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Smirnova A, Chahine S, Milani C, Schuh A, Sebok-Syer SS, Swartz JL, Wilhite JA, Kalet A, Durning SJ, Lombarts KM, van der Vleuten CP, Schumacher DJ. Using Resident-Sensitive Quality Measures Derived From Electronic Health Record Data to Assess Residents' Performance in Pediatric Emergency Medicine. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:367-375. [PMID: 36351056 PMCID: PMC9944759 DOI: 10.1097/acm.0000000000005084] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
PURPOSE Traditional quality metrics do not adequately represent the clinical work done by residents and, thus, cannot be used to link residency training to health care quality. This study aimed to determine whether electronic health record (EHR) data can be used to meaningfully assess residents' clinical performance in pediatric emergency medicine using resident-sensitive quality measures (RSQMs). METHOD EHR data for asthma and bronchiolitis RSQMs from Cincinnati Children's Hospital Medical Center, a quaternary children's hospital, between July 1, 2017, and June 30, 2019, were analyzed by ranking residents based on composite scores calculated using raw, unadjusted, and case-mix adjusted latent score models, with lower percentiles indicating a lower quality of care and performance. Reliability and associations between the scores produced by the 3 scoring models were compared. Resident and patient characteristics associated with performance in the highest and lowest tertiles and changes in residents' rank after case-mix adjustments were also identified. RESULTS 274 residents and 1,891 individual encounters of bronchiolitis patients aged 0-1 as well as 270 residents and 1,752 individual encounters of asthmatic patients aged 2-21 were included in the analysis. The minimum reliability requirement to create a composite score was met for asthma data (α = 0.77), but not bronchiolitis (α = 0.17). The asthma composite scores showed high correlations ( r = 0.90-0.99) between raw, latent, and adjusted composite scores. After case-mix adjustments, residents' absolute percentile rank shifted on average 10 percentiles. Residents who dropped by 10 or more percentiles were likely to be more junior, saw fewer patients, cared for less acute and younger patients, or had patients with a longer emergency department stay. CONCLUSIONS For some clinical areas, it is possible to use EHR data, adjusted for patient complexity, to meaningfully assess residents' clinical performance and identify opportunities for quality improvement.
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Affiliation(s)
- Alina Smirnova
- A. Smirnova is clinical assistant professor, Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada, and adjunct assistant professor, Kern Institute for the Transformation of Medical Education, Medical College of Wisconsin, Milwaukee, Wisconsin; ORCID: https://orcid.org/0000-0003-4491-3007
| | - Saad Chahine
- S. Chahine is associate professor of measurement and assessment, Faculty of Education, Queen’s University, Kingston, Ontario, Canada; ORCID: https://orcid.org/0000-0003-0488-773X
| | - Christina Milani
- C. Milani is clinical research assistant, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Abigail Schuh
- A. Schuh is associate professor of pediatrics, Division of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; ORCID: http://orcid.org/0000-0002-6422-2361
| | - Stefanie S. Sebok-Syer
- S.S. Sebok-Syer is assistant professor, Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California; ORCID: http://orcid.org/0000-0002-3572-5971
| | - Jordan L. Swartz
- J.L. Swartz is clinical associate professor, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, and director of clinical informatics, Department of Emergency Medicine, NYU Langone Health, New York, New York
| | - Jeffrey A. Wilhite
- J.A. Wilhite is senior research coordinator, Department of Medicine, NYU Langone Health, New York, New York; ORCID: https://orcid.org/0000-0003-4096-8473
| | - Adina Kalet
- A. Kalet is professor and Steven and Shelagh Roell Chair, Robert D. and Patricia P. Kern Institute for the Transformation of Medical Education, Medical College of Wisconsin, Milwaukee, Wisconsin; ORCID: http://orcid.org/0000-0003-4855-0223
| | - Steven J. Durning
- S.J. Durning is professor and vice chair, Department of Medicine, and director, Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland; ORCID: http://orcid.org/0000-0001-5223-1597
| | - Kiki M.J.M.H. Lombarts
- K.M.J.M.H. Lombarts is professor of professional performance, Department of Medical Psychology, Amsterdam University Medical Centers, University of Amsterdam, and Amsterdam Public Health research institute, Amsterdam, The Netherlands; ORCID: https://orcid.org/0000-0001-6167-0620
| | - Cees P.M. van der Vleuten
- C.P.M. van der Vleuten is professor of education, Department of Educational Development and Research. Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands; ORCID: http://orcid.org/0000-0001-6802-3119
| | - Daniel J. Schumacher
- D.J. Schumacher is professor of pediatrics, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: http://orcid.org/0000-0001-5507-8452
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Kinnear B, Kelleher M, Sall D, Schauer DP, Warm EJ, Kachelmeyer A, Martini A, Schumacher DJ. Development of Resident-Sensitive Quality Measures for Inpatient General Internal Medicine. J Gen Intern Med 2021; 36:1271-1278. [PMID: 33105001 PMCID: PMC8131459 DOI: 10.1007/s11606-020-06320-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/20/2020] [Accepted: 10/14/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Graduate medical education (GME) training has long-lasting effects on patient care quality. Despite this, few GME programs use clinical care measures as part of resident assessment. Furthermore, there is no gold standard to identify clinical care measures that are reflective of resident care. Resident-sensitive quality measures (RSQMs), defined as "measures that are meaningful in patient care and are most likely attributable to resident care," have been developed using consensus methodology and piloted in pediatric emergency medicine. However, this approach has not been tested in internal medicine (IM). OBJECTIVE To develop RSQMs for a general internal medicine (GIM) inpatient residency rotation using previously described consensus methods. DESIGN The authors used two consensus methods, nominal group technique (NGT) and a subsequent Delphi method, to generate RSQMs for a GIM inpatient rotation. RSQMs were generated for specific clinical conditions found on a GIM inpatient rotation, as well as for general care on a GIM ward. PARTICIPANTS NGT participants included nine IM and medicine-pediatrics (MP) residents and six IM and MP faculty members. The Delphi group included seven IM and MP residents and seven IM and MP faculty members. MAIN MEASURES The number and description of RSQMs generated during this process. KEY RESULTS Consensus methods resulted in 89 RSQMs with the following breakdown by condition: GIM general care-21, diabetes mellitus-16, hyperkalemia-14, COPD-13, hypertension-11, pneumonia-10, and hypokalemia-4. All RSQMs were process measures, with 48% relating to documentation and 51% relating to orders. Fifty-eight percent of RSQMs were related to the primary admitting diagnosis, while 42% could also be related to chronic comorbidities that require management during an admission. CONCLUSIONS Consensus methods resulted in 89 RSQMs for a GIM inpatient service. While all RSQMs were process measures, they may still hold value in learner assessment, formative feedback, and program evaluation.
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Affiliation(s)
- Benjamin Kinnear
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA. .,Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Matthew Kelleher
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA.,Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dana Sall
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel P Schauer
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Eric J Warm
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrea Kachelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA
| | - Abigail Martini
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA
| | - Daniel J Schumacher
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA
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Epstein JA, Noronha C, Berkenblit G. Smarter Screen Time: Integrating Clinical Dashboards Into Graduate Medical Education. J Grad Med Educ 2020; 12:19-24. [PMID: 32064058 PMCID: PMC7012529 DOI: 10.4300/jgme-d-19-00584.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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Smirnova A, Sebok-Syer SS, Chahine S, Kalet AL, Tamblyn R, Lombarts KMJMH, van der Vleuten CPM, Schumacher DJ. Defining and Adopting Clinical Performance Measures in Graduate Medical Education: Where Are We Now and Where Are We Going? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:671-677. [PMID: 30720528 DOI: 10.1097/acm.0000000000002620] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Assessment and evaluation of trainees' clinical performance measures is needed to ensure safe, high-quality patient care. These measures also aid in the development of reflective, high-performing clinicians and hold graduate medical education (GME) accountable to the public. Although clinical performance measures hold great potential, challenges of defining, extracting, and measuring clinical performance in this way hinder their use for educational and quality improvement purposes. This article provides a way forward by identifying and articulating how clinical performance measures can be used to enhance GME by linking educational objectives with relevant clinical outcomes. The authors explore four key challenges: defining as well as measuring clinical performance measures, using electronic health record and clinical registry data to capture clinical performance, and bridging silos of medical education and health care quality improvement. The authors also propose solutions to showcase the value of clinical performance measures and conclude with a research and implementation agenda. Developing a common taxonomy of uniform specialty-specific clinical performance measures, linking these measures to large-scale GME databases, and applying both quantitative and qualitative methods to create a rich understanding of how GME affects quality of care and patient outcomes is important, the authors argue. The focus of this article is primarily GME, yet similar challenges and solutions will be applicable to other areas of medical and health professions education as well.
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Affiliation(s)
- Alina Smirnova
- A. Smirnova is a PhD researcher, School of Health Professions Education, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands, and Professional Performance Research Group, Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. S.S. Sebok-Syer is instructor, Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California. S. Chahine is assistant professor and scientist, Centre for Educational Research and Innovation (CERI), Western University, London, Ontario, Canada. A.L. Kalet is professor of medicine and surgery, director of research on medical education outcomes (ROMEO), Unit of the Division of General Internal Medicine and Clinical Innovation, Department of Medicine, and director of research, Program on Medical Education and Technology, NYU School of Medicine, New York, New York. R. Tamblyn is professor, Department of Medicine and Department of Epidemiology and Biostatistics, McGill University, medical scientist, McGill University Health Center Research Institute, scientific director, Clinical and Health Informatics Research Group, McGill University, and scientific director, Canadian Institutes of Health Research-Institute of Health Services and Policy Research, Montreal, Quebec, Canada. K.M.J.M.H. Lombarts is professor and lead investigator, Professional Performance Research Group, Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. C.P.M. van der Vleuten is professor and scientific director, School of Health Professions Education, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands. D.J. Schumacher is associate professor, Division of Emergency Medicine, and pediatric emergency physician, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, Ohio
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