspectives

OBJECTIVE

To evaluate practitioners' expectations of, and satisfaction with, older and newer electronic health records (EHRs) after a transition.

MATERIAL AND METHODS

Pre- and post-transition survey administered at six academic-affiliated ambulatory care practices from 2006 to 2008. Four practices transitioned to one commercial EHR and two practices to another. We compared respondents' expectations of, and satisfaction with, the newer EHR.

RESULTS

523 subjects were eligible: 217 were available before transition and 306 after transition. 162 pre-transition and 197 post-transition responses were received, yielding 75% and 64% response rates, respectively. Practitioners were more satisfied with the newer EHRs (64%) compared with the older (56%) (p=0.15) and a small majority (58%) were satisfied with the transition. Practitioners' satisfaction with the older EHRs for completing clinical tasks was high. The newer EHRs exceeded practitioner expectations regarding remote access (61% vs 74%; p=0.03). However, the newer EHRs did not meet practitioners' expectations regarding their ability to perform clinical tasks, or more globally, improve medication safety (81% vs 61%; p<0.001), efficiency (70% vs 44%; p<0.001), and quality of care (77% vs 67%; p=0.04).

DISCUSSION

Most practitioners had favorable opinions about EHRs and reported overall improved satisfaction with the newer EHRs. However, practitioners' high expectations of the newer EHRs were often unmet regarding facilitation of specific clinical tasks or for improving quality, safety, and efficiency.

CONCLUSION

To ensure practitioners' expectations, for instance regarding improvements in medication safety, are met, vendors should develop and implement refinements in their software as practices upgrade to newer, certified EHRs.

Electronic health records in small physician practices: availability, use, and perceived benefits

OBJECTIVE

To examine variation in the adoption of electronic health record (EHR) functionalities and their use patterns, barriers to adoption, and perceived benefits by physician practice size.

DESIGN

Mailed survey of a nationally representative random sample of practicing physicians identified from the Physician Masterfile of the American Medical Association. Measurements We measured, stratified by practice size: (1) availability of EHR functionalities, (2) functionality use, (3) barriers to the adoption and use of EHR, and (4) impact of the EHR on the practice and quality of patient care.

RESULTS

With a response rate of 62%, we found that < 2% of physicians in solo or two-physician (small) practices reported a fully functional EHR and 5% reported a basic EHR compared with 13% of physicians from 11+ group (largest group) practices with a fully functional system and 26% with a basic system. Between groups, a 21-46% difference in specific functionalities available was reported. Among adopters there were moderate to large differences in the use of the EHR systems. Financial barriers were more likely to be reported by smaller practices, along with concerns about future obsolescence. These differences were sizable (13-16%) and statistically significant (p < 0.001). All adopters reported similar benefits. Limitations Although we have adjusted for response bias, influences may still exist.

CONCLUSION

Our study found that physicians in small practices have lower levels of EHR adoption and that these providers were less likely to use these systems. Ensuring that unique barriers are addressed will be critical to the widespread meaningful use of EHR systems among small practices.

Errors associated with outpatient computerized prescribing systems

OBJECTIVE

To report the frequency, types, and causes of errors associated with outpatient computer-generated prescriptions, and to develop a framework to classify these errors to determine which strategies have greatest potential for preventing them.

MATERIALS AND METHODS

This is a retrospective cohort study of 3850 computer-generated prescriptions received by a commercial outpatient pharmacy chain across three states over 4 weeks in 2008. A clinician panel reviewed the prescriptions using a previously described method to identify and classify medication errors. Primary outcomes were the incidence of medication errors; potential adverse drug events, defined as errors with potential for harm; and rate of prescribing errors by error type and by prescribing system.

RESULTS

Of 3850 prescriptions, 452 (11.7%) contained 466 total errors, of which 163 (35.0%) were considered potential adverse drug events. Error rates varied by computerized prescribing system, from 5.1% to 37.5%. The most common error was omitted information (60.7% of all errors).

DISCUSSION

About one in 10 computer-generated prescriptions included at least one error, of which a third had potential for harm. This is consistent with the literature on manual handwritten prescription error rates. The number, type, and severity of errors varied by computerized prescribing system, suggesting that some systems may be better at preventing errors than others.

CONCLUSIONS

Implementing a computerized prescribing system without comprehensive functionality and processes in place to ensure meaningful system use does not decrease medication errors. The authors offer targeted recommendations on improving computerized prescribing systems to prevent errors.

Willingness to use eHealth services in Lithuanian healthcare institutions. Countrywide survey

BACKGROUND

Lithuania started to implement its own National eHealth Service System (NESS) in 2005. In May 2007, an eHealth system development strategy for the period 2007-2015 was prepared. In general, it is expected that these processes will lead to a higher level of citizens' awareness and involvement in protecting their health, as well as more effective use of available resources for provision and expansion of healthcare services, based on modern IT technologies. However, the implementation of the system is very slow and difficult. We aimed to assess competence and willingness of healthcare institutions (HCIs) to implement the NESS in primary care healthcare institutions in Lithuania.

METHODS

A cross-sectional study design was used. Questionnaires with letters of invitation to participate in the study were sent to 150 Lithuanian HCIs by mail. Only one questionnaire per HCI was sent. HCI head administrative staff (e.g., director, medical director, head of administration) was asked to answer the questionnaires.

RESULTS

A total of 68 replies from all HCIs were received. Response rate to the survey was 45.3%. The eHealth system implementation was mostly expected in eAdministration (77.9%), eReimbursement (47.1%) and Institutional EPR systems (47.1%). There was a lower willingness to start implementing ePrescriptions (4.4%), a picture archiving and communication system (PACS, 8.8%), eLaboratory (11.8%) and Telemedicine (13.2%) services. A lack of competence and knowledge in eHealth system implementation was recorded in the following: digital data protection (p=0.006), IT (p=0.028), health technology (p=0.032) and National eHealth Strategy (p=0.036).

CONCLUSIONS

Most Lithuanian HCIs are planning to participate in the implementation of NESS. HCIs are mostly willing to use eAdministration, eReimbursement and Institutional electronic patient record systems. HCIs highlighted a lack of key competences in eHealth system implementation.

Comparison of clinical knowledge management capabilities of commercially-available and leading internally-developed electronic health records

BACKGROUND

We have carried out an extensive qualitative research program focused on the barriers and facilitators to successful adoption and use of various features of advanced, state-of-the-art electronic health records (EHRs) within large, academic, teaching facilities with long-standing EHR research and development programs. We have recently begun investigating smaller, community hospitals and out-patient clinics that rely on commercially-available EHRs. We sought to assess whether the current generation of commercially-available EHRs are capable of providing the clinical knowledge management features, functions, tools, and techniques required to deliver and maintain the clinical decision support (CDS) interventions required to support the recently defined "meaningful use" criteria.

METHODS

We developed and fielded a 17-question survey to representatives from nine commercially available EHR vendors and four leading internally developed EHRs. The first part of the survey asked basic questions about the vendor's EHR. The second part asked specifically about the CDS-related system tools and capabilities that each vendor provides. The final section asked about clinical content.

RESULTS

All of the vendors and institutions have multiple modules capable of providing clinical decision support interventions to clinicians. The majority of the systems were capable of performing almost all of the key knowledge management functions we identified.

CONCLUSION

If these well-designed commercially-available systems are coupled with the other key socio-technical concepts required for safe and effective EHR implementation and use, and organizations have access to implementable clinical knowledge, we expect that the transformation of the healthcare enterprise that so many have predicted, is achievable using commercially-available, state-of-the-art EHRs.

Physicians' potential use and preferences related to health information exchange

PURPOSE

To characterize physician attitudes and preferences towards health information exchange (HIE), which is the ability to transmit health information electronically across institutions, and identify factors that influence physicians' interest in using HIE for their clinical work.

METHODS

A survey was conducted of physicians affiliated with institutions that are stakeholders of a regional health information organization in the United States (U.S.). Surveys were administered between May and October, 2009 at educational conferences and on site at physician practices.

RESULTS

Of the 328 physicians asked to participate, 44% (n=144) completed the survey. Sixty-eight percent (n=88) of physicians expressed interest in using HIE for their clinical work. Most physicians expected HIE to improve provider communication (89%), coordination and continuity of care (87%) and efficiency (87%). Potential barriers to adopting or using HIE included start-up costs (57%) and resources to select and implement a system (38%). A majority reported that technical assistance (70%) and financial incentives to use (65%) or purchase (54%) health IT systems would positively influence their adoption and use of HIE. Physicians who believe that financial incentives would be helpful, that HIE would be easy to use, or who prefer viewing patient health information electronically were found to be at least three times more likely to indicate they would adopt and use HIE.

CONCLUSIONS

These findings suggest that providers largely consider HIE as potentially valuable and a majority would be willing to use HIE. Recent U.S. federal health IT policies that provide financial incentives as well as technical assistance may address potential barriers to adoption and usage of HIE.

Physician opinions of the importance, accessibility, and quality of health information and their use of the information

This study compared physicians' perceptions of the importance, accessibility, and quality of different types of patient information that could potentially be available with Health Information Exchange (HIE) with how they use patient information. The results showed that while the physicians rated the majority of 11 data types as very important, accessible, and of high quality, they regularly used only a few data types before having access to a new HIE system. The three major types of information regularly used by the physicians were diagnoses, current medication lists, and allergy information. This study provides new data about how opinions on the importance of information relate to reported information use. Our findings suggest that having important, accessible, and high quality information does not necessarily lead to routine use, but that much of the early value of HIE may lie in improving access to a few data areas.

Barriers to follow-up for women with a history of gestational diabetes

Women with gestational diabetes (GDM) are at increased risk for type 2 diabetes (T2DM), but many do not receive recommended follow-up. We sought to identify barriers to follow-up screening. We surveyed primary care providers (PCPs) and obstetric and gynecology care providers (OBCPs) in a large health system. We also assessed documentation of GDM history in the health care system's electronic medical record. Four hundred seventy-eight clinicians were surveyed, among whom 207 responded. Most participants (81.1%) gave an accurate estimate of risk of progression to T2DM. PCPs were less likely than OBCPs to ask patients about history of GDM (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.20 to 0.90), but they were far more likely to indicate that they order glucose screening for women with a known history (OR 4.31, 95% CI 2.01 to 9.26). Providers identified poor communication between OBCPs and PCPs as a major barrier to screening. Fewer than half (45.8%) of 450 women with GDM by glucose tolerance test criteria had that history documented on their electronic problem list. Clinicians are aware that women with GDM are at high risk of developing type 2 diabetes, but they do not routinely assess and screen patients, and communication between OBCPs and PCPs can be improved.

Ability to generate patient registries among practices with and without electronic health records

Background

The ability to generate registries of patients with particular clinical attributes, such as diagnoses or medications taken, is central to measuring and improving the quality of health care. However, it is not known how many providers have the ability to generate such registries.

Objectives

To assess the proportion of physician practices that can construct registries of patients with specific diagnoses, laboratory results, or medications, and to determine the relationship between electronic health record (EHR) usage and the ability to perform registry functions.

Methods

We conducted a mail survey of a stratified random sample of physician practices in Massachusetts in the northeastern United States (N = 1884). The survey included questions about the physicians’ ability to generate diagnosis, laboratory result, and medication registries; the presence of EHR; and usage of specific EHR features.

Results

The response rate was 71% (1345/1884). Overall, 79.8% of physician practices reported being able to generate registries of patients by diagnosis; 56.1% by laboratory result; and 55.8% by medication usage. In logistic regression analyses, adjusting for urban/rural location, practice size and ownership, teaching status, hospital affiliation, and specialty, physician practices with an EHR were more likely to be able to construct diagnosis registries (adjusted odds ratio [OR] 1.53, 95% confidence interval [CI] 1.25 - 1.86), laboratory registries (OR 1.42, 95% CI 1.22 - 1.66), and medication registries (OR 2.30, 95% CI 1.96 - 2.70).

Conclusions

Many physician practices were able to generate registries, but this capability is far from universal. Adoption of EHRs appears to be a useful step toward this end, and practices with EHRs are considerably more likely to be able to carry out registry functions. Because practices need registries to perform broad-based quality improvement, they should consider adopting EHRs that have built-in registry functionality.

Reducing the prescribing of heavily marketed medications: a randomized controlled trial

CONTEXT

Prescription drug costs are a major component of health care expenditures, yet resources to support evidence-based prescribing are not widely available.

OBJECTIVE

To evaluate the effectiveness of computerized prescribing alerts, with or without physician-led group educational sessions, to reduce the prescribing of heavily marketed hypnotic medications.

DESIGN

Cluster-randomized controlled trial.

SETTING

We randomly allocated 14 internal medicine practice sites to receive usual care, computerized prescribing alerts alone, or alerts plus group educational sessions.

MEASUREMENTS

Proportion of heavily marketed hypnotics prescribed before and after the implementation of computerized alerts and educational sessions.

MAIN RESULTS

The activation of computerized alerts held the prescribing of heavily marketed hypnotic medications at pre-intervention levels in both the alert-only group (adjusted risk ratio [RR] 0.97; 95% CI 0.82-1.14) and the alert-plus-education group (RR 0.98; 95% CI 0.83-1.17) while the usual-care group experienced an increase in prescribing (RR 1.31; 95% CI 1.08-1.60). Compared to the usual-care group, the relative risk of prescribing heavily marketed medications was less in both the alert-group (Ratio of risk ratios [RRR] 0.74; 95% CI 0.57-0.96) and the alert-plus-education group (RRR 0.74; 95% CI 0.58-0.97). The prescribing of heavily marketed medications was similar in the alert-group and alert-plus-education group (RRR 1.02; 95% CI 0.80-1.29). Most clinicians reported that the alerts provided useful prescribing information (88%) and did not interfere with daily workflow (70%).

CONCLUSIONS

Computerized decision support is an effective tool to reduce the prescribing of heavily marketed hypnotic medications in ambulatory care settings.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00788346.

The relationship between electronic health record use and quality of care over time

OBJECTIVE Electronic health records (EHRs) have the potential to advance the quality of care, but studies have shown mixed results. The authors sought to examine the extent of EHR usage and how the quality of care delivered in ambulatory care practices varied according to duration of EHR availability. METHODS The study linked two data sources: a statewide survey of physicians' adoption and use of EHR and claims data reflecting quality of care as indicated by physicians' performance on widely used quality measures. Using four years of measurement, we combined 18 quality measures into 6 clinical condition categories. While the survey of physicians was cross-sectional, respondents indicated the year in which they adopted EHR. In an analysis accounting for duration of EHR use, we examined the relationship between EHR adoption and quality of care. RESULTS The percent of physicians reporting adoption of EHR and availability of EHR core functions more than doubled between 2000 and 2005. Among EHR users in 2005, the average duration of EHR use was 4.8 years. For all 6 clinical conditions, there was no difference in performance between EHR users and non-users. In addition, for these 6 clinical conditions, there was no consistent pattern between length of time using an EHR and physicians performance on quality measures in both bivariate and multivariate analyses. CONCLUSIONS In this cross-sectional study, we found no association between duration of using an EHR and performance with respect to quality of care, although power was limited. Intensifying the use of key EHR features, such as clinical decision support, may be needed to realize quality improvement from EHRs. Future studies should examine the relationship between the extent to which physicians use key EHR functions and their performance on quality measures over time.