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Lees AF, Beni C, Lee A, Wedgeworth P, Dzara K, Joyner B, Tarczy-Hornoch P, Leu M. Uses of Electronic Health Record Data to Measure the Clinical Learning Environment of Graduate Medical Education Trainees: A Systematic Review. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:1326-1336. [PMID: 37267042 PMCID: PMC10615720 DOI: 10.1097/acm.0000000000005288] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE This study systematically reviews the uses of electronic health record (EHR) data to measure graduate medical education (GME) trainee competencies. METHOD In January 2022, the authors conducted a systematic review of original research in MEDLINE from database start to December 31, 2021. The authors searched for articles that used the EHR as their data source and in which the individual GME trainee was the unit of observation and/or unit of analysis. The database query was intentionally broad because an initial survey of pertinent articles identified no unifying Medical Subject Heading terms. Articles were coded and clustered by theme and Accreditation Council for Graduate Medical Education (ACGME) core competency. RESULTS The database search yielded 3,540 articles, of which 86 met the study inclusion criteria. Articles clustered into 16 themes, the largest of which were trainee condition experience (17 articles), work patterns (16 articles), and continuity of care (12 articles). Five of the ACGME core competencies were represented (patient care and procedural skills, practice-based learning and improvement, systems-based practice, medical knowledge, and professionalism). In addition, 25 articles assessed the clinical learning environment. CONCLUSIONS This review identified 86 articles that used EHR data to measure individual GME trainee competencies, spanning 16 themes and 6 competencies and revealing marked between-trainee variation. The authors propose a digital learning cycle framework that arranges sequentially the uses of EHR data within the cycle of clinical experiential learning central to GME. Three technical components necessary to unlock the potential of EHR data to improve GME are described: measures, attribution, and visualization. Partnerships between GME programs and informatics departments will be pivotal in realizing this opportunity.
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Affiliation(s)
- A Fischer Lees
- A. Fischer Lees is a clinical informatics fellow, Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle, Washington
| | - Catherine Beni
- C. Beni is a general surgery resident, Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Albert Lee
- A. Lee is a clinical informatics fellow, Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle, Washington
| | - Patrick Wedgeworth
- P. Wedgeworth is a clinical informatics fellow, Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle, Washington
| | - Kristina Dzara
- K. Dzara is assistant dean for educator development, director, Center for Learning and Innovation in Medical Education, and associate professor of medical education, Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle, Washington
| | - Byron Joyner
- B. Joyner is vice dean for graduate medical education and a designated institutional official, Graduate Medical Education, University of Washington School of Medicine, Seattle, Washington
| | - Peter Tarczy-Hornoch
- P. Tarczy-Hornoch is professor and chair, Department of Biomedical Informatics and Medical Education, and professor, Department of Pediatrics (Neonatology), University of Washington School of Medicine, and adjunct professor, Allen School of Computer Science and Engineering, University of Washington, Seattle, Washington
| | - Michael Leu
- M. Leu is professor and director, Clinical Informatics Fellowship, Department of Biomedical Informatics and Medical Education, and professor, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Ryskina K, Jessica Dine C, Gitelman Y, Leri D, Patel M, Kurtzman G, Lin LY, Epstein AJ. Effect of Social Comparison Feedback on Laboratory Test Ordering for Hospitalized Patients: A Randomized Controlled Trial. J Gen Intern Med 2018; 33:1639-1645. [PMID: 29790072 PMCID: PMC6153251 DOI: 10.1007/s11606-018-4482-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 02/14/2018] [Accepted: 05/04/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Social comparison feedback is an increasingly popular strategy that uses performance report cards to modify physician behavior. Our objective was to test the effect of such feedback on the ordering of routine laboratory tests for hospitalized patients, a practice considered overused. METHODS This was a single-blinded randomized controlled trial. Between January and June 2016, physicians on six general medicine teams at the Hospital of the University of Pennsylvania were cluster randomized with equal allocation to two arms: (1) those e-mailed a summary of their routine laboratory test ordering vs. the service average for the prior week, linked to a continuously updated personalized dashboard containing patient-level details, and snapshot of the dashboard and (2) those who did not receive the intervention. The primary outcome was the count of routine laboratory test orders placed by a physician per patient-day. We modeled the count of orders by each physician per patient-day after the intervention as a function of trial arm and the physician's order count before the intervention. The count outcome was modeled using negative binomial models with adjustment for clustering within teams. RESULTS One hundred and fourteen interns and residents participated. We did not observe a statistically significant difference in adjusted reduction in routine laboratory ordering between the intervention and control physicians (physicians in the intervention group ordered 0.14 fewer tests per patient-day than physicians in the control group, 95% CI - 0.56 to 0.27, p = 0.50). Physicians whose absolute ordering rate deviated from the peer rate by more than 1.0 laboratory test per patient-day reduced their laboratory ordering by 0.80 orders per patient-day (95% CI - 1.58 to - 0.02, p = 0.04). CONCLUSIONS Personalized social comparison feedback on routine laboratory ordering did not change targeted behavior among physicians, although there was a significant decrease in orders among participants who deviated more from the peer rate. TRIAL REGISTRATION Clinicaltrials.gov registration: #NCT02330289.
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Affiliation(s)
- Kira Ryskina
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - C Jessica Dine
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Pulmonary and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Yevgeniy Gitelman
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Damien Leri
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
| | - Mitesh Patel
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Gregory Kurtzman
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lisa Y Lin
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrew J Epstein
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
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Itoga NK, Minami HR, Chelvakumar M, Pearson K, Mell MM, Bendavid E, Owens DK. Cost-effectiveness analysis of asymptomatic peripheral artery disease screening with the ABI test. Vasc Med 2018; 23:97-106. [PMID: 29345540 PMCID: PMC5893367 DOI: 10.1177/1358863x17745371] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Screening for asymptomatic peripheral artery disease (aPAD) with the ankle-brachial index (ABI) test is hypothesized to reduce disease progression and cardiovascular (CV) events by identifying individuals who may benefit from early initiation of medical therapy. Using a Markov model, we evaluated the cost effectiveness of initiating medical therapy (e.g. statin and ACE-inhibitor) after a positive ankle-brachial index (ABI) screen in 65-year-old patients. We modeled progression to symptomatic PAD (sPAD) and CV events with and without ABI screening, evaluating differences in costs and quality-adjusted life years (QALYs). The cost of the ABI test, physician visit, new medication, CV events, and interventions for sPAD were incorporated in the model. We performed sensitivity analysis on model variables with uncertainty. Our model found an incremental cost of US $338 and an incremental QALY of 0.00380 with one-time ABI screening, resulting in an incremental cost-effectiveness ratio (ICER) of $88,758/QALY over a 35-year period. The variables with the largest effects in the ICER were aPAD disease prevalence, cost of monthly medication after a positive screen and 2-year medication adherence rates. Screening high-risk populations, such as tobacco users, where the prevalence of PAD may be 2.5 times higher, decreases the ICER to $24,092/QALY. Our analysis indicates the cost effectiveness of one-time screening for aPAD depends on prevalence, medication costs, and adherence to therapies for CV disease risk reduction. Screening in higher-risk populations under favorable assumptions about medication adherence results in the most favorable cost effectiveness, but limitations in the primary data preclude definitive assessment of cost effectiveness.
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Affiliation(s)
- Nathan K. Itoga
- Stanford University; Department of Surgery, Division of Vascular Surgery
| | | | - Meena Chelvakumar
- Stanford University; Center for Health Policy and Primary Care and Outcomes Research
| | - Keon Pearson
- Stanford University; Department of Surgery, Division of Vascular Surgery
| | - Matthew M. Mell
- Stanford University; Department of Surgery, Division of Vascular Surgery
| | - Eran Bendavid
- Stanford University; Center for Health Policy and Primary Care and Outcomes Research
| | - Douglas K. Owens
- Stanford University; Center for Health Policy and Primary Care and Outcomes Research
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Ryskina KL, Holmboe ES, Shea JA, Kim E, Long JA. Physician Experiences With High Value Care in Internal Medicine Residency: Mixed-Methods Study of 2003-2013 Residency Graduates. TEACHING AND LEARNING IN MEDICINE 2018; 30:57-66. [PMID: 28753038 PMCID: PMC5803790 DOI: 10.1080/10401334.2017.1335207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
UNLABELLED Phenomenon: High healthcare costs and relatively poor health outcomes in the United States have led to calls to improve the teaching of high value care (defined as care that balances potential benefits of interventions with their harms including costs) to physicians-in-training. Numerous interventions to increase high value care in graduate medical education were implemented at the national and local levels over the past decade. However, there has been little evaluation of their impact on physician experiences during training and perceived preparedness for practice. We aimed to assess trends in U.S. physician experiences with high value care during residency over the past decade. APPROACH This mixed-methods study used a cross-sectional survey mailed July 2014 to January 2015 to 902 internists who completed residency in 2003-2013, randomly selected from the American Medical Association Masterfile. Quantitative analyses of survey responses and content analysis of free-text comments submitted by respondents were performed. FINDINGS A total of 456 physicians (50.6%) responded. Fewer than one fourth reported being exposed to teaching about high value care at least frequently (23.6%, 106/450). Only 43.8% of respondents (193/446) felt prepared to use overtreatment guidelines in conversations with patients, whereas 85.8% (379/447) felt prepared to participate in shared decision making with patients at the conclusion of their training, and 84.4% (380/450) reported practicing generic prescribing. Physicians who completed residency more recently were more likely to report practicing generic prescribing and feeling well prepared to use overtreatment guidelines in conversations with patients (p < .01 for both). Insights: In a national survey, recent U.S. internal medicine residency graduates were more likely to experience high value care during training, which may reflect increased national and local efforts in this area. However, being exposed to high value care as a trainee may not translate into specific tools for practice. In fact, many U.S. internists reported inadequate exposure to prepare them for patient discussions about costs and the use of overtreatment guidelines in practice.
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Affiliation(s)
- Kira L Ryskina
- a Division of General Internal Medicine , Perelman School of Medicine of the University of Pennsylvania , Philadelphia , Pennsylvania , USA
| | - Eric S Holmboe
- b Accreditation Council for Graduate Medical Education , Chicago , Illinois , USA
| | - Judy A Shea
- a Division of General Internal Medicine , Perelman School of Medicine of the University of Pennsylvania , Philadelphia , Pennsylvania , USA
| | - Esther Kim
- a Division of General Internal Medicine , Perelman School of Medicine of the University of Pennsylvania , Philadelphia , Pennsylvania , USA
| | - Judith A Long
- a Division of General Internal Medicine , Perelman School of Medicine of the University of Pennsylvania , Philadelphia , Pennsylvania , USA
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Summers A, Ruderman C, Leung FH, Slater M. Examining patterns in medication documentation of trade and generic names in an academic family practice training centre. BMC MEDICAL EDUCATION 2017; 17:175. [PMID: 28938883 PMCID: PMC5610475 DOI: 10.1186/s12909-017-1015-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 09/18/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Studies in the United States have shown that physicians commonly use brand names when documenting medications in an outpatient setting. However, the prevalence of prescribing and documenting brand name medication has not been assessed in a clinical teaching environment. The purpose of this study was to describe the use of generic versus brand names for a select number of pharmaceutical products in clinical documentation in a large, urban academic family practice centre. METHODS A retrospective chart review of the electronic medical records of the St. Michael's Hospital Academic Family Health Team (SMHAFHT). Data for twenty commonly prescribed medications were collected from the Cumulative Patient Profile as of August 1, 2014. Each medication name was classified as generic or trade. Associations between documentation patterns and physician characteristics were assessed. RESULTS Among 9763 patients prescribed any of the twenty medications of interest, 45% of patient charts contained trade nomenclature exclusively. 32% of charts contained only generic nomenclature, and 23% contained a mix of generic and trade nomenclature. There was large variation in use of generic nomenclature amongst physicians, ranging from 19% to 93%. CONCLUSIONS Trade names in clinical documentation, which likely reflect prescribing habits, continue to be used abundantly in the academic setting. This may become part of the informal curriculum, potentially facilitating undue bias in trainees. Further study is needed to determine characteristics which influence use of generic or trade nomenclature and the impact of this trend on trainees' clinical knowledge and decision-making.
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Affiliation(s)
- Alexander Summers
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON Canada
| | - Carly Ruderman
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON Canada
| | - Fok-Han Leung
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON Canada
| | - Morgan Slater
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON Canada
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Morgan DJ, Leppin A, Smith CD, Korenstein D. A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction. J Hosp Med 2017; 12:346-351. [PMID: 28459906 PMCID: PMC5570540 DOI: 10.12788/jhm.2738] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Overuse of medical services is an increasingly recognized driver of poor-quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert-informed, evidence-based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient-clinician interaction as the nexus of decisions regarding inappropriate care. This interaction is influenced by other utilization drivers, including healthcare system factors, the practice environment, the culture of professional medicine, the culture of healthcare consumption, and individual patient and clinician factors. The variable strength of the evidence supporting these domains highlights important areas for further investigation. Journal of Hospital Medicine 2017;12:346-351.
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Affiliation(s)
- Daniel J. Morgan
- VA Maryland Healthcare System, University of Maryland School of Medicine and Centers for Disease Dynamics, Economics and Policy, Baltimore, MD, USA
| | - Aaron Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester MN, USA
| | | | - Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Riaz H, Krasuski RA. Should Physicians be Encouraged to use Generic Names and to Prescribe Generic Drugs? Am J Cardiol 2016; 117:1851-2. [PMID: 27179932 DOI: 10.1016/j.amjcard.2016.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 03/08/2016] [Accepted: 03/08/2016] [Indexed: 11/27/2022]
Abstract
While using the brand names seems like a trivial issue at the outset, using these names is inherently problematic. Cardiovascular drugs remain the most commonly prescribed drugs by the physicians. The junior doctors are likely to introject practices of their seniors and consequently to reciprocate from the experiences learnt from their preceptors. Using the generic names may be one way to facilitate prescription of the generic drugs who have a better cost profile and similar efficacy than the more expensive branded drugs. In this editorial, we have outlined several arguments to suggest the importance of using the generic names in academic discussions and clinical documentation.
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Affiliation(s)
- Haris Riaz
- Department of Internal Medicine, Cleveland Clinic, Ohio; Department of Cardiovascular Medicine, Duke University, North Carolina
| | - Richard A Krasuski
- Department of Internal Medicine, Cleveland Clinic, Ohio; Department of Cardiovascular Medicine, Duke University, North Carolina
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Ryskina KL, Dine CJ, Kim EJ, Bishop TF, Epstein AJ. Effect of Attending Practice Style on Generic Medication Prescribing by Residents in the Clinic Setting: An Observational Study. J Gen Intern Med 2015; 30:1286-93. [PMID: 26173522 PMCID: PMC4539316 DOI: 10.1007/s11606-015-3323-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite increased emphasis on cost-consciousness in graduate medical training, there is little empirical evidence of the role of attending physician supervision on resident practice in this area. OBJECTIVE To study whether the prescribing practices of attendings influence residents' prescribing of brand-name statin medications in the ambulatory clinic setting. DESIGN AND PARTICIPANTS A retrospective study of statin prescriptions by residents at two internal medicine residency programs, using electronic medical record data from July 2007 through November 2011. MAIN MEASURES We estimated multivariable hierarchical logistic regression models to assess the independent effect of the supervising attending's rate of brand-name prescribing in the preceding quarter on the likelihood of a resident prescribing a brand-name statin. KEY RESULTS The sample included 342 residents and 58 attendings, accounting for 10,151 initial statin prescriptions, including 3,942 by residents. Brand-name statins were prescribed in about one-fourth of encounters. After adjusting for patient-, physician-, and practice-level factors, the supervising attendings' brand-name prescribing rate in the quarter preceding the encounter was positively associated with a postgraduate year (PGY)-1 resident's prescribing a brand-name statin, but not for PGY-2 or PGY-3 residents. For PGY-1 residents, the adjusted probability of a resident prescribing a brand-name statin ranged from 22.6 % (95 % CI 17.3-28.0 %, p < 0.001) for residents supervised by an attending who prescribed < 20 % brand-name statins in the previous quarter to 41.6 % (95 % CI 24.6-58.5 %, p < 0.001) for residents supervised by an attending who prescribed at least 80 % brand-name statins in the previous quarter. A higher PGY level was associated with brand-name prescribing (aOR 2.07, 95 % CI 1.28-3.35, p = 0.003 for PGY-2; aOR 2.15, 95 % CI 1.31-3.55, p = 0.003 for PGY-3, vs. PGY-1). CONCLUSIONS Supervising attendings' prescribing of brand-name medications may have a significant influence on PGY-1 residents' prescribing of brand-name medications, but not on prescribing by more senior residents.
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Affiliation(s)
- Kira L Ryskina
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, 13-30B4 13th Floor Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA,
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