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Ivanova AA, Gardner MS, Kusovschi JD, Parks BA, Schieltz DM, Bareja A, McGarrah RW, Kraus WE, Kuklenyik Z, Pirkle JL, Barr JR. Inaccurately Reported Statin Use Affects the Assessing of Lipid Profile Measures and Their Association with Coronary Artery Disease Risk. Clin Chem 2024; 70:528-537. [PMID: 38431279 DOI: 10.1093/clinchem/hvad223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/04/2023] [Indexed: 03/05/2024]
Abstract
BACKGROUND Lipid profiling is central for coronary artery disease (CAD) risk assessment. Nonadherence or unreported use of lipid-lowering drugs, particularly statins, can significantly complicate the association between lipid profile measures and CAD clinical outcomes. By combining medication history evaluation with statin analysis in plasma, we determined the effects of inaccurately reported statin use on lipid profile measures and their association with CAD risk. METHODS We compared medication history of statin use with statin concentration measurements, by liquid chromatography-tandem mass spectrometry, in 690 participants undergoing coronary angiography (63 ± 11 years of age). Nominal logistic regression was employed to model CAD diagnosis with statin measurements, phenotypic, and lipid profile characteristics. RESULTS Medication history of statin use was confirmed by statin assay for 81% of the patients. Surprisingly, statins were detected in 46% of patients without statin use records. Nonreported statin use was disproportionately higher among older participants. Stratifying samples by statin history resulted in underestimated LDL-lipid measures. Apolipoprotein B concentrations had a significant inverse CAD association, which became nonsignificant upon re-stratification using the statin assay data. CONCLUSIONS Our study uncovered prominent discrepancies between medication records and actual statin use measured by mass spectrometry. We showed that inaccurate statin use assessments may lead to overestimation and underestimation of LDL levels in statin user and nonuser categories, exaggerating the reverse epidemiology association between LDL levels and CAD diagnosis. Combining medication history and quantitative statin assay data can significantly improve the design, analysis, and interpretation of clinical and epidemiological studies.
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Affiliation(s)
- Anna A Ivanova
- Clinical Chemistry Branch, Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Michael S Gardner
- Clinical Chemistry Branch, Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jennifer D Kusovschi
- Clinical Chemistry Branch, Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Bryan A Parks
- Clinical Chemistry Branch, Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - David M Schieltz
- Clinical Chemistry Branch, Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Akshay Bareja
- Duke Molecular Physiology Institute, Duke University School of Medicine, Duke University, Durham, NC, United States
| | - Robert W McGarrah
- Duke Molecular Physiology Institute, Duke University School of Medicine, Duke University, Durham, NC, United States
| | - William E Kraus
- Duke Molecular Physiology Institute, Duke University School of Medicine, Duke University, Durham, NC, United States
| | - Zsuzsanna Kuklenyik
- Clinical Chemistry Branch, Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - James L Pirkle
- Clinical Chemistry Branch, Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - John R Barr
- Clinical Chemistry Branch, Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, United States
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Livaudais M, Deng D, Frederick T, Grey-Theriot F, Kroth PJ. Perceived Value of the Electronic Health Record and Its Association with Physician Burnout. Appl Clin Inform 2022; 13:778-784. [PMID: 35981548 PMCID: PMC9388222 DOI: 10.1055/s-0042-1755372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/01/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND There is a common belief that seniority and gender are associated with clinicians' perceptions of the value of electronic health record (EHR) technology and the propensity for burnout. Insufficient evidence exists on the relationship between these variables. OBJECTIVE The aim of this study was to investigate how seniority/years of practice, gender, and screened burnout status are associated with opinions of EHR use on quality, cost, and efficiency of care. METHODS We surveyed ambulatory primary care and subspecialty clinicians at three different institutions to screen for burnout status and to measure their opinions (positive, none, negative, don't know) on how EHR technology has impacted three important attributes of health care: quality, cost, and efficiency of care. We used chi-square tests to analyze association between years of practice (≤10 years or 11+ years), gender, and screened burnout status and the reported attributes. We used a Bonferroni-corrected α = 0.0167 for significance to protect against type I error among multiple comparisons. RESULTS Overall, 281 clinicians responded from 640 that were surveyed with 44% overall response rate. There were no significant associations of years in practice (≤10 years or 11+ years) or gender (p > 0.0167 for both) with any of the health care attributes. Clinicians who screened burnout negative (n = 154, 55%) were more likely to indicate that EHR technology has a positive impact on both the quality (p = 0.0025) and efficiency (p = 0.0003) health care attributes compared with those who screened burnout positive (n = 127, 45%). CONCLUSION Burnout status is significantly associated with clinicians' perceived value of EHR technologies, while years of practice and gender are not. This contests the popular notion that junior clinicians view EHR technology more favorably than their more senior counterparts. Hence, burnout status may be an important factor associated with the overall value clinicians ascribe to EHR technologies.
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Affiliation(s)
- Maria Livaudais
- Department of Public Health, California State University East Bay, California, United States
| | - Derek Deng
- Department of Biomedical Informatics, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, United States
| | - Tracy Frederick
- Department of Biomedical Informatics, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, United States
| | - Francine Grey-Theriot
- Department of Biomedical Informatics, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, United States
| | - Philip J. Kroth
- Department of Biomedical Informatics, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, United States
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Heponiemi T, Gluschkoff K, Vehko T, Kaihlanen AM, Saranto K, Nissinen S, Nadav J, Kujala S. Electronic Health Record Implementations and Insufficient Training Endanger Nurses' Well-being: Cross-sectional Survey Study. J Med Internet Res 2021; 23:e27096. [PMID: 34941546 PMCID: PMC8738988 DOI: 10.2196/27096] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/22/2021] [Accepted: 11/10/2021] [Indexed: 01/26/2023] Open
Abstract
Background High expectations have been set for the implementations of health information systems (HIS) in health care. However, nurses have been dissatisfied after implementations of HIS. In particular, poorly functioning electronic health records (EHRs) have been found to induce stress and cognitive workload. Moreover, the need to learn new systems may require considerable effort from nurses. Thus, EHR implementations may have an effect on the well-being of nurses. Objective This study aimed to examine the associations of EHR-to-EHR implementations and the sufficiency of related training with perceived stress related to information systems (SRIS), time pressure, and cognitive failures among registered nurses. Moreover, we examined the moderating effect of the employment sector (hospital, primary care, social services, and others) on these associations. Methods This study was a cross-sectional survey study of 3610 registered Finnish nurses in 2020. EHR implementation was measured by assessing whether the work unit of each respondent had implemented or will implement a new EHR (1) within the last 6 months, (2) within the last 12 months, (3) in the next 12 months, and (4) at no point within the last 12 months or in the forthcoming 12 months. The associations were examined using analyses of covariance adjusted for age, gender, and employment sector. Results The highest levels of SRIS (adjusted mean 4.07, SE 0.05) and time pressure (adjusted mean 4.55, SE 0.06) were observed among those who had experienced an EHR implementation within the last 6 months. The lowest levels of SRIS (adjusted mean 3.26, SE 0.04), time pressure (adjusted mean 4.41, SE 0.05), and cognitive failures (adjusted mean 1.84, SE 0.02) were observed among those who did not experience any completed or forthcoming implementations within 12 months. Nurses who perceived that they had received sufficient implementation-related training experienced less SRIS (F1=153.40, P<.001), time pressure (F1=80.95, P<.001), and cognitive failures (F1=34.96, P<.001) than those who had received insufficient training. Recent implementations and insufficient training were especially strongly associated with high levels of SRIS in hospitals. Conclusions EHR implementations and insufficient training related to these implementations may endanger the well-being of nurses and even lead to errors. Thus, it is extremely important for organizations to offer comprehensive training before, during, and after implementations. Moreover, easy-to-use systems that allow transition periods, a re-engineering approach, and user involvement may be beneficial to nurses in the implementation process. Training and other improvements would be especially important in hospitals.
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Affiliation(s)
| | - Kia Gluschkoff
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Tuulikki Vehko
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | | | | | | | - Janna Nadav
- Finnish Institute for Health and Welfare, Helsinki, Finland
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Eberts M, Capurro D. Patient and Physician Perceptions of the Impact of Electronic Health Records on the Patient-Physician Relationship. Appl Clin Inform 2019; 10:729-734. [PMID: 31556076 PMCID: PMC6760987 DOI: 10.1055/s-0039-1696667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 07/26/2019] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVES Limited studies have been performed in South America to assess patient and physician perceptions of electronic health record (EHR) usage. We aim to study the perceptions of patients and physicians regarding the impact of EHRs on the patient-physician relationship. METHODS We use a survey instrument to assess the physician computer experience and opinions regarding EHR impact on various aspects of patient care. An additional survey is used to assess patient opinions related to their medical visit. Surveys are administered in two outpatient clinics in a private, academic health care network. RESULTS While a majority of physicians believed that EHRs have an overall positive impact on the quality of health care, many physicians had negative perceptions of the impact of EHRs on the patient-physician relationship. A majority of patients felt comfortable with their physician's use of the EHR and felt that their physician was able to maintain good personal contact while using the computer. CONCLUSION Although physicians believe EHRs have a generally positive impact on the overall quality of care, the EHR's impact on the patient-physician relationship is still of concern. Patients do not perceive a negative interference from the EHR on the patient-physician relationship.
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Affiliation(s)
- Margaret Eberts
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
- Department of Computer Science, Swarthmore College, Swarthmore, Pennsylvania, United States
| | - Daniel Capurro
- Pontificia Universidad Catolica de Chile Facultad de Medicina, Santiago, Chile
- School of Computing and Information Systems, Melbourne School of Engineering, University of Melbourne Melbourne, Victoria, Australia
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Prater L, Sanchez A, Modan G, Burgess J, Frier K, Richards N, Bose-Brill S. Electronic Health Record Documentation Patterns of Recorded Primary Care Visits Focused on Complex Communication: A Qualitative Study. Appl Clin Inform 2019; 10:247-253. [PMID: 30970382 DOI: 10.1055/s-0039-1683986] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND In a time-constrained clinical environment, physicians cannot feasibly document all aspects of an office visit in the electronic health record (EHR). This is especially true for patients with multiple chronic conditions requiring complex clinical reasoning. It is unclear how physicians prioritize the documentation of health information in the EHR. OBJECTIVE The goal of this study is to examine documentation tradeoffs made by physicians when caring for complex patients by comparing the content of office visit conversations with resulting EHR documentation. METHODS We used grounded theory method of qualitative analysis to assess emergent themes in the transcripts of 10 office visits, and then compared the themes to documentation in the EHR. Differences between discussion and subsequent documentation of social and emotional health topics and each of the other key categories were compared using the Wilcoxon signed-rank test. RESULTS The categories that emerged included "chronic conditions," "acute/new problems," "disease prevention," and "social and emotional health." We found that when social and emotional topics were discussed in the office visit, it was documented in the medical record only 30.6% of the time. Chronic conditions, acute/new problems, and disease prevention were documented in the EHR between 87.5 and 91.7% of the time after discussion. The differences between discussion and documentation of social and emotional topics were significantly greater than the differences for chronic conditions, acute/new problems, and disease prevention (all p < 0.05). CONCLUSION Social and emotional factors, while extremely relevant to health management, are less likely than medical concerns to be documented after discussion in an office visit. This lack of documentation may hinder interdisciplinary communication between teams informing individualized therapeutic decisions during acute care handoffs, such as outpatient to inpatient care.
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Affiliation(s)
- Laura Prater
- Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Grandview, Ohio, United States
| | - Anthony Sanchez
- College of Medicine, The Ohio State University, Columbus, Ohio, United States
| | - Gabriella Modan
- Department of English, The Ohio State University, Columbus, Ohio, United States
| | - Jennifer Burgess
- Department of English, The Ohio State University, Columbus, Ohio, United States
| | - Kim Frier
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Nathan Richards
- Department of English, The Ohio State University, Columbus, Ohio, United States
| | - Seuli Bose-Brill
- Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Grandview, Ohio, United States
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Williams DC, Warren RW, Ebeling M, Andrews AL, Teufel Ii RJ. Physician Use of Electronic Health Records: Survey Study Assessing Factors Associated With Provider Reported Satisfaction and Perceived Patient Impact. JMIR Med Inform 2019; 7:e10949. [PMID: 30946023 PMCID: PMC6470463 DOI: 10.2196/10949] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 12/10/2018] [Accepted: 12/31/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The effect electronic health record (EHR) implementation has on physician satisfaction and patient care remains unclear. A better understanding of physician perceptions of EHRs and factors that influence those perceptions is needed to improve the physician and patient experience when using EHRs. OBJECTIVE The objective of this study was to determine provider and clinical practice factors associated with physician EHR satisfaction and perception of patient impact. METHODS We surveyed a random sample of physicians, including residents and fellows, at a US quaternary care academic hospital from February to March 2016. The survey assessed provider demographics, clinical practice factors (ie, attending, fellow, or resident), and overall EHR experience. The primary outcomes assessed were provider satisfaction and provider perceptions of impact to patient care. Responses on the satisfaction and patient impact questions were recorded on a continuous scale initially anchored at neutral (scale range 0 to 100: 0 defined as "extremely negatively" and 100 as "extremely positively"). Independent variables assessed included demographic and clinical practice factors, including perceived efficiency in using the EHR. One-way analysis of variance or the Kruskal-Wallis test was used for bivariate comparisons, and linear regression was used for multivariable modeling. RESULTS Of 157 physicians, 111 (70.7%) completed the survey; 51.4% (57/111) of the respondents were attending physicians, and of those, 71.9% (41/57) reported a >50% clinical full-time-equivalency and half reported supervising residents >50% of the time. A total of 50.5% (56/111) of the respondents were primary care practitioners, previous EHR experience was evenly distributed, and 12.6% (14/111) of the total sample were EHR super-users. Responses to how our current EHR affects satisfaction were rated above the neutral survey anchor point (mean 58 [SD 22]), as were their perceptions as to how the EHR impacts the patient (mean 61 [SD 18]). In bivariate comparisons, only physician age, clinical role (resident, fellow, or attending), and perceived efficiency were associated with EHR satisfaction. In the linear regression models, physicians with higher reported perceived efficiency reported higher overall satisfaction and patient impact after controlling for other variables in the model. CONCLUSIONS Physician satisfaction with EHRs and their perception of its impact on clinical care were generally positive, but physician characteristics, greater age, and attending level were associated with worse EHR satisfaction. Perceived efficiency is the factor most associated with physician satisfaction with EHRs when controlling for other factors. Understanding physician perceptions of EHRs may allow targeting of technology resources to ensure efficiency and satisfaction with EHR system use during clinical care.
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Affiliation(s)
- Daniel Clay Williams
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Robert W Warren
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Myla Ebeling
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Annie L Andrews
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Ronald J Teufel Ii
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
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O’Donnell A, Kaner E, Shaw C, Haighton C. Primary care physicians' attitudes to the adoption of electronic medical records: a systematic review and evidence synthesis using the clinical adoption framework. BMC Med Inform Decis Mak 2018; 18:101. [PMID: 30424758 PMCID: PMC6234586 DOI: 10.1186/s12911-018-0703-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 09/25/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Recent decades have seen rapid growth in the implementation of Electronic Medical Records (EMRs) in healthcare settings in both developed regions as well as low and middle income countries. Yet despite substantial investment, the implementation of EMRs in some primary care systems has lagged behind other settings, with piecemeal adoption of EMR functionality by primary care physicians (PCPs) themselves. We aimed to review and synthesise international literature on the attitudes of PCPs to EMR adoption using the Clinical Adoption (CA) Framework. METHODS MEDLINE, PsycINFO, and EMBASE were searched from 1st January 1996 to 1st August 2017 for studies investigating PCP attitudes towards EMR adoption. Papers were screened by two independent reviewers, and eligible studies selected for further assessment. Findings were categorised against the CA Framework and the quality of studies assessed against one of three appropriate tools. RESULTS Out of 2263 potential articles, 33 were included, based in North and South America, Europe, Middle East and Hong Kong. Concerns about the accessibility, reliability and EMR utility exerted an adverse influence on PCPs' attitudes to adoption. However many were positive about their potential to improve clinical productivity, patient safety and care quality. Younger, computer-literate PCPs, based in large/multi-group practices, were more likely to be positively inclined to EMR use than older physicians, less-skilled in technology use, based in solo practices. Adequate training, policies and procedures favourably impacted on PCPs' views on EMR implementation. Financial factors were common system level influencers shaping EMR adoption, from start-up costs to the resources required by ongoing use. CONCLUSIONS By using the CA Framework to synthesise the evidence, we identified a linked series of factors influencing PCPs attitudes to EMR adoption. Findings underline the need to involve end-users in future implementation programmes from the outset, to avoid the development of an EMR which is neither feasible nor acceptable for use in practice. TRIAL REGISTRATION PROSPERO CRD42016038790 .
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Affiliation(s)
- Amy O’Donnell
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Eileen Kaner
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Caroline Shaw
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Catherine Haighton
- Department of Social Work, Education and Community Wellbeing, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE7 7XA UK
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Kruse CS, Stein A, Thomas H, Kaur H. The use of Electronic Health Records to Support Population Health: A Systematic Review of the Literature. J Med Syst 2018; 42:214. [PMID: 30269237 PMCID: PMC6182727 DOI: 10.1007/s10916-018-1075-6] [Citation(s) in RCA: 127] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 09/19/2018] [Indexed: 12/16/2022]
Abstract
Electronic health records (EHRs) have emerged among health information technology as "meaningful use" to improve the quality and efficiency of healthcare, and health disparities in population health. In other instances, they have also shown lack of interoperability, functionality and many medical errors. With proper implementation and training, are electronic health records a viable source in managing population health? The primary objective of this systematic review is to assess the relationship of electronic health records' use on population health through the identification and analysis of facilitators and barriers to its adoption for this purpose. Authors searched Cumulative Index of Nursing and Allied Health Literature (CINAHL) and MEDLINE (PubMed), 10/02/2012-10/02/2017, core clinical/academic journals, MEDLINE full text, English only, human species and evaluated the articles that were germane to our research objective. Each article was analyzed by multiple reviewers. Group members recognized common facilitators and barriers associated with EHRs effect on population health. A final list of articles was selected by the group after three consensus meetings (n = 55). Among a total of 26 factors identified, 63% (147/232) of those were facilitators and 37% (85/232) barriers. About 70% of the facilitators consisted of productivity/efficiency in EHRs occurring 33 times, increased quality and data management each occurring 19 times, surveillance occurring 17 times, and preventative care occurring 15 times. About 70% of the barriers consisted of missing data occurring 24 times, no standards (interoperability) occurring 13 times, productivity loss occurring 12 times, and technology too complex occurring 10 times. The analysis identified more facilitators than barriers to the use of the EHR to support public health. Wider adoption of the EHR and more comprehensive standards for interoperability will only enhance the ability for the EHR to support this important area of surveillance and disease prevention. This review identifies more facilitators than barriers to using the EHR to support public health, which implies a certain level of usability and acceptance to use the EHR in this manner. The public-health industry should combine their efforts with the interoperability projects to make the EHR both fully adopted and fully interoperable. This will greatly increase the availability, accuracy, and comprehensiveness of data across the country, which will enhance benchmarking and disease surveillance/prevention capabilities.
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Affiliation(s)
- Clemens Scott Kruse
- Texas State University, 601 University Dr, Encino 250, San Marcos, TX, 78666, USA.
| | - Anna Stein
- Texas State University, 601 University Dr, Encino 250, San Marcos, TX, 78666, USA
| | - Heather Thomas
- Texas State University, 601 University Dr, Encino 250, San Marcos, TX, 78666, USA
| | - Harmander Kaur
- Texas State University, 601 University Dr, Encino 250, San Marcos, TX, 78666, USA
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Shin EY, Ochuko P, Bhatt K, Howard B, McGorisk G, Delaney L, Langdon K, Khosravanipour M, Nambi AA, Grahovec A, Morris DC, Castellano PZ, Shaw LJ, Sperling LS, Goyal A. Errors in Electronic Health Record-Based Data Query of Statin Prescriptions in Patients With Coronary Artery Disease in a Large, Academic, Multispecialty Clinic Practice. J Am Heart Assoc 2018; 7:e007762. [PMID: 29650707 PMCID: PMC6015411 DOI: 10.1161/jaha.117.007762] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 03/19/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND With the recent implementation of the Medicare Quality Payment Program, providers face increasing accountability for delivering high-quality care. Such pay-for-performance programs aim to leverage systematic data captured by electronic health record (EHR) systems to measure performance; however, the fidelity of EHR query for assessing performance has not been validated compared with manual chart review. We sought to determine whether our institution's methodology of EHR query could accurately identify cases in which providers failed to prescribe statins for eligible patients with coronary artery disease. METHODS AND RESULTS A total of 9459 patients with coronary artery disease were seen at least twice at the Emory Clinic between July 2014 and June 2015, of whom 1338 (14.1%, 95% confidence interval 13.5-14.9%) had no statin prescription or exemption per EHR query. A total of 120 patient cases were randomly selected and reviewed by 2 physicians for further adjudication. Of the 120 cases initially classified as statin prescription failures, only 21 (17.5%; 95% confidence interval, 11.7-25.3%) represented true failure following physician review. CONCLUSIONS Sole reliance on EHR data query to measure quality metrics may lead to significant errors in assessing provider performance. Institutions should be cognizant of these potential sources of error, provide support to medical providers, and form collaborative data management teams to promote and improve meaningful use of EHRs. We propose actionable steps to improve the accuracy of EHR data query that require hypothesis testing and prospective validation in future studies.
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Affiliation(s)
- Eric Y Shin
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Kunal Bhatt
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Brian Howard
- Division of Cardiology, Wellstar Health System, Atlanta, GA
| | - Gerard McGorisk
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | | | | | | | | | | | - Douglas C Morris
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Penny Z Castellano
- Department of Obstetrics and Gynecology, Emory University School of Medicine, Atlanta, GA
| | - Leslee J Shaw
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Laurence S Sperling
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Abhinav Goyal
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
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Emani S, Ting DY, Healey M, Lipsitz SR, Karson AS, Bates DW. Physician Beliefs about the Meaningful Use of the Electronic Health Record: A Follow-Up Study. Appl Clin Inform 2017; 8:1044-1053. [PMID: 29241244 DOI: 10.4338/aci-2017-05-ra-0079] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background There is continuing interest in how physicians are responding to the meaningful use of the electronic health record (EHR) incentive program. However, little research has been done on physician beliefs about the meaningful use of the EHR.
Objective This study aims to conduct a follow-up study of physician beliefs about the meaningful use of the EHR.
Methods Online survey of physicians at two academic medical centers (AMCs) in the northeast who were participating in the meaningful use of the EHR incentive program and were using an internally developed EHR was conducted.
Results Of the 2,033 physicians surveyed, 1,075 completed the survey for an overall response rate of 52.9%. Only one-fifth (20.5%) of the physicians agreed or strongly agreed that meaningful use of the EHR would help them improve quality of care, and only a quarter (25.2%) agreed or strongly agreed that the meaningful use of the EHR would improve the care that their organization delivers. Physician satisfaction with the outpatient EHR was the strongest predictor of self-efficacy with achieving stage 2 of the meaningful use of the EHR incentive program (odds ratio: 2.10, 95% confidence interval: 1.61, 2.75, p < 0.001). Physicians reported more negative beliefs in stage 2 than stage 1 across all belief items. For example, 28.1% agreed or strongly agreed that the meaningful use of the EHR would decrease medical errors in stage 2 as compared with 35.9% in stage 1 (p < 0.001).
Conclusion Only one-fifth of the physicians in our study believed that the meaningful use of the EHR would improve quality of care, patient-centeredness of care, or the care they personally provide. Primary care physicians expressed more negative beliefs about the meaningful use of the EHR in stage 2 than in stage 1. These findings show that physicians continue to express negative beliefs about the meaningful use of the EHR. These ongoing negative beliefs are concerning for both implementation and policy.
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Affiliation(s)
- Srinivas Emani
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - David Y Ting
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Michael Healey
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Brigham and Women's Physicians Organization, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Stuart R Lipsitz
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Andrew S Karson
- Decision Support Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - David W Bates
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Healthcare Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States
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11
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Heponiemi T, Hyppönen H, Vehko T, Kujala S, Aalto AM, Vänskä J, Elovainio M. Finnish physicians' stress related to information systems keeps increasing: a longitudinal three-wave survey study. BMC Med Inform Decis Mak 2017; 17:147. [PMID: 29041971 PMCID: PMC5646125 DOI: 10.1186/s12911-017-0545-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 10/09/2017] [Indexed: 11/18/2022] Open
Abstract
Background Poorly functioning, time-consuming, and inadequate information systems are among the most important work-related psychosocial factors causing stress in physicians. The present study examined the trend in the perceived stress that was related to information systems (SRIS) among Finnish physicians during a nine-year follow-up. In addition, we examined the associations of gender, age, employment sector, specialization status, leadership position, on-call burden, and time pressure with SRIS change and levels. Methods A longitudinal design with three survey data collection waves (2006, 2010 and 2015) based on a random sample of Finnish physicians in 2006 was used. The study sample included 1095 physicians (62.3% women, mean age 54.4 years) who provided data on SRIS in every wave. GLM repeated measures analyses were used to examine the associations between independent variables and the SRIS trend during the years 2006, 2010, and 2015. Results SRIS increased during the study period. The estimated marginal mean of SRIS in 2006 was 2.80 (95% CI = 2.68–2.92) and the mean increase was 0.46 (95% CI = 0.30–0.61) points from 2006 to 2010 and 0.25 (95% CI = 0.11–0.39) points from 2010 to 2015. Moreover, our results show that the increase was most pronounced in primary care, whereas in hospitals SRIS did not increase between 2010 and 2015. SRIS increased more among those in a leadership position. On-call duties and high time-pressures were associated with higher SRIS levels during all waves. Conclusions Changing, difficult, and poorly functioning information systems (IS) are a prominent source of stress among Finnish physicians and this perceived stress continues to increase. Organizations should implement arrangements to ease stress stemming from IS especially for those with a high workload and on-call or leadership duties. To decrease IS-related stress, it would be important to study in more detail the main IS factors that contribute to SRIS. Earlier studies indicate that the usability and stability of information systems as well as end-user involvement in system development and work-procedure planning may be significant factors.
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Affiliation(s)
- Tarja Heponiemi
- National Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland.
| | - Hannele Hyppönen
- National Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
| | - Tuulikki Vehko
- National Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
| | | | - Anna-Mari Aalto
- National Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
| | | | - Marko Elovainio
- National Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland.,University of Helsinki, Helsinki, Finland
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12
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Connecting Professional Practice and Technology at the Bedside: Nurses' Beliefs about Using an Electronic Health Record and Their Ability to Incorporate Professional and Patient-Centered Nursing Activities in Patient Care. Comput Inform Nurs 2017; 34:578-586. [PMID: 27496045 PMCID: PMC5145246 DOI: 10.1097/cin.0000000000000280] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this research is to determine the effects of implementing an electronic health record on medical-surgical registered nurses' time spent in direct professional patient-centered nursing activities, attitudes and beliefs related to implementation, and changes in level of nursing engagement after deployment of the electronic health record. Patient-centered activities were categorized using Watson's Caritas Processes and the Relationship-Based Care Delivery System. Methods included use of an Attitudes and Beliefs Assessment Questionnaire, Nursing Engagement Questionnaire, and Rapid Modeling Corporation's personal digital assistants for time and motion data collection. There was a significant difference in normative belief between nurses with less than 15 years' experience and nurses with more than 15 years' experience (t21 = 2.7, P = .01). While nurses spent less time at the nurses' station, less time charting, significantly more time in patients' rooms and in purposeful interactions, time spent in relationship-based caring behavior categories actually decreased in most categories. Nurses' engagement scores did not significantly increase. These results serve to inform healthcare organizations about potential factors related to electronic health record deployment which create shifts in nursing time spent across care categories and can be used to explore further patient centered care practices.
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13
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Tonner C, Schmajuk G, Yazdany J. A new era of quality measurement in rheumatology: electronic clinical quality measures and national registries. Curr Opin Rheumatol 2017; 29:131-137. [PMID: 27941392 PMCID: PMC5538369 DOI: 10.1097/bor.0000000000000364] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW This article reviews the evolution of quality measurement in rheumatology, highlighting new health-information technology infrastructure and standards that are enabling unprecedented innovation in this field. RECENT FINDINGS Spurred by landmark legislation that ties physician payment to value, the widespread use of electronic health records, and standards such as the Quality Data Model, quality measurement in rheumatology is rapidly evolving. Rather than relying on retrospective assessments of care gathered through administrative claims or manual chart abstraction, new electronic clinical quality measures (eCQMs) allow automated data capture from electronic health records. At the same time, qualified clinical data registries, like the American College of Rheumatology's Rheumatology Informatics System for Effectiveness registry, are enabling large-scale implementation of eCQMs across national electronic health record networks with real-time performance feedback to clinicians. Although successful examples of eCQM development and implementation in rheumatology and other fields exist, there also remain challenges, such as lack of health system data interoperability and problems with measure accuracy. SUMMARY Quality measurement and improvement is increasingly an essential component of rheumatology practice. Advances in health information technology are likely to continue to make implementation of eCQMs easier and measurement more clinically meaningful and accurate in coming years.
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Affiliation(s)
- Chris Tonner
- Department of Medicine, Division of Rheumatology, University of California, San Francisco
| | - Gabriela Schmajuk
- Division of Rheumatology, Veterans Affairs Medical Center, San Francisco
| | - Jinoos Yazdany
- Department of Medicine, Division of Rheumatology, University of California, San Francisco
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14
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Genes N, Kim MS, Thum FL, Rivera L, Beato R, Song C, Soriano J, Kannry J, Baumlin K, Hwang U. Usability Evaluation of a Clinical Decision Support System for Geriatric ED Pain Treatment. Appl Clin Inform 2016; 7:128-42. [PMID: 27081412 DOI: 10.4338/aci-2015-08-ra-0108] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 01/05/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Older adults are at risk for inadequate emergency department (ED) pain care. Unrelieved acute pain is associated with poor outcomes. Clinical decision support systems (CDSS) hold promise to improve patient care, but CDSS quality varies widely, particularly when usability evaluation is not employed. OBJECTIVE To conduct an iterative usability and redesign process of a novel geriatric abdominal pain care CDSS. We hypothesized this process would result in the creation of more usable and favorable pain care interventions. METHODS Thirteen emergency physicians familiar with the Electronic Health Record (EHR) in use at the study site were recruited. Over a 10-week period, 17 1-hour usability test sessions were conducted across 3 rounds of testing. Participants were given 3 patient scenarios and provided simulated clinical care using the EHR, while interacting with the CDSS interventions. Quantitative System Usability Scores (SUS), favorability scores and qualitative narrative feedback were collected for each session. Using a multi-step review process by an interdisciplinary team, positive and negative usability issues in effectiveness, efficiency, and satisfaction were considered, prioritized and incorporated in the iterative redesign process of the CDSS. Video analysis was used to determine the appropriateness of the CDS appearances during simulated clinical care. RESULTS Over the 3 rounds of usability evaluations and subsequent redesign processes, mean SUS progressively improved from 74.8 to 81.2 to 88.9; mean favorability scores improved from 3.23 to 4.29 (1 worst, 5 best). Video analysis revealed that, in the course of the iterative redesign processes, rates of physicians' acknowledgment of CDS interventions increased, however most rates of desired actions by physicians (such as more frequent pain score updates) decreased. CONCLUSION The iterative usability redesign process was instrumental in improving the usability of the CDSS; if implemented in practice, it could improve geriatric pain care. The usability evaluation process led to improved acknowledgement and favorability. Incorporating usability testing when designing CDSS interventions for studies may be effective to enhance clinician use.
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Affiliation(s)
- Nicholas Genes
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Min Soon Kim
- Department of Health Management & Informatics, University of Missouri School of Medicine, Columbia, MO; Informatics Institute, University of Missouri, Columbia, MO
| | - Frederick L Thum
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Laura Rivera
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Rosemary Beato
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Carolyn Song
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Jared Soriano
- Information Technology, Mount Sinai Health System , New York, NY
| | - Joseph Kannry
- Information Technology, Mount Sinai Health System, New York, NY; Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kevin Baumlin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai , New York, NY
| | - Ula Hwang
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research, Education and Clinical Center, James J Peters VAMC, Bronx, NY
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15
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Lehmann CU, Gundlapalli AV. Improving Bridging from Informatics Practice to Theory. Methods Inf Med 2015; 54:540-5. [PMID: 26577504 DOI: 10.3414/me15-01-0138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 10/22/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND In 1962, Methods of Information in Medicine ( MIM ) began to publish papers on the methodology and scientific fundamentals of organizing, representing, and analyzing data, information, and knowledge in biomedicine and health care. Considered a companion journal, Applied Clinical Informatics ( ACI ) was launched in 2009 with a mission to establish a platform that allows sharing of knowledge between clinical medicine and health IT specialists as well as to bridge gaps between visionary design and successful and pragmatic deployment of clinical information systems. Both journals are official journals of the International Medical Informatics Association. OBJECTIVES As a follow-up to prior work, we set out to explore congruencies and interdependencies in publications of ACI and MIM. The objectives were to describe the major topics discussed in articles published in ACI in 2014 and to determine if there was evidence that theory in 2014 MIM publications was informed by practice described in ACI publications in any year. We also set out to describe lessons learned in the context of bridging informatics practice and theory and offer opinions on how ACI editorial policies could evolve to foster and improve such bridging. METHODS We conducted a retrospective observational study and reviewed all articles published in ACI during the calendar year 2014 (Volume 5) for their main theme, conclusions, and key words. We then reviewed the citations of all MIM papers from 2014 to determine if there were references to ACI articles from any year. Lessons learned in the context of bridging informatics practice and theory and opinions on ACI editorial policies were developed by consensus among the two authors. RESULTS A total of 70 articles were published in ACI in 2014. Clinical decision support, clinical documentation, usability, Meaningful Use, health information exchange, patient portals, and clinical research informatics emerged as major themes. Only one MIM article from 2014 cited an ACI article. There are several lessons learned including the possibility that there may not be direct links between MIM theory and ACI practice articles. ACI editorial policies will continue to evolve to reflect the breadth and depth of the practice of clinical informatics and articles received for publication. Efforts to encourage bridging of informatics practice and theory may be considered by the ACI editors. CONCLUSIONS The lack of direct links from informatics theory-based papers published in MIM in 2014 to papers published in ACI continues as was described for papers published during 2012 to 2013 in the two companion journals. Thus, there is little evidence that theory in MIM has been informed by practice in ACI.
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Affiliation(s)
| | - A V Gundlapalli
- Adi V. Gundlapalli, MD, PhD, MS, Chief Health Informatics Officer, VA Salt Lake City Health Care System, Salt Lake City, UT 84148, USA, E-mail:
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Emani S, Ting DY, Healey M, Lipsitz SR, Ramelson H, Suric V, Bates DW. Physician Perceptions and Beliefs about Generating and Providing a Clinical Summary of the Office Visit. Appl Clin Inform 2015; 6:577-90. [PMID: 26448799 DOI: 10.4338/aci-2015-04-ra-0043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/25/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A core measure of the meaningful use of EHR incentive program is the generation and provision of the clinical summary of the office visit, or the after visit summary (AVS), to patients. However, little research has been conducted on physician perceptions and beliefs about the AVS. OBJECTIVES Evaluate physician perceptions and beliefs about the AVS and the effect of the AVS on workload, patient outcomes, and the care the physician delivers. METHODS A cross-sectional online survey of physicians at two academic medical centers (AMCs) in the northeast who are participating in the meaningful use EHR incentive program. RESULTS Of the 1 795 physicians at both AMCs participating in the incentive program, 853 completed the survey for a response rate of 47.5%. Eighty percent of the respondents reported that the AVS was easy (very easy or quite easy or somewhat easy) to generate and provide to patients. Nonetheless, more than three-fourths of the respondents reported a negative effect of generating and providing the AVS on workload of office staff (78%) and workload of physicians (76%). Primary care physicians had more positive beliefs about the effect of the AVS on patient outcomes than specialists (p<0.001) and also had more positive beliefs about the effect of the AVS on the care they delivered than specialists (p<0.001). CONCLUSIONS Achieving the core meaningful use measure of generating and providing the AVS was easy for physicians but it did not necessarily translate into positive beliefs about the effect of the AVS on patient outcomes or the care the physician delivered. Physicians also had negative beliefs about the effect of the AVS on workload. To promote positive beliefs among physicians around the AVS, organizations should obtain physician input into the design and implementation of the AVS and develop strategies to mitigate its negative impacts on workload.
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Affiliation(s)
- S Emani
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, United States
| | - D Y Ting
- Massachusetts General Physicians Organization, Massachusetts General Hospital , Boston,MA, United States
| | - M Healey
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, United States ; Brigham and Women's Physician Organization, Brigham and Women's Hospital , Boston, MA, United States
| | - S R Lipsitz
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, United States
| | - H Ramelson
- Information Services, Partners HealthCare , Boston, MA, United States
| | - V Suric
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, United States
| | - D W Bates
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, United States ; Department of Healthcare Policy and Management, Harvard School of Public Health , Boston, MA, United States
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