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Levine DM, Syrowatka A, Salmasian H, Shahian DM, Lipsitz S, Zebrowski JP, Myers LC, Logan MS, Roy CG, Iannaccone C, Frits ML, Volk LA, Dulgarian S, Amato MG, Edrees HH, Sato L, Folcarelli P, Einbinder JS, Reynolds ME, Mort E, Bates DW. The Safety of Outpatient Health Care : Review of Electronic Health Records. Ann Intern Med 2024. [PMID: 38710086 DOI: 10.7326/m23-2063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Despite considerable emphasis on delivering safe care, substantial patient harm occurs. Although most care occurs in the outpatient setting, knowledge of outpatient adverse events (AEs) remains limited. OBJECTIVE To measure AEs in the outpatient setting. DESIGN Retrospective review of the electronic health record (EHR). SETTING 11 outpatient sites in Massachusetts in 2018. PATIENTS 3103 patients who received outpatient care. MEASUREMENTS Using a trigger method, nurse reviewers identified possible AEs and physicians adjudicated them, ranked severity, and assessed preventability. Generalized estimating equations were used to assess the association of having at least 1 AE with age, sex, race, and primary insurance. Variation in AE rates was analyzed across sites. RESULTS The 3103 patients (mean age, 52 years) were more often female (59.8%), White (75.1%), English speakers (90.8%), and privately insured (70.4%) and had a mean of 4 outpatient encounters in 2018. Overall, 7.0% (95% CI, 4.6% to 9.3%) of patients had at least 1 AE (8.6 events per 100 patients annually). Adverse drug events were the most common AE (63.8%), followed by health care-associated infections (14.8%) and surgical or procedural events (14.2%). Severity was serious in 17.4% of AEs, life-threatening in 2.1%, and never fatal. Overall, 23.2% of AEs were preventable. Having at least 1 AE was less often associated with ages 18 to 44 years than with ages 65 to 84 years (standardized risk difference, -0.05 [CI, -0.09 to -0.02]) and more often associated with Black race than with Asian race (standardized risk difference, 0.09 [CI, 0.01 to 0.17]). Across study sites, 1.8% to 23.6% of patients had at least 1 AE and clinical category of AEs varied substantially. LIMITATION Retrospective EHR review may miss AEs. CONCLUSION Outpatient harm was relatively common and often serious. Adverse drug events were most frequent. Rates were higher among older adults. Interventions to curtail outpatient harm are urgently needed. PRIMARY FUNDING SOURCE Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.
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Affiliation(s)
- David M Levine
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (D.M.L., A.S., H.S., S.L., H.H.E.)
| | - Ania Syrowatka
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (D.M.L., A.S., H.S., S.L., H.H.E.)
| | - Hojjat Salmasian
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (D.M.L., A.S., H.S., S.L., H.H.E.)
| | - David M Shahian
- Harvard Medical School; Lawrence Center for Quality and Safety, Massachusetts General Hospital; and Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts (D.M.S.)
| | - Stuart Lipsitz
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (D.M.L., A.S., H.S., S.L., H.H.E.)
| | - Jonathan P Zebrowski
- Harvard Medical School; Lawrence Center for Quality and Safety, Massachusetts General Hospital; and Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts (J.P.Z.)
| | - Laura C Myers
- Kaiser Permanente Northern California Division of Research, Oakland, California (L.C.M.)
| | - Merranda S Logan
- Harvard Medical School and Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts (M.S.L.)
| | | | - Christine Iannaccone
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts (C.I., M.L.F., S.D., M.G.A.)
| | - Michelle L Frits
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts (C.I., M.L.F., S.D., M.G.A.)
| | - Lynn A Volk
- Mass General Brigham, Somerville, Massachusetts (L.A.V.)
| | - Sevan Dulgarian
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts (C.I., M.L.F., S.D., M.G.A.)
| | - Mary G Amato
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts (C.I., M.L.F., S.D., M.G.A.)
| | - Heba H Edrees
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (D.M.L., A.S., H.S., S.L., H.H.E.)
| | - Luke Sato
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital; Harvard Medical School; and CRICO and the Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts (L.S.)
| | - Patricia Folcarelli
- CRICO and the Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts (P.F., J.S.E., M.E.R.)
| | - Jonathan S Einbinder
- CRICO and the Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts (P.F., J.S.E., M.E.R.)
| | - Mark E Reynolds
- CRICO and the Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts (P.F., J.S.E., M.E.R.)
| | - Elizabeth Mort
- Harvard Medical School; Lawrence Center for Quality and Safety, Massachusetts General Hospital; Division of General Internal Medicine, Massachusetts General Hospital; and Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (E.M.)
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital; Harvard Medical School; and Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (D.W.B.)
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Garabedian PM, Rui A, Volk LA, Neville BA, Lipsitz SR, Healey MJ, Bates DW. A Multiyear Survey Evaluating Clinician Electronic Health Record Satisfaction. Appl Clin Inform 2023; 14:632-643. [PMID: 37586414 PMCID: PMC10431971 DOI: 10.1055/s-0043-1770900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/12/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVES We assessed how clinician satisfaction with a vendor electronic health record (EHR) changed over time in the 4 years following the transition from a homegrown EHR system to identify areas for improvement. METHODS We conducted a multiyear survey of clinicians across a large health care system after transitioning to a vendor EHR. Eligible clinicians from the first institution to transition received a survey invitation by email in fall 2016 and then eligible clinicians systemwide received surveys in spring 2018 and spring 2019. The survey included items assessing ease/difficulty of completing tasks and items assessing perceptions of the EHR's value, usability, and impact. One item assessing overall satisfaction and one open-ended question were included. Frequencies and means were calculated, and comparison of means was performed between 2018 and 2019 on all clinicians. A multivariable generalized linear model was performed to predict the outcome of overall satisfaction. RESULTS Response rates for the surveys ranged from 14 to 19%. The mean response from 3 years of surveys for one institution, Brigham and Women's Hospital, increased for overall satisfaction between 2016 (2.85), 2018 (3.01), and 2019 (3.21, p < 0.001). We found no significant differences in mean response for overall satisfaction between all responders of the 2018 survey (3.14) and those of the 2019 survey (3.19). Systemwide, tasks rated the most difficult included "Monitoring patient medication adherence," "Identifying when a referral has not been completed," and "Making a list of patients based on clinical information (e.g., problem, medication)." Clinicians disagreed the most with "The EHR helps me focus on patient care rather than the computer" and "The EHR allows me to complete tasks efficiently." CONCLUSION Survey results indicate room for improvement in clinician satisfaction with the EHR. Usability of EHRs should continue to be an area of focus to ease clinician burden and improve clinician experience.
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Affiliation(s)
- Pamela M. Garabedian
- Clinical Quality and IS Analysis, Mass General Brigham, Inc., Somerville, Massachusetts, United States
| | - Angela Rui
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Lynn A. Volk
- Clinical Quality and IS Analysis, Mass General Brigham, Inc., Somerville, Massachusetts, United States
| | - Bridget A. Neville
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Stuart R. Lipsitz
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Harvard University, Ariadne Labs, Boston, Massachusetts, United States
| | - Michael J. Healey
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - David W. Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
- Harvard School of Public Health, Harvard University, Boston, Massachusetts
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3
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Rui A, Garabedian PM, Marceau M, Syrowatka A, Volk LA, Edrees HH, Seger DL, Amato MG, Cambre J, Dulgarian S, Newmark LP, Nanji KC, Schultz P, Jackson GP, Rozenblum R, Bates DW. Correction: Performance of a Web-Based Reference Database With Natural Language Searching Capabilities: Usability Evaluation of DynaMed and Micromedex With Watson. JMIR Hum Factors 2023; 10:e48468. [PMID: 37201180 DOI: 10.2196/48468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 05/02/2023] [Indexed: 05/20/2023] Open
Abstract
[This corrects the article DOI: 10.2196/43960.].
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Affiliation(s)
- Angela Rui
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Pamela M Garabedian
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
| | - Marlika Marceau
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
| | - Ania Syrowatka
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Lynn A Volk
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
| | - Heba H Edrees
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Massachusetts College of Pharmacy and Health Sciences (MCPHS), Boston, MA, United States
| | - Diane L Seger
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
| | - Mary G Amato
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
- Massachusetts College of Pharmacy and Health Sciences (MCPHS), Boston, MA, United States
| | - Jacob Cambre
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Sevan Dulgarian
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Lisa P Newmark
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
| | - Karen C Nanji
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
- Harvard Medical School, Boston, MA, United States
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | | | - Gretchen Purcell Jackson
- Vanderbilt University Medical Center, Nashville, TN, United States
- Intuitive Surgical, Sunnyvale, CA, United States
| | - Ronen Rozenblum
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - David W Bates
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
- Harvard Medical School, Boston, MA, United States
- Harvard TH Chan School of Public Health, Boston, MA, United States
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4
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Rui A, Garabedian PM, Marceau M, Syrowatka A, Volk LA, Edrees HH, Seger DL, Amato MG, Cambre J, Dulgarian S, Newmark LP, Nanji KC, Schultz P, Jackson GP, Rozenblum R, Bates DW. Performance of a Web-Based Reference Database With Natural Language Searching Capabilities: Usability Evaluation of DynaMed and Micromedex With Watson. JMIR Hum Factors 2023; 10:e43960. [PMID: 37067858 PMCID: PMC10152386 DOI: 10.2196/43960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Evidence-based point-of-care information (POCI) tools can facilitate patient safety and care by helping clinicians to answer disease state and drug information questions in less time and with less effort. However, these tools may also be visually challenging to navigate or lack the comprehensiveness needed to sufficiently address a medical issue. OBJECTIVE This study aimed to collect clinicians' feedback and directly observe their use of the combined POCI tool DynaMed and Micromedex with Watson, now known as DynaMedex. EBSCO partnered with IBM Watson Health, now known as Merative, to develop the combined tool as a resource for clinicians. We aimed to identify areas for refinement based on participant feedback and examine participant perceptions to inform further development. METHODS Participants (N=43) within varying clinical roles and specialties were recruited from Brigham and Women's Hospital and Massachusetts General Hospital in Boston, Massachusetts, United States, between August 10, 2021, and December 16, 2021, to take part in usability sessions aimed at evaluating the efficiency and effectiveness of, as well as satisfaction with, the DynaMed and Micromedex with Watson tool. Usability testing methods, including think aloud and observations of user behavior, were used to identify challenges regarding the combined tool. Data collection included measurements of time on task; task ease; satisfaction with the answer; posttest feedback on likes, dislikes, and perceived reliability of the tool; and interest in recommending the tool to a colleague. RESULTS On a 7-point Likert scale, pharmacists rated ease (mean 5.98, SD 1.38) and satisfaction (mean 6.31, SD 1.34) with the combined POCI tool higher than the physicians, nurse practitioner, and physician's assistants (ease: mean 5.57, SD 1.64, and satisfaction: mean 5.82, SD 1.60). Pharmacists spent longer (mean 2 minutes, 26 seconds, SD 1 minute, 41 seconds) on average finding an answer to their question than the physicians, nurse practitioner, and physician's assistants (mean 1 minute, 40 seconds, SD 1 minute, 23 seconds). CONCLUSIONS Overall, the tool performed well, but this usability evaluation identified multiple opportunities for improvement that would help inexperienced users.
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Affiliation(s)
- Angela Rui
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Pamela M Garabedian
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
| | - Marlika Marceau
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
| | - Ania Syrowatka
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Lynn A Volk
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
| | - Heba H Edrees
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Massachusetts College of Pharmacy and Health Sciences (MCPHS), Boston, MA, United States
| | - Diane L Seger
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
| | - Mary G Amato
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
- Massachusetts College of Pharmacy and Health Sciences (MCPHS), Boston, MA, United States
| | - Jacob Cambre
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Sevan Dulgarian
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Lisa P Newmark
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
| | - Karen C Nanji
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
- Harvard Medical School, Boston, MA, United States
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | | | - Gretchen Purcell Jackson
- Vanderbilt University Medical Center, Nashville, TN, United States
- Intuitive Surgical, Sunnyvale, CA, United States
| | - Ronen Rozenblum
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - David W Bates
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States
- Clinical and Quality Analysis, Mass General Brigham, Somerville, MA, United States
- Harvard Medical School, Boston, MA, United States
- Harvard TH Chan School of Public Health, Boston, MA, United States
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5
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Salazar A, Amato MG, Shah SN, Khazen M, Aminmozaffari S, Klinger EV, Volk LA, Mirica M, Schiff GD. Pharmacists' role in detection and evaluation of adverse drug reactions: Developing proactive systems for pharmacosurveillance. Am J Health Syst Pharm 2023; 80:207-214. [PMID: 36331446 DOI: 10.1093/ajhp/zxac325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To identify current challenges in detection of medication-related symptoms, and review technology-based opportunities to increase the patient-centeredness of postmarketing pharmacosurveillance to promote more accountable, safer, patient-friendly, and equitable medication prescribing. SUMMARY Pharmacists have an important role to play in detection and evaluation of adverse drug reactions (ADRs). The pharmacist's role in medication management should extend beyond simply dispensing drugs, and this article delineates the rationale and proactive approaches for pharmacist detection and assessment of ADRs. We describe a stepwise approach for assessment, best practices, and lessons learned from a pharmacist-led randomized trial, the CEDAR (Calling for Detection of Adverse Drug Reactions) project. CONCLUSION Health systems need to be redesigned to more fully utilize health information technologies and pharmacists in detecting and responding to ADRs.
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Affiliation(s)
- Alejandra Salazar
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, and Boston Medical Center, Boston, MA, USA
| | - Mary G Amato
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, and MCPH University, Boston, MA, USA
| | - Sonam N Shah
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, and Dana Farber Cancer Institute, Boston, MA, USA
| | - Maram Khazen
- School of Public Health, Haifa University, Haifa, Israel.,Nursing School, Zefat Academic College, Zefat, Israel
| | - Saina Aminmozaffari
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Elissa V Klinger
- Penn Medicine Center for Digital Health, Philadelphia, PA, and Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
| | | | - Maria Mirica
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Gordon D Schiff
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, and Harvard Medical School, Boston, MA, USA
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Myers LC, Salmasian H, Iannaccone C, Frits ML, Volk LA, Bates DW, Mort E. A Description of the Variation in Quality and Patient Safety Structures Within a Health System. Jt Comm J Qual Patient Saf 2023; 49:285-287. [PMID: 36868978 DOI: 10.1016/j.jcjq.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/24/2023] [Accepted: 01/24/2023] [Indexed: 01/30/2023]
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7
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Bates DW, Levine DM, Salmasian H, Syrowatka A, Shahian DM, Lipsitz S, Zebrowski JP, Myers LC, Logan MS, Roy CG, Iannaccone C, Frits ML, Volk LA, Dulgarian S, Amato MG, Edrees HH, Sato L, Folcarelli P, Einbinder JS, Reynolds ME, Mort E. The Safety of Inpatient Health Care. N Engl J Med 2023; 388:142-153. [PMID: 36630622 DOI: 10.1056/nejmsa2206117] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Adverse events during hospitalization are a major cause of patient harm, as documented in the 1991 Harvard Medical Practice Study. Patient safety has changed substantially in the decades since that study was conducted, and a more current assessment of harm during hospitalization is warranted. METHODS We conducted a retrospective cohort study to assess the frequency, preventability, and severity of patient harm in a random sample of admissions from 11 Massachusetts hospitals during the 2018 calendar year. The occurrence of adverse events was assessed with the use of a trigger method (identification of information in a medical record that was previously shown to be associated with adverse events) and from review of medical records. Trained nurses reviewed records and identified admissions with possible adverse events that were then adjudicated by physicians, who confirmed the presence and characteristics of the adverse events. RESULTS In a random sample of 2809 admissions, we identified at least one adverse event in 23.6%. Among 978 adverse events, 222 (22.7%) were judged to be preventable and 316 (32.3%) had a severity level of serious (i.e., caused harm that resulted in substantial intervention or prolonged recovery) or higher. A preventable adverse event occurred in 191 (6.8%) of all admissions, and a preventable adverse event with a severity level of serious or higher occurred in 29 (1.0%). There were seven deaths, one of which was deemed to be preventable. Adverse drug events were the most common adverse events (accounting for 39.0% of all events), followed by surgical or other procedural events (30.4%), patient-care events (which were defined as events associated with nursing care, including falls and pressure ulcers) (15.0%), and health care-associated infections (11.9%). CONCLUSIONS Adverse events were identified in nearly one in four admissions, and approximately one fourth of the events were preventable. These findings underscore the importance of patient safety and the need for continuing improvement. (Funded by the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.).
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Affiliation(s)
- David W Bates
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - David M Levine
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Hojjat Salmasian
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Ania Syrowatka
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - David M Shahian
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Stuart Lipsitz
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Jonathan P Zebrowski
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Laura C Myers
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Merranda S Logan
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Christopher G Roy
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Christine Iannaccone
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Michelle L Frits
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Lynn A Volk
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Sevan Dulgarian
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Mary G Amato
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Heba H Edrees
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Luke Sato
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Patricia Folcarelli
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Jonathan S Einbinder
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Mark E Reynolds
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
| | - Elizabeth Mort
- From the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (D.W.B., D.M.L., H.S., A.S., S.L., C.I., M.L.F., S.D., M.G.A., H.H.E., L.S.), the Department of Health Care Policy (E.M.), Harvard Medical School (D.W.B., D.M.L., H.S., A.S., D.M.S., S.L., J.P.Z., M.S.L., H.H.E., L.S., E.M.), the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health (D.W.B.), the Edward P. Lawrence Center for Quality and Safety (D.M.S., J.P.Z., E.M.), the Division of Cardiac Surgery, Department of Surgery (D.M.S.), the Department of Psychiatry (J.P.Z.), the Division of Nephrology (M.S.L.), and the Division of General Internal Medicine (E.M.), Massachusetts General Hospital, and the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions (L.S., P.F., J.S.E., M.E.R.) - all in Boston; the Kaiser Permanente Northern California Division of Research, Oakland (L.C.M.); Maine Medical Center, Portland (C.G.R.); and Mass General Brigham, Somerville, MA (L.A.V.)
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Logan MS, Myers LC, Salmasian H, Levine DM, Roy CG, Reynolds ME, Sato L, Keohane C, Frits ML, Volk LA, Akindele RN, Randazza JM, Dulgarian SM, Shahian DM, Bates DW, Mort E. Expert Consensus on Currently Accepted Measures of Harm. J Patient Saf 2021; 17:e1726-e1731. [PMID: 32769419 PMCID: PMC8612889 DOI: 10.1097/pts.0000000000000754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND Twenty-five years after the seminal work of the Harvard Medical Practice Study, the numbers and specific types of health care measures of harm have evolved and expanded. Using the World Café method to derive expert consensus, we sought to generate a contemporary list of triggers and adverse event measures that could be used for chart review to determine the current incidence of inpatient and outpatient adverse events. METHODS We held a modified World Café event in March 2018, during which content experts were divided into 10 tables by clinical domain. After a focused discussion of a prepopulated list of literature-based triggers and measures relevant to that domain, they were asked to rate each measure on clinical importance and suitability for chart review and electronic extraction (very low, low, medium, high, very high). RESULTS Seventy-one experts from 9 diverse institutions attended (primary acceptance rate, 72%). Of 525 total triggers and measures, 67% of 391 measures and 46% of 134 triggers were deemed to have high or very high clinical importance. For those triggers and measures with high or very high clinical importance, 218 overall were deemed to be highly amenable to chart review and 198 overall were deemed to be suitable for electronic surveillance. CONCLUSIONS The World Café method effectively prioritized measures/triggers of high clinical importance including those that can be used in chart review, which is considered the gold standard. A future goal is to validate these measures using electronic surveillance mechanisms to decrease the need for chart review.
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Affiliation(s)
- Merranda S. Logan
- From the Division of Nephrology, Massachusetts General Hospital
- Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital
- Harvard Medical School
| | - Laura C. Myers
- Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital
- Harvard Medical School
- Division of Pulmonary and Critical Care, Massachusetts General Hospital
| | | | - David Michael Levine
- Harvard Medical School
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston
| | - Christopher G. Roy
- Harvard Medical School
- Division of General Internal Medicine, Mt Auburn Hospital, Cambridge
| | - Mark E. Reynolds
- Risk Management Foundation of the Harvard Medical Institutions (CRICO)
| | - Luke Sato
- Harvard Medical School
- Risk Management Foundation of the Harvard Medical Institutions (CRICO)
| | - Carol Keohane
- Risk Management Foundation of the Harvard Medical Institutions (CRICO)
| | - Michelle L. Frits
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston
| | - Lynn A. Volk
- Clinical and Quality Analysis, Mass General Brigham
| | - Ruth N. Akindele
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston
| | | | - Sevan M. Dulgarian
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston
| | - David M. Shahian
- Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital
- Harvard Medical School
- Department of Surgery, Massachusetts General Hospital
| | - David Westfall Bates
- Harvard Medical School
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston
- Clinical and Quality Analysis, Mass General Brigham
- Harvard T. H. Chan School of Public Health
| | - Elizabeth Mort
- Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital
- Division of Internal Medicine, Massachusetts General Hospital
- Department of Health Care Policy, Harvard Medical School, Boston, MA
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9
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Galanter W, Eguale T, Gellad W, Lambert B, Mirica M, Cashy J, Salazar A, Volk LA, Falck S, Shilka J, Van Dril E, Jarrett J, Zulueta J, Fiskio J, Orav J, Norwich D, Bennett S, Seger D, Wright A, Linder JA, Schiff G. Personal Formularies of Primary Care Physicians Across 4 Health Care Systems. JAMA Netw Open 2021; 4:e2117038. [PMID: 34264328 PMCID: PMC8283562 DOI: 10.1001/jamanetworkopen.2021.17038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE More conservative prescribing has the potential to reduce adverse drug events and patient harm and cost; however, no method exists defining the extent to which individual clinicians prescribe conservatively. One potential domain is prescribing a more limited number of drugs. Personal formularies-defined as the number and mix of unique, newly initiated drugs prescribed by a physician-may enable comparisons among clinicians, practices, and institutions. OBJECTIVES To develop a method of defining primary care physicians' personal formularies and examine how they differ among primary care physicians at 4 institutions; evaluate associations between personal formularies and patient, physician, and practice site characteristics; and empirically derive and examine the variability of the top 200 core drugs prescribed at the 4 sites. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted at 4 US health care systems among 4655 internal and family medicine physicians and 4 930 707 patients who had at least 1 visit to these physicians between January 1, 2017, and December 31, 2018. EXPOSURES Personal formulary size was defined as the number of unique, newly initiated drugs. MAIN OUTCOMES AND MEASURES Personal formulary size and drugs used, physician and patient characteristics, core drugs, and analysis of selected drug classes. RESULTS The study population included 4655 primary care physicians (2274 women [48.9%]; mean [SD] age, 48.5 [4.4] years) and 4 930 707 patients (16.5% women; mean [SD] age, 51.9 [8.3] years). There were 41 378 903 outpatient prescriptions written, of which 9 496 766 (23.0%) were new starts. Institution median personal formulary size ranged from 150 (interquartile range, 82.0-212.0) to 296 (interquartile range, 230.0-347.0) drugs. In multivariable modeling, personal formulary size was significantly associated with panel size (total number of unique patients with face-to-face encounters during the study period; 1.2 medications per 100 patients), physician's total number of encounters (5.7 drugs per 10% increase), and physician's sex (-6.2 drugs per 100 patients for female physicians). There were 1527 unique, newly prescribed drugs across the 4 sites. Fewer than half the drugs (626 [41.0%]) were used at every site. Physicians' prescribing of drugs from a pooled core list varied from 0% to 100% of their prescriptions. CONCLUSIONS AND RELEVANCE Personal formularies, measured at the level of individual physicians and institutions, reveal variability in size and mix of drugs. Similarly, defining a list of commonly prescribed core drugs in primary care revealed interphysician and interinstitutional differences. Personal formularies and core medication lists enable comparisons and may identify outliers and opportunities for safer and more appropriate prescribing.
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Affiliation(s)
- William Galanter
- Department of Medicine, University of Illinois at Chicago, Chicago
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago
| | | | - Walid Gellad
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | | | - John Cashy
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | | | - Suzanne Falck
- Department of Medicine, University of Illinois at Chicago, Chicago
| | - John Shilka
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago
| | - Elizabeth Van Dril
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago
| | - Jennie Jarrett
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago
| | - John Zulueta
- Department of Psychiatry, University of Illinois at Chicago, Chicago
| | | | - John Orav
- Mass General Brigham, Boston, Massachusetts
| | | | | | | | | | - Jeffrey A. Linder
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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10
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Salazar A, Karmiy SJ, Forsythe KJ, Amato MG, Wright A, Lai KH, Lambert BL, Liebovitz DM, Eguale T, Volk LA, Schiff GD. How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions. Am J Health Syst Pharm 2020; 76:970-979. [PMID: 31361884 DOI: 10.1093/ajhp/zxz082] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To examine the extent to which outpatient clinicians currently document drug indications in prescription instructions. METHODS Free-text sigs were extracted from all outpatient prescriptions generated by the computerized prescriber order entry system of a major academic institution during a 5-year period. Natural language processing was used to identify drug indications. The data set was analyzed to determine the rates at which prescribers included indications. It was stratified by provider specialty, drug class, and specific medications, to determine how often these indications were in prescriptions for as-needed (PRN) versus non-PRN medications. RESULTS During the study period, 4,356,086 prescriptions were ordered. Indications were included in 322,961 orders (7.41%). From these orders, 249,262 indications (77.18%) were written for PRN orders. Although internal medicine prescribers generated the highest number of medication orders, they included indications in only 6.26% of their prescriptions, whereas orthopedic surgery providers had the highest rate of documenting indications (33.41%). Pain was the most common indication, accounting for 30.35% of all documented indications. The drug class with the highest number of sigs-containing indications was narcotic analgesics. Non-PRN chronic medication prescriptions rarely included the indication. CONCLUSION Prescribers rarely included drug indications in electronic free-text prescription instructions, and, when they did, it was mostly for PRN uses such as pain.
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Affiliation(s)
- Alejandra Salazar
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston Medical Center, Boston, MA
| | | | | | - Mary G Amato
- Division of General Internal Medicine, Brigham and Women's Hospital, MCPHS University, Boston, MA
| | - Adam Wright
- Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kenneth H Lai
- Partners HealthCare, Somerville, MA, and Brandeis University, Waltham, MA
| | | | | | - Tewodros Eguale
- Division of General Internal Medicine, Brigham and Women's Hospital, MCPHS University, Boston, MA
| | | | - Gordon D Schiff
- Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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11
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Rozenblum R, Rodriguez-Monguio R, Volk LA, Forsythe KJ, Myers S, McGurrin M, Williams DH, Bates DW, Schiff G, Seoane-Vazquez E. Using a Machine Learning System to Identify and Prevent Medication Prescribing Errors: A Clinical and Cost Analysis Evaluation. Jt Comm J Qual Patient Saf 2019; 46:3-10. [PMID: 31786147 DOI: 10.1016/j.jcjq.2019.09.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clinical decision support (CDS) alerting tools can identify and reduce medication errors. However, they are typically rule-based and can identify only the errors previously programmed into their alerting logic. Machine learning holds promise for improving medication error detection and reducing costs associated with adverse events. This study evaluates the ability of a machine learning system (MedAware) to generate clinically valid alerts and estimates the cost savings associated with potentially prevented adverse events. METHODS Alerts were generated retrospectively by the MedAware system on outpatient data from two academic medical centers between 2009 and 2013. MedAware alerts were compared to alerts in an existing CDS system. A random sample of 300 alerts was selected for medical record review. Frequency and severity of potential outcomes of alerted medication errors of medium and high clinical value were estimated, along with associated health care costs of these potentially prevented adverse events. RESULTS A total of 10,668 alerts were generated. Overall, 68.2% of MedAware alerts would not have been generated by the existing CDS system. Ninety-two percent of a random sample of the chart-reviewed alerts were accurate based on structured data available in the record, and 79.7% were clinically valid. Estimated cost of adverse events potentially prevented in an outpatient setting was more than $60 per drug alert and $1.3 million when extrapolating study findings to the full patient population. CONCLUSION A machine learning system identified clinically valid medication error alerts that might otherwise be missed with existing CDS systems. Estimates show potential for cost savings associated with potentially prevented adverse events.
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12
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Garabedian PM, Wright A, Newbury I, Volk LA, Salazar A, Amato MG, Nathan AW, Forsythe KJ, Galanter WL, Kron K, Myers S, Abraham J, McCord SK, Eguale T, Bates DW, Schiff GD. Comparison of a Prototype for Indications-Based Prescribing With 2 Commercial Prescribing Systems. JAMA Netw Open 2019; 2:e191514. [PMID: 30924903 PMCID: PMC6450312 DOI: 10.1001/jamanetworkopen.2019.1514] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE The indication (reason for use) for a medication is rarely included on prescriptions despite repeated recommendations to do so. One barrier has been the way existing electronic prescribing systems have been designed. OBJECTIVE To evaluate, in comparison with the prescribing modules of 2 leading electronic health record prescribing systems, the efficiency, error rate, and satisfaction with a new computerized provider order entry prototype for the outpatient setting that allows clinicians to initiate prescribing using the indication. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study used usability tests requiring internal medicine physicians, residents, and physician assistants to enter prescriptions electronically, including indication, for 8 clinical scenarios. The tool order assignments were randomized and prescribers were asked to use the prototype for 4 of the scenarios and their usual system for the other 4. Time on task, number of clicks, and order details were captured. User satisfaction was measured using posttask ratings and a validated system usability scale. The study participants practiced in 2 health systems' outpatient practices. Usability tests were conducted between April and October of 2017. MAIN OUTCOMES AND MEASURES Usability (efficiency, error rate, and satisfaction) of indications-based computerized provider order entry prototype vs the electronic prescribing interface of 2 electronic health record vendors. RESULTS Thirty-two participants (17 attending physicians, 13 residents, and 2 physician assistants) used the prototype to complete 256 usability test scenarios. The mean (SD) time on task was 1.78 (1.17) minutes. For the 20 participants who used vendor 1's system, it took a mean (SD) of 3.37 (1.90) minutes to complete a prescription, and for the 12 participants using vendor 2's system, it took a mean (SD) of 2.93 (1.52) minutes. Across all scenarios, when comparing number of clicks, for those participants using the prototype and vendor 1, there was a statistically significant difference from the mean (SD) number of clicks needed (18.39 [12.62] vs 46.50 [27.29]; difference, 28.11; 95% CI, 21.47-34.75; P < .001). For those using the prototype and vendor 2, there was also a statistically significant difference in number of clicks (20.10 [11.52] vs 38.25 [19.77]; difference, 18.14; 95% CI, 11.59-24.70; P < .001). A blinded review of the order details revealed medication errors (eg, drug-allergy interactions) in 38 of 128 prescribing sessions using a vendor system vs 7 of 128 with the prototype. CONCLUSIONS AND RELEVANCE Reengineering prescribing to start with the drug indication allowed indications to be captured in an easy and useful way, which may be associated with saved time and effort, reduced medication errors, and increased clinician satisfaction.
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Affiliation(s)
| | - Adam Wright
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Lynn A. Volk
- Partners HealthCare System, Inc, Somerville, Massachusetts
| | | | - Mary G. Amato
- Brigham and Women’s Hospital, Boston, Massachusetts
- Massachusetts College of Pharmacy and Health Sciences University, Boston
| | - Aaron W. Nathan
- Brigham and Women’s Hospital, Boston, Massachusetts
- Mayo Clinic, Rochester, Minnesota
| | | | | | - Kevin Kron
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Sara Myers
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joanna Abraham
- Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Sarah K. McCord
- Massachusetts College of Pharmacy and Health Sciences University, Boston
| | - Tewodros Eguale
- Brigham and Women’s Hospital, Boston, Massachusetts
- Massachusetts College of Pharmacy and Health Sciences University, Boston
| | - David W. Bates
- Partners HealthCare System, Inc, Somerville, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Gordon D. Schiff
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
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13
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Schiff GD, Martin SA, Eidelman DH, Volk LA, Ruan E, Cassel C, Galanter W, Johnson M, Jutel A, Kroenke K, Lambert BL, Lexchin J, Myers S, Miller A, Mushlin S, Sanders L, Sheikh A. Ten Principles for More Conservative, Care-Full Diagnosis. Ann Intern Med 2018; 169:643-645. [PMID: 30285046 DOI: 10.7326/m18-1468] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Gordon D Schiff
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (G.D.S., M.J.)
| | - Stephen A Martin
- University of Massachusetts Medical School, Worcester, Massachusetts (S.A.M.)
| | | | - Lynn A Volk
- Brigham and Women's Hospital, Boston, Massachusetts, and Partners HealthCare, Somerville, Massachusetts (L.A.V., S.M.)
| | - Elise Ruan
- Brigham and Women's Hospital and Tufts University School of Medicine, Boston, Massachusetts, and Partners HealthCare, Somerville, Massachusetts (E.R.)
| | - Christine Cassel
- Kaiser Permanente School of Medicine, Pasadena, California (C.C.)
| | | | - Mark Johnson
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (G.D.S., M.J.)
| | - Annemarie Jutel
- Harvard Medical School, Boston, Massachusetts; Victoria University of Wellington, Wellington, New Zealand (A.J.)
| | - Kurt Kroenke
- Indiana University, Indianapolis, Indiana (K.K.)
| | | | - Joel Lexchin
- York University, Toronto, Ontario, Canada (J.L.)
| | - Sara Myers
- Brigham and Women's Hospital, Boston, Massachusetts, and Partners HealthCare, Somerville, Massachusetts (L.A.V., S.M.)
| | | | - Stuart Mushlin
- Brigham Circle Medical Associates, Boston, Massachusetts (S.M.)
| | - Lisa Sanders
- Yale University School of Medicine, New Haven, Connecticut (L.S.)
| | - Aziz Sheikh
- The University of Edinburgh, Edinburgh, United Kingdom (A.S.)
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14
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Cheng CM, Salazar A, Amato MG, Lambert BL, Volk LA, Schiff GD. Using drug knowledgebase information to distinguish between look-alike-sound-alike drugs. J Am Med Inform Assoc 2018; 25:872-884. [PMID: 29800453 DOI: 10.1093/jamia/ocy043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/05/2018] [Indexed: 11/12/2022] Open
Abstract
Objective To extract drug indications from a commercial drug knowledgebase and determine to what extent drug indications can discriminate between look-alike-sound-alike (LASA) drugs. Methods We extracted drug indications disease concepts from the MedKnowledge Indications module from First Databank Inc. (South San Francisco, CA) and associated them with drugs on the Institute for Safe Medication Practices (ISMP) list of commonly confused drug names. We used high-level concepts (rather than granular concepts) to represent the general indications for each drug. Two pharmacists reviewed each drug's association with its high-level indications concepts for accuracy and clinical relevance. We compared the high-level indications for each commonly confused drug pair and categorized each pair as having a complete overlap, partial overlap or no overlap in high-level indications. Results Of 278 LASA drug pairs, 165 (59%) had no overlap and 58 (21%) had partial overlap in high-level indications. Fifty-five pairs (20%) had complete overlap in high-level indications; nearly half of these were comprised of drugs with the same active ingredient and route of administration (e.g., Adderall, Adderall XR). Conclusions Drug indications data from a drug knowledgebase can discriminate between many LASA drugs.
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Affiliation(s)
- Christine M Cheng
- First Databank, Inc., Disease Decision Support Group, South San Francisco, CA, USA
| | - Alejandra Salazar
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Mary G Amato
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,Department of Pharmacy Practice, MCPHS University, Boston, MA, USA
| | - Bruce L Lambert
- Department of Communication Studies, Northwestern University, Chicago, IL, USA.,Center for Communication and Health, Northwestern University, Chicago, IL, USA
| | - Lynn A Volk
- Clinical and Quality Analysis, Partners HealthCare, Somerville, MA, USA
| | - Gordon D Schiff
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
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15
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Amato MG, Salazar A, Hickman TTT, Quist AJ, Volk LA, Wright A, McEvoy D, Galanter WL, Koppel R, Loudin B, Adelman J, McGreevey JD, Smith DH, Bates DW, Schiff GD. Computerized prescriber order entry-related patient safety reports: analysis of 2522 medication errors. J Am Med Inform Assoc 2017; 24:316-322. [PMID: 27678459 DOI: 10.1093/jamia/ocw125] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 07/21/2016] [Indexed: 11/13/2022] Open
Abstract
Objective To examine medication errors potentially related to computerized prescriber order entry (CPOE) and refine a previously published taxonomy to classify them. Materials and Methods We reviewed all patient safety medication reports that occurred in the medication ordering phase from 6 sites participating in a United States Food and Drug Administration-sponsored project examining CPOE safety. Two pharmacists independently reviewed each report to confirm whether the error occurred in the ordering/prescribing phase and was related to CPOE. For those related to CPOE, we assessed whether CPOE facilitated (actively contributed to) the error or failed to prevent the error (did not directly cause it, but optimal systems could have potentially prevented it). A previously developed taxonomy was iteratively refined to classify the reports. Results Of 2522 medication error reports, 1308 (51.9%) were related to CPOE. Of these, CPOE facilitated the error in 171 (13.1%) and potentially could have prevented the error in 1137 (86.9%). The most frequent categories of "what happened to the patient" were delays in medication reaching the patient, potentially receiving duplicate drugs, or receiving a higher dose than indicated. The most frequent categories for "what happened in CPOE" included orders not routed to or received at the intended location, wrong dose ordered, and duplicate orders. Variations were seen in the format, categorization, and quality of reports, resulting in error causation being assignable in only 403 instances (31%). Discussion and Conclusion Errors related to CPOE commonly involved transmission errors, erroneous dosing, and duplicate orders. More standardized safety reporting using a common taxonomy could help health care systems and vendors learn and implement prevention strategies.
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Affiliation(s)
- Mary G Amato
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,MCPHS University, Boston, USA
| | - Alejandra Salazar
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Thu-Trang T Hickman
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Arbor Jl Quist
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lynn A Volk
- Partners HealthCare, Information Systems, Wellesley, Massachusetts, USA
| | - Adam Wright
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, USA
| | - Dustin McEvoy
- Partners HealthCare, Information Systems, Wellesley, Massachusetts, USA
| | | | - Ross Koppel
- University of Pennsylvania, Philadelphia, USA
| | | | - Jason Adelman
- Columbia University Medical Center, New York, New York, USA
| | | | - David H Smith
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Partners HealthCare, Information Systems, Wellesley, Massachusetts, USA.,Harvard Medical School, Boston, USA.,Harvard School of Public Health, Boston, USA
| | - Gordon D Schiff
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, USA
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16
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Schiff GD, Volk LA, Volodarskaya M, Williams DH, Walsh L, Myers SG, Bates DW, Rozenblum R. Screening for medication errors using an outlier detection system. J Am Med Inform Assoc 2017; 24:281-287. [PMID: 28104826 DOI: 10.1093/jamia/ocw171] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 11/22/2016] [Indexed: 11/13/2022] Open
Abstract
Objective The study objective was to evaluate the accuracy, validity, and clinical usefulness of medication error alerts generated by an alerting system using outlier detection screening. Materials and Methods Five years of clinical data were extracted from an electronic health record system for 747 985 patients who had at least one visit during 2012-2013 at practices affiliated with 2 academic medical centers. Data were screened using the system to detect outliers suggestive of potential medication errors. A sample of 300 charts was selected for review from the 15 693 alerts generated. A coding system was developed and codes assigned based on chart review to reflect the accuracy, validity, and clinical value of the alerts. Results Three-quarters of the chart-reviewed alerts generated by the screening system were found to be valid in which potential medication errors were identified. Of these valid alerts, the majority (75.0%) were found to be clinically useful in flagging potential medication errors or issues. Discussion A clinical decision support (CDS) system that used a probabilistic, machine-learning approach based on statistically derived outliers to detect medication errors generated potentially useful alerts with a modest rate of false positives. The performance of such a surveillance and alerting system is critically dependent on the quality and completeness of the underlying data. Conclusion The screening system was able to generate alerts that might otherwise be missed with existing CDS systems and did so with a reasonably high degree of alert usefulness when subjected to review of patients' clinical contexts and details.
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Affiliation(s)
- Gordon D Schiff
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,Center for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Lynn A Volk
- Clinical and Quality Analysis, Partners HealthCare, Boston, MA, USA
| | - Mayya Volodarskaya
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Deborah H Williams
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Lake Walsh
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Sara G Myers
- Clinical and Quality Analysis, Partners HealthCare, Boston, MA, USA
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,Center for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Ronen Rozenblum
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,Center for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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17
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Hickman TTT, Quist AJL, Salazar A, Amato MG, Wright A, Volk LA, Bates DW, Schiff G. Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors. BMJ Qual Saf 2017; 27:293-298. [PMID: 28754812 DOI: 10.1136/bmjqs-2017-006597] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 07/14/2017] [Accepted: 07/16/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Computerised prescriber order entry (CPOE) systems users often discontinue medications because the initial order was erroneous. OBJECTIVE To elucidate error types by querying prescribers about their reasons for discontinuing outpatient medication orders that they had self-identified as erroneous. METHODS During a nearly 3 year retrospective data collection period, we identified 57 972 drugs discontinued with the reason 'Error (erroneous entry)." Because chart reviews revealed limited information about these errors, we prospectively studied consecutive, discontinued erroneous orders by querying prescribers in near-real-time to learn more about the erroneous orders. RESULTS From January 2014 to April 2014, we prospectively emailed prescribers about outpatient drug orders that they had discontinued due to erroneous initial order entry. Of 2 50 806 medication orders in these 4 months, 1133 (0.45%) of these were discontinued due to error. From these 1133, we emailed 542 unique prescribers to ask about their reason(s) for discontinuing these mediation orders in error. We received 312 responses (58% response rate). We categorised these responses using a previously published taxonomy. The top reasons for these discontinued erroneous orders included: medication ordered for wrong patient (27.8%, n=60); wrong drug ordered (18.5%, n=40); and duplicate order placed (14.4%, n=31). Other common discontinued erroneous orders related to drug dosage and formulation (eg, extended release versus not). Oxycodone (3%) was the most frequent drug discontinued error. CONCLUSION Drugs are not infrequently discontinued 'in error.' Wrong patient and wrong drug errors constitute the leading types of erroneous prescriptions recognised and discontinued by prescribers. Data regarding erroneous medication entries represent an important source of intelligence about how CPOE systems are functioning and malfunctioning, providing important insights regarding areas for designing CPOE more safely in the future.
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Affiliation(s)
- Thu-Trang T Hickman
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Arbor Jessica Lauren Quist
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alejandra Salazar
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mary G Amato
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Pharmacy, MCPHS University, Boston, Massachusetts, USA
| | - Adam Wright
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Clinical Quality and Analysis, Partners Healthcare System, Somerville, Massachusetts, USA
| | - Lynn A Volk
- Department of Clinical Quality and Analysis, Partners Healthcare System, Somerville, Massachusetts, USA
| | - David W Bates
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Clinical Quality and Analysis, Partners Healthcare System, Somerville, Massachusetts, USA
| | - Gordon Schiff
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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18
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Quist AJL, Hickman TTT, Amato MG, Volk LA, Salazar A, Robertson A, Wright A, Bates DW, Phansalkar S, Lambert BL, Schiff GD. Analysis of variations in the display of drug names in computerized prescriber-order-entry systems. Am J Health Syst Pharm 2017; 74:499-509. [DOI: 10.2146/ajhp151051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Arbor J. L. Quist
- Epidemiology Department, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Mary G. Amato
- Department of Pharmacy Practice, MCPHS University, Boston, MA
| | | | | | | | | | | | - Shobha Phansalkar
- Brigham and Women’s Hospital, Boston, MA
- Clinical Drug Information Division, Wolters Kluwer Health, Indianapolis, IN
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Klinkenberg-Ramirez S, Neri PM, Volk LA, Samaha SJ, Newmark LP, Pollard S, Varugheese M, Baxter S, Aronson SJ, Rehm HL, Bates DW. Evaluation: A Qualitative Pilot Study of Novel Information Technology Infrastructure to Communicate Genetic Variant Updates. Appl Clin Inform 2016; 7:461-76. [PMID: 27437054 DOI: 10.4338/aci-2015-11-ra-0162] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 03/21/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Partners HealthCare Personalized Medicine developed GeneInsight Clinic (GIC), a tool designed to communicate updated variant information from laboratory geneticists to treating clinicians through automated alerts, categorized by level of variant interpretation change. OBJECTIVES The study aimed to evaluate feedback from the initial users of the GIC, including the advantages and challenges to receiving this variant information and using this technology at the point of care. METHODS Healthcare professionals from two clinics that ordered genetic testing for cardiomyopathy and related disorders were invited to participate in one-hour semi-structured interviews and/ or a one-hour focus group. Using a Grounded Theory approach, transcript concepts were coded and organized into themes. RESULTS Two genetic counselors and two physicians from two treatment clinics participated in individual interviews. Focus group participants included one genetic counselor and four physicians. Analysis resulted in 8 major themes related to structuring and communicating variant knowledge, GIC's impact on the clinic, and suggestions for improvements. The interview analysis identified longitudinal patient care, family data, and growth in genetic testing content as potential challenges to optimization of the GIC infrastructure. DISCUSSION Participants agreed that GIC implementation increased efficiency and effectiveness of the clinic through increased access to genetic variant information at the point of care. CONCLUSION Development of information technology (IT) infrastructure to aid in the organization and management of genetic variant knowledge will be critical as the genetic field moves towards whole exome and whole genome sequencing. Findings from this study could be applied to future development of IT support for genetic variant knowledge management that would serve to improve clinicians' ability to manage and care for patients.
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Affiliation(s)
| | - Pamela M Neri
- Clinical and Quality Analysis, Partners HealthCare System , Wellesley, MA
| | - Lynn A Volk
- Clinical and Quality Analysis, Partners HealthCare System , Wellesley, MA
| | - Sara J Samaha
- Clinical and Quality Analysis, Partners HealthCare System , Wellesley, MA
| | - Lisa P Newmark
- Clinical and Quality Analysis, Partners HealthCare System , Wellesley, MA
| | - Stephanie Pollard
- Clinical and Quality Analysis, Partners HealthCare System , Wellesley, MA
| | - Matthew Varugheese
- Information Systems, Partners HealthCare Personalized Medicine , Cambridge, MA
| | - Samantha Baxter
- Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine , Cambridge, MA
| | - Samuel J Aronson
- Information Systems, Partners HealthCare Personalized Medicine , Cambridge, MA
| | - Heidi L Rehm
- Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge, MA; Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Boston, MA
| | - David W Bates
- Clinical and Quality Analysis, Partners HealthCare System, Wellesley, MA; Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Boston, MA
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Samal L, Dykes PC, Greenberg JO, Hasan O, Venkatesh AK, Volk LA, Bates DW. Care coordination gaps due to lack of interoperability in the United States: a qualitative study and literature review. BMC Health Serv Res 2016; 16:143. [PMID: 27106509 PMCID: PMC4841960 DOI: 10.1186/s12913-016-1373-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 04/01/2016] [Indexed: 12/22/2022] Open
Abstract
Background Health information technology (HIT) could improve care coordination by providing clinicians remote access to information, improving legibility, and allowing asynchronous communication, among other mechanisms. We sought to determine, from a clinician perspective, how care is coordinated and to what extent HIT is involved when transitioning patients between emergency departments, acute care hospitals, skilled nursing facilities, and home health agencies in settings across the United States. Methods We performed a qualitative study with clinicians and information technology professionals from six regions of the U.S. which were chosen as national leaders in HIT. We analyzed data through a two person consensus approach, assigning responses to each of nine care coordination activities. We also conducted a literature review of MEDLINE®, CINAHL®, and Embase, analyzing results of studies that examined interventions to improve information transfer during transitions of care. Results We enrolled 29 respondents from 17 organizations and conducted six focus groups. Respondents reported how HIT is currently used for care coordination activities. HIT is currently used to monitor patients and to align systems-level resources with population needs. However, we identified multiple areas where the lack of interoperability leads to inefficient processes and missing data. Additionally, the literature review identified ten intervention studies that address information transfer, seven of which employed HIT and three of which utilized other communication methods such as telephone calls, faxed records, and nurse case management. Conclusions Significant care coordination gaps exist due to the lack of interoperability across the United States. We must design, evaluate, and incentivize the use of HIT for care coordination. We should focus on the domains where we found the largest gaps: information transfer, systems to monitor patients, tools to support patients’ self-management goals, and tools to link patients and their caregivers with community resources. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1373-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lipika Samal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St., Suite OBC-03-02V, Boston, MA, 02120, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Patricia C Dykes
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St., Suite OBC-03-02V, Boston, MA, 02120, USA.,Harvard Medical School, Boston, MA, USA
| | - Jeffrey O Greenberg
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St., Suite OBC-03-02V, Boston, MA, 02120, USA.,Harvard Medical School, Boston, MA, USA
| | - Omar Hasan
- American Medical Association, Chicago, IL, USA
| | | | | | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St., Suite OBC-03-02V, Boston, MA, 02120, USA.,Harvard Medical School, Boston, MA, USA.,Partners Healthcare System, Boston, MA, USA
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Schiff GD, Hickman TTT, Volk LA, Bates DW, Wright A. Computerised prescribing for safer medication ordering: still a work in progress. BMJ Qual Saf 2015; 25:315-9. [DOI: 10.1136/bmjqs-2015-004677] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/11/2015] [Indexed: 11/04/2022]
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Dykes PC, Samal L, Donahue M, Greenberg JO, Hurley AC, Hasan O, O'Malley TA, Venkatesh AK, Volk LA, Bates DW. A patient-centered longitudinal care plan: vision versus reality. J Am Med Inform Assoc 2014; 21:1082-90. [PMID: 24996874 PMCID: PMC4215040 DOI: 10.1136/amiajnl-2013-002454] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 06/08/2014] [Accepted: 06/17/2014] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE As healthcare systems and providers move toward meaningful use of electronic health records, longitudinal care plans (LCPs) may provide a means to improve communication and coordination as patients transition across settings. The objective of this study was to determine the current state of communication of LCPs across settings and levels of care. MATERIALS AND METHODS We conducted surveys and interviews with professionals from emergency departments, acute care hospitals, skilled nursing facilities, and home health agency settings in six regions in the USA. We coded the transcripts according to the Agency for Healthcare Research and Quality (AHRQ) 'Broad Approaches' to care coordination to understand the degree to which current practice meets the definition of an LCP. RESULTS Participants (n=22) from all settings reported that LCPs do not exist in their current state. We found LCPs in practice, and none of these were shared or reconciled across settings. Moreover, we found wide variation in the types and formats of care plan information that was communicated as patients transitioned. The most common formats, even when care plan information was communicated within the same healthcare system, were paper and fax. DISCUSSION These findings have implications for data reuse, interoperability, and achieving widespread adoption of LCPs. CONCLUSIONS The use of LCPs to support care transitions is suboptimal. Strategies are needed to transform the LCP from vision to reality.
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Affiliation(s)
- Patricia C Dykes
- Center for Patient Safety, Research, & Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lipika Samal
- Center for Patient Safety, Research, & Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jeffrey O Greenberg
- Center for Patient Safety, Research, & Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ann C Hurley
- Western Connecticut Health Network, Danbury, Connecticut, USA
| | - Omar Hasan
- American Medical Association, Chicago, Illinois, USA
| | - Terrance A O'Malley
- Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | | | - Lynn A Volk
- Partners HealthCare System, Boston, Massachusetts, USA
| | - David W Bates
- Center for Patient Safety, Research, & Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Partners HealthCare System, Boston, Massachusetts, USA
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Neri PM, Volk LA, Samaha S, Pollard SE, Williams DH, Fiskio JM, Burdick E, Edwards ST, Ramelson H, Schiff GD, Bates DW. Relationship between documentation method and quality of chronic disease visit notes. Appl Clin Inform 2014; 5:480-90. [PMID: 25024762 DOI: 10.4338/aci-2014-01-ra-0007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 04/15/2014] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To assses the relationship between methods of documenting visit notes and note quality for primary care providers (PCPs) and specialists, and to determine the factors that contribute to higher quality notes for two chronic diseases. METHODS Retrospective chart review of visit notes at two academic medical centers. Two physicians rated the subjective quality of content areas of the note (vital signs, medications, lifestyle, labs, symptoms, assessment & plan), overall quality, and completed the 9 item Physician Documentation Quality Instrument (PDQI-9). We evaluated quality ratings in relation to the primary method of documentation (templates, free-form or dictation) for both PCPs and specialists. A one factor analysis of variance test was used to examine differences in mean quality scores among the methods. RESULTS A total of 112 physicians, 71 primary care physicians (PCP) and 41 specialists, wrote 240 notes. For specialists, templated notes had the highest overall quality scores (p≤0.001) while for PCPs, there was no statistically significant difference in overall quality score. For PCPs, free form received higher quality ratings on vital signs (p = 0.01), labs (p = 0.002), and lifestyle (p = 0.002) than other methods; templated notes had a higher rating on medications (p≤0.001). For specialists, templated notes received higher ratings on vital signs, labs, lifestyle and medications (p = 0.001). DISCUSSION There was no significant difference in subjective quality of visit notes written using free-form documentation, dictation or templates for PCPs. The subjective quality rating of templated notes was higher than that of dictated notes for specialists. CONCLUSION As there is wide variation in physician documentation methods, and no significant difference in note quality between methods, recommending one approach for all physicians may not deliver optimal results.
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Affiliation(s)
- P M Neri
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - L A Volk
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - S Samaha
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - S E Pollard
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - D H Williams
- Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA
| | - J M Fiskio
- Information Systems, Partners Healthcare System , Wellesley, MA
| | - E Burdick
- Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA
| | - S T Edwards
- Harvard Medical School , Boston, MA ; Massachusetts Veteran's Epidemiology Research and Information Center, Veteran's Affairs Boston Healthcare System , Boston, MA ; Section of General Internal Medicine, Veteran's Affairs Boston Healthcare System , Boston, MA
| | - H Ramelson
- Information Systems, Partners Healthcare System , Wellesley, MA ; Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA ; Harvard Medical School , Boston, MA
| | - G D Schiff
- Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA ; Harvard Medical School , Boston, MA
| | - D W Bates
- Information Systems, Partners Healthcare System , Wellesley, MA ; Division of General Internal Medicine, Brigham and Women's Hospital , Boston, MA ; Harvard Medical School , Boston, MA
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Abstract
BACKGROUND While physician notes are known to vary in organisation, content and quality, the relationship between note quality and clinical quality is uncertain. METHODS We performed a cross-sectional study of outpatient visit physician notes by adult patients with coronary artery disease or diabetes mellitus seen in 2010. We assessed physician note quality using the 9-item Physician Documentation Quality Instrument (PDQI-9) and compared this to disease-specific clinical quality scores constructed from data extracted from the electronic health record (EHR). We also assessed the presence of typical note subsections, and indicators of quality care in physician notes. RESULTS We evaluated 239 notes, written by 111 physicians; 110 notes were written by primary care physicians, 52 by cardiologists and 77 by endocrinologists. Reason for visit was absent in 10% of notes, medication list was not present in the note in 19.7% and timing for follow-up was absent in 18.0% of notes. Significant copy/pasted material was present in 10.5% of notes. Laboratory quality indicators were more often found in other EHR sections than in the physician note. Clinical quality scores for diabetes and coronary artery disease (CAD) showed no significant association with subjective note quality (diabetes: r -0.119, p=0.065, CAD: r -0.124, p=0.06). CONCLUSIONS Notes varied in documentation method and length, and important note subsections were frequently missing. Key clinical data to support quality patient care were often not present in physician notes, but were often found elsewhere in the EHR. Subjective assessment of note quality did not correlate with clinical quality scores, suggesting that writing high-quality notes and meeting quality measures are not mutually reinforcing activities.
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Affiliation(s)
- Samuel T Edwards
- Massachusetts Veteran's Epidemiology Research and Information Center, Veteran's Affairs Boston Healthcare System, , Boston, Massachusetts, USA
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Samal L, Dykes PC, Greenberg J, Hasan O, Venkatesh AK, Volk LA, Bates DW. The current capabilities of health information technology to support care transitions. AMIA Annu Symp Proc 2013; 2013:1231. [PMID: 24551404 PMCID: PMC3900141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
To determine whether HIT currently supports care transitions we interviewed clinicians from several healthcare settings. We learned about HIT tools to help nurses facilitate transitions, but discovered that there are few tools to promote high quality, safe transitions of care. We also found that HIT is rarely employed for patient-centered care coordination mechanisms. In conclusion, HIT tools are typically used within one healthcare setting to prepare for a transition, rather than across healthcare settings.
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Affiliation(s)
- Lipika Samal
- Brigham and Women's Hospital, Boston, MA ; Harvard Medical School, Boston, MA
| | - Patricia C Dykes
- Brigham and Women's Hospital, Boston, MA ; Harvard Medical School, Boston, MA
| | | | - Omar Hasan
- American Medical Association, Chicago, IL
| | | | - Lynn A Volk
- Brigham and Women's Hospital, Boston, MA ; Partners Healthcare System, Boston, MA
| | - David W Bates
- Brigham and Women's Hospital, Boston, MA ; Harvard Medical School, Boston, MA ; Partners Healthcare System, Boston, MA
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Nanji KC, Slight SP, Seger DL, Cho I, Fiskio JM, Redden LM, Volk LA, Bates DW. Overrides of medication-related clinical decision support alerts in outpatients. J Am Med Inform Assoc 2013; 21:487-91. [PMID: 24166725 DOI: 10.1136/amiajnl-2013-001813] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Electronic prescribing is increasingly used, in part because of government incentives for its use. Many of its benefits come from clinical decision support (CDS), but often too many alerts are displayed, resulting in alert fatigue. OBJECTIVE To characterize the override rates for medication-related CDS alerts in the outpatient setting, the reasons cited for overrides at the time of prescribing, and the appropriateness of overrides. METHODS We measured CDS alert override rates and the coded reasons for overrides cited by providers at the time of prescribing. Our primary outcome was the rate of CDS alert overrides; our secondary outcomes were the rate of overrides by alert type, reasons cited for overrides at the time of prescribing, and override appropriateness for a subset of 600 alert overrides. Through detailed chart reviews of alert override cases, and selective literature review, we developed appropriateness criteria for each alert type, which were modified iteratively as necessary until consensus was reached on all criteria. RESULTS We reviewed 157,483 CDS alerts (7.9% alert rate) on 2,004,069 medication orders during the study period. 82,889 (52.6%) of alerts were overridden. The most common alerts were duplicate drug (33.1%), patient allergy (16.8%), and drug-drug interactions (15.8%). The most likely alerts to be overridden were formulary substitutions (85.0%), age-based recommendations (79.0%), renal recommendations (78.0%), and patient allergies (77.4%). An average of 53% of overrides were classified as appropriate, and rates of appropriateness varied by alert type (p<0.0001) from 12% for renal recommendations to 92% for patient allergies. DISCUSSION About half of CDS alerts were overridden by providers and about half of the overrides were classified as appropriate, but the likelihood of overriding an alert varied widely by alert type. Refinement of these alerts has the potential to improve the relevance of alerts and reduce alert fatigue.
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Affiliation(s)
- Karen C Nanji
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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27
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Wilcox AR, Neri PM, Volk LA, Newmark LP, Clark EH, Babb LJ, Varugheese M, Aronson SJ, Rehm HL, Bates DW. A novel clinician interface to improve clinician access to up-to-date genetic results. J Am Med Inform Assoc 2013; 21:e117-21. [PMID: 24013137 DOI: 10.1136/amiajnl-2013-001965] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES To understand the impact of GeneInsight Clinic (GIC), a web-based tool designed to manage genetic information and facilitate communication of test results and variant updates from the laboratory to the clinics, we measured the use of GIC and the time it took for new genetic knowledge to be available to clinicians. METHODS Usage data were collected across four study sites for the GIC launch and post-GIC implementation time periods. The primary outcome measures were the time (average number of days) between variant change approval and notification of clinic staff, and the time between notification and viewing the patient record. RESULTS Post-GIC, time between a variant change approval and provider notification was shorter than at launch (average days at launch 503.8, compared to 4.1 days post-GIC). After e-mail alerts were sent at launch, providers clicked into the patient record associated with 91% of these alerts. In the post period, clinic providers clicked into the patient record associated with 95% of the alerts, on average 12 days after the e-mail was sent. DISCUSSION We found that GIC greatly increased the likelihood that a provider would receive updated variant information as well as reduced the time associated with distributing that variant information, thus providing a more efficient process for incorporating new genetic knowledge into clinical care. CONCLUSIONS Our study results demonstrate that health information technology systems have the potential effectively to assist providers in utilizing genetic information in patient care.
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Affiliation(s)
- Allison R Wilcox
- Clinical and Quality Analysis, Partners HealthCare System, Inc, Wellesley, Massachusetts, USA
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Slight SP, Nanji KC, Seger DL, Cho I, Volk LA, Bates DW. Overrides of clinical decision support alerts in primary care clinics. Stud Health Technol Inform 2013; 192:923. [PMID: 23920697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Clinical Decision Support (CDS) systems can alert physicians about potential clinical risks and suggest suitable treatment alternatives at appropriate times in the health care process. We evaluated the frequency with which physicians overrode medication alerts and the override reasons provided. Data obtained from primary care practices affiliated with two Harvard teaching hospitals were downloaded. Physicians overrode more than half of CDS medication alerts, with formulary, age-based, and renal substitutions the most likely. Many drug-drug and drug-allergy interactions overridden had the potential to cause patient harm.
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Affiliation(s)
- Sarah P Slight
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Heyworth L, Zhang F, Jenter CA, Kell R, Volk LA, Tripathi M, Bates DW, Simon SR. Physician satisfaction following electronic health record adoption in three massachusetts communities. Interact J Med Res 2012; 1:e12. [PMID: 23611987 PMCID: PMC3626123 DOI: 10.2196/ijmr.2064] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Revised: 09/04/2012] [Accepted: 09/21/2012] [Indexed: 12/01/2022] Open
Abstract
Background Despite mandates and incentives for electronic health record (EHR) adoption, little is known about factors predicting physicians’ satisfaction following EHR implementation. Objective To measure predictors of physician satisfaction following EHR adoption. Methods A total of 163 physicians completed a mailed survey before and after EHR implementation through a statewide pilot project in Massachusetts. Multivariable logistic regression identified predictors of physician satisfaction with their current practice situation in 2009 and generalized estimating equations accounted for clustering. Results The response rate was 77% in 2005 and 68% in 2009. In 2005, prior to EHR adoption, 28% of physicians were very satisfied with their current practice situation compared to 25% in 2009, following EHR adoption (P < .001). In multivariate analysis, physician satisfaction following EHR adoption was correlated with self-reported ease of EHR implementation (adjusted odds ratio [OR] = 5.7, 95% CI 2.1 - 16), resources for practice improvement (adjusted OR = 2.6, 95% CI 1.2 - 6.1), pre-intervention satisfaction (adjusted OR = 4.8, 95% CI 1.5 - 15), and stress (adjusted OR = 5.3, 95% CI 1.1 - 25). Male physicians reported lower satisfaction following EHR adoption (adjusted OR = 0.3, 95% CI 0.2 - 0.6). Conclusions Interventions to expand EHR use should consider additional support for practices with fewer resources for improvement and ensure ease of EHR implementation. EHR adoption may be a factor in alleviating physicians’ stress. Addressing physicians’ satisfaction prior to practice transformation and anticipating greater dissatisfaction among male physicians will be essential to retaining the physician workforce and ensuring the quality of care they deliver.
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Affiliation(s)
- Leonie Heyworth
- VA Boston Healthcare System, Section of General Internal Medicine, Jamaica Plain, MA, United States.
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Schnipper JL, Gandhi TK, Wald JS, Grant RW, Poon EG, Volk LA, Businger A, Williams DH, Siteman E, Buckel L, Middleton B. Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. J Am Med Inform Assoc 2012; 19:728-34. [PMID: 22556186 DOI: 10.1136/amiajnl-2011-000723] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To determine the effects of a personal health record (PHR)-linked medications module on medication accuracy and safety. DESIGN From September 2005 to March 2007, we conducted an on-treatment sub-study within a cluster-randomized trial involving 11 primary care practices that used the same PHR. Intervention practices received access to a medications module prompting patients to review their documented medications and identify discrepancies, generating 'eJournals' that enabled rapid updating of medication lists during subsequent clinical visits. MEASUREMENTS A sample of 267 patients who submitted medications eJournals was contacted by phone 3 weeks after an eligible visit and compared with a matched sample of 274 patients in control practices that received a different PHR-linked intervention. Two blinded physician adjudicators determined unexplained discrepancies between documented and patient-reported medication regimens. The primary outcome was proportion of medications per patient with unexplained discrepancies. RESULTS Among 121,046 patients in eligible practices, 3979 participated in the main trial and 541 participated in the sub-study. The proportion of medications per patient with unexplained discrepancies was 42% in the intervention arm and 51% in the control arm (adjusted OR 0.71, 95% CI 0.54 to 0.94, p=0.01). The number of unexplained discrepancies per patient with potential for severe harm was 0.03 in the intervention arm and 0.08 in the control arm (adjusted RR 0.31, 95% CI 0.10 to 0.92, p=0.04). CONCLUSIONS When used, concordance between documented and patient-reported medication regimens and reduction in potentially harmful medication discrepancies can be improved with a PHR medication review tool linked to the provider's medical record. TRIAL REGISTRATION NUMBER This study was registered at ClinicalTrials.gov (NCT00251875).
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Affiliation(s)
- Jeffrey L Schnipper
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts 02120-1613, USA.
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Pollard SE, Neri PM, Wilcox AR, Volk LA, Williams DH, Schiff GD, Ramelson HZ, Bates DW. How physicians document outpatient visit notes in an electronic health record. Int J Med Inform 2012; 82:39-46. [PMID: 22542717 DOI: 10.1016/j.ijmedinf.2012.04.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 03/07/2012] [Accepted: 04/03/2012] [Indexed: 12/01/2022]
Abstract
BACKGROUND Clinical documentation, an essential process within electronic health records (EHRs), takes a significant amount of clinician time. How best to optimize documentation methods to deliver effective care remains unclear. OBJECTIVE We evaluated whether EHR visit note documentation method was influenced by physician or practice characteristics, and the association of physician satisfaction with an EHR notes module. MEASUREMENTS We surveyed primary care physicians (PCPs) and specialists, and used EHR and provider data to perform a multinomial logistic regression of visit notes from 2008. We measured physician documentation method use and satisfaction with an EHR notes module and determined the relationship between method and physician and practice characteristics. RESULTS Of 1088 physicians, 85% used a single method to document the majority of their visits. PCPs predominantly documented using templates (60%) compared to 34% of specialists, while 38% of specialists predominantly dictated. Physicians affiliated with academic medical centers (OR 1.96, CI (1.23, 3.12)), based at a hospital (OR 1.57, 95% CI (1.04, 2.36)) and using the EHR for longer (OR 1.13, 95% CI (1.03, 1.25)) were more likely to dictate than use templates. Most physicians of 383 survey responders were satisfied with the EHR notes module, regardless of their preferred documentation method. CONCLUSIONS Physicians predominantly utilized a single method of visit note documentation and were satisfied with their approach, but the approaches they chose varied. Demographic characteristics were associated with preferred documentation method. Further research should focus on why variation exists, and the quality of the documentation resulting from different methods used.
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Neri PM, Pollard SE, Volk LA, Newmark LP, Varugheese M, Baxter S, Aronson SJ, Rehm HL, Bates DW. Usability of a novel clinician interface for genetic results. J Biomed Inform 2012; 45:950-7. [PMID: 22521718 DOI: 10.1016/j.jbi.2012.03.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 03/21/2012] [Accepted: 03/27/2012] [Indexed: 10/28/2022]
Abstract
The complexity and rapid growth of genetic data demand investment in information technology to support effective use of this information. Creating infrastructure to communicate genetic information to healthcare providers and enable them to manage that data can positively affect a patient's care in many ways. However, genetic data are complex and present many challenges. We report on the usability of a novel application designed to assist providers in receiving and managing a patient's genetic profile, including ongoing updated interpretations of the genetic variants in those patients. Because these interpretations are constantly evolving, managing them represents a challenge. We conducted usability tests with potential users of this application and reported findings to the application development team, many of which were addressed in subsequent versions. Clinicians were excited about the value this tool provides in pushing out variant updates to providers and overall gave the application high usability ratings, but had some difficulty interpreting elements of the interface. Many issues identified required relatively little development effort to fix suggesting that consistently incorporating this type of analysis in the development process can be highly beneficial. For genetic decision support applications, our findings suggest the importance of designing a system that can deliver the most current knowledge and highlight the significance of new genetic information for clinical care. Our results demonstrate that using a development and design process that is user focused helped optimize the value of this application for personalized medicine.
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Affiliation(s)
- Pamela M Neri
- Partners HealthCare System, Inc., 93 Worcester Street, Wellesley, MA 02481, USA.
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Rudin RS, Schneider EC, Volk LA, Szolovits P, Salzberg CA, Simon SR, Bates DW. Simulation Suggests That Medical Group Mergers Won’t Undermine The Potential Utility Of Health Information Exchanges. Health Aff (Millwood) 2012; 31:548-59. [DOI: 10.1377/hlthaff.2011.0799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Robert S. Rudin
- Robert S. Rudin ( ) is an associate policy researcher at the RAND Corporation in Boston, Massachusetts
| | - Eric C. Schneider
- Eric C. Schneider is a senior scientist and director of the RAND Corporation’s Boston office
| | - Lynn A. Volk
- Lynn A. Volk is associate director of the Clinical and Quality Analysis Department in Partners HealthCare’s Information Services, in Boston
| | - Peter Szolovits
- Peter Szolovits is a professor of computer science and engineering at the Massachusetts Institute of Technology, in Cambridge, Massachusetts
| | - Claudia A. Salzberg
- Claudia A. Salzberg is a doctoral student in health policy and management at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Steven R. Simon
- Steven R. Simon is chief of general internal medicine at the Veterans Affairs Boston Healthcare System and an associate professor at both Harvard Medical School and Brigham and Women’s Hospital, in Boston
| | - David W. Bates
- David W. Bates is chief quality officer and chief of general internal medicine at Brigham and Women’s Hospital and a professor at Harvard Medical School
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Fleurant M, Kell R, Jenter C, Volk LA, Zhang F, Bates DW, Simon SR. Factors associated with difficult electronic health record implementation in office practice. J Am Med Inform Assoc 2012; 19:541-4. [PMID: 22249965 DOI: 10.1136/amiajnl-2011-000689] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Little is known about physicians' perception of the ease or difficulty of implementing electronic health records (EHR). This study identified factors related to the perceived difficulty of implementing EHR. 163 physicians completed surveys before and after the implementation of EHR in an externally funded pilot program in three Massachusetts communities. Ordinal hierarchical logistic regression was used to identify baseline factors that correlated with physicians' report of difficulty with EHR implementation. Compared with physicians with ownership stake in their practices, physician employees were less likely to describe EHR implementation as difficult (adjusted OR 0.5, 95% CI 0.3 to 1.0). Physicians who perceived their staff to be innovative were also less likely to view EHR implementation as difficult (adjusted OR 0.4, 95% CI 0.2 to 0.8). Physicians who own their practice may need more external support for EHR implementation than those who do not. Innovative clinical support staff may ease the EHR implementation process and contribute to its success.
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Affiliation(s)
- Marshall Fleurant
- Boston Medical Center, Boston University School of Medicine, Section of General Internal Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA.
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Wright A, Poon EG, Wald J, Feblowitz J, Pang JE, Schnipper JL, Grant RW, Gandhi TK, Volk LA, Bloom A, Williams DH, Gardner K, Epstein M, Nelson L, Businger A, Li Q, Bates DW, Middleton B. Randomized controlled trial of health maintenance reminders provided directly to patients through an electronic PHR. J Gen Intern Med 2012; 27:85-92. [PMID: 21904945 PMCID: PMC3250545 DOI: 10.1007/s11606-011-1859-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 06/23/2011] [Accepted: 08/17/2011] [Indexed: 02/05/2023]
Abstract
BACKGROUND Provider and patient reminders can be effective in increasing rates of preventive screenings and vaccinations. However, the effect of patient-directed electronic reminders is understudied. OBJECTIVE To determine whether providing reminders directly to patients via an electronic Personal Health Record (PHR) improved adherence to care recommendations. DESIGN We conducted a cluster randomized trial without blinding from 2005 to 2007 at 11 primary care practices in the Partners HealthCare system. PARTICIPANTS A total of 21,533 patients with access to a PHR were invited to the study, and 3,979 (18.5%) consented to enroll. INTERVENTIONS Patients in the intervention arm received health maintenance (HM) reminders via a secure PHR "eJournal," which allowed them to review and update HM and family history information. Patients in the active control arm received access to an eJournal that allowed them to input and review information related to medications, allergies and diabetes management. MAIN MEASURES The primary outcome measure was adherence to guideline-based care recommendations. KEY RESULTS Intention-to-treat analysis showed that patients in the intervention arm were significantly more likely to receive mammography (48.6% vs 29.5%, p = 0.006) and influenza vaccinations (22.0% vs 14.0%, p = 0.018). No significant improvement was observed in rates of other screenings. Although Pap smear completion rates were higher in the intervention arm (41.0% vs 10.4%, p < 0.001), this finding was no longer significant after excluding women's health clinics. Additional on-treatment analysis showed significant increases in mammography (p = 0.019) and influenza vaccination (p = 0.015) for intervention arm patients who opened an eJournal compared to control arm patients, but no differences for any measure among patients who did not open an eJournal. CONCLUSIONS Providing patients with HM reminders via a PHR may be effective in improving some elements of preventive care.
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Affiliation(s)
- Adam Wright
- Brigham & Women's Hospital, Boston, MA 02115, USA.
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Love JS, Wright A, Simon SR, Jenter CA, Soran CS, Volk LA, Bates DW, Poon EG. Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use? J Am Med Inform Assoc 2011; 19:610-4. [PMID: 22199017 DOI: 10.1136/amiajnl-2011-000544] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Electronic health record (EHR) adoption is a national priority in the USA, and well-designed EHRs have the potential to improve quality and safety. However, physicians are reluctant to implement EHRs due to financial constraints, usability concerns, and apprehension about unintended consequences, including the introduction of medical errors related to EHR use. The goal of this study was to characterize and describe physicians' attitudes towards three consequences of EHR implementation: (1) the potential for EHRs to introduce new errors; (2) improvements in healthcare quality; and (3) changes in overall physician satisfaction. METHODS Using data from a 2007 statewide survey of Massachusetts physicians, we conducted multivariate regression analysis to examine relationships between practice characteristics, perceptions of EHR-related errors, perceptions of healthcare quality, and overall physician satisfaction. RESULTS 30% of physicians agreed that EHRs create new opportunities for error, but only 2% believed their EHR has created more errors than it prevented. With respect to perceptions of quality, there was no significant association between perceptions of EHR-associated errors and perceptions of EHR-associated changes in healthcare quality. Finally, physicians who believed that EHRs created new opportunities for error were less likely be satisfied with their practice situation (adjusted OR 0.49, p=0.001). CONCLUSIONS Almost one third of physicians perceived that EHRs create new opportunities for error. This perception was associated with lower levels of physician satisfaction.
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Affiliation(s)
- Jennifer S Love
- Partners HealthCare, Clinical and Quality Analysis Information Systems, Boston, Massachusetts, USA.
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Zachariah M, Phansalkar S, Seidling HM, Neri PM, Cresswell KM, Duke J, Bloomrosen M, Volk LA, Bates DW. Development and preliminary evidence for the validity of an instrument assessing implementation of human-factors principles in medication-related decision-support systems--I-MeDeSA. J Am Med Inform Assoc 2011; 18 Suppl 1:i62-72. [PMID: 21946241 PMCID: PMC3241174 DOI: 10.1136/amiajnl-2011-000362] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 08/22/2011] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Medication-related decision support can reduce the frequency of preventable adverse drug events. However, the design of current medication alerts often results in alert fatigue and high over-ride rates, thus reducing any potential benefits. METHODS The authors previously reviewed human-factors principles for relevance to medication-related decision support alerts. In this study, instrument items were developed for assessing the appropriate implementation of these human-factors principles in drug-drug interaction (DDI) alerts. User feedback regarding nine electronic medical records was considered during the development process. Content validity, construct validity through correlation analysis, and inter-rater reliability were assessed. RESULTS The final version of the instrument included 26 items associated with nine human-factors principles. Content validation on three systems resulted in the addition of one principle (Corrective Actions) to the instrument and the elimination of eight items. Additionally, the wording of eight items was altered. Correlation analysis suggests a direct relationship between system age and performance of DDI alerts (p=0.0016). Inter-rater reliability indicated substantial agreement between raters (κ=0.764). CONCLUSION The authors developed and gathered preliminary evidence for the validity of an instrument that measures the appropriate use of human-factors principles in the design and display of DDI alerts. Designers of DDI alerts may use the instrument to improve usability and increase user acceptance of medication alerts, and organizations selecting an electronic medical record may find the instrument helpful in meeting their clinicians' usability needs.
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Affiliation(s)
| | - Shobha Phansalkar
- Partners HealthCare System, Wellesley, Massachusetts, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
- Division of Medical Information Sciences, University Hospitals of Geneva, Geneva, Switzerland
| | - Pamela M Neri
- Partners HealthCare System, Wellesley, Massachusetts, USA
| | - Kathrin M Cresswell
- eHealth Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Jon Duke
- Regenstrief Institute, Indianapolis, Indiana, USA
| | - Meryl Bloomrosen
- The American Medical Informatics Association, Bethesda, Maryland, USA
| | - Lynn A Volk
- Partners HealthCare System, Wellesley, Massachusetts, USA
| | - David W Bates
- Partners HealthCare System, Wellesley, Massachusetts, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Abramson EL, Bates DW, Jenter C, Volk LA, Barrón Y, Quaresimo J, Seger AC, Burdick E, Simon S, Kaushal R. Ambulatory prescribing errors among community-based providers in two states. J Am Med Inform Assoc 2011; 19:644-8. [PMID: 22140209 DOI: 10.1136/amiajnl-2011-000345] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Little is known about the frequency and types of prescribing errors in the ambulatory setting among community-based, primary care providers. Therefore, the rates and types of prescribing errors were assessed among community-based, primary care providers in two states. MATERIAL AND METHODS A non-randomized cross-sectional study was conducted of 48 providers in New York and 30 providers in Massachusetts, all of whom used paper prescriptions, from September 2005 to November 2006. Using standardized methodology, prescriptions and medical records were reviewed to identify errors. RESULTS 9385 prescriptions were analyzed from 5955 patients. The overall prescribing error rate, excluding illegibility errors, was 36.7 per 100 prescriptions (95% CI 30.7 to 44.0) and did not vary significantly between providers from each state (p=0.39). One or more non-illegibility errors were found in 28% of prescriptions. Rates of illegibility errors were very high (175.0 per 100 prescriptions, 95% CI 169.1 to 181.3). Inappropriate abbreviation and direction errors also occurred frequently (13.4 and 4.2 errors per 100 prescriptions, respectively). Reviewers determined that the vast majority of errors could have been eliminated through the use of e-prescribing with clinical decision support. DISCUSSION Prescribing errors appear to occur at very high rates among community-based primary care providers, especially when compared with studies of academic-affiliated providers that have found nearly threefold lower error rates. Illegibility errors are particularly problematical. CONCLUSIONS Further characterizing prescribing errors of community-based providers may inform strategies to improve ambulatory medication safety, especially e-prescribing. TRIAL REGISTRATION NUMBER http://www.clinicaltrials.gov, NCT00225576.
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Affiliation(s)
- Erika L Abramson
- Department of Pediatrics, Weill Medical College of Cornell University, New York, New York 10065, USA.
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Fleurant M, Kell R, Love J, Jenter C, Volk LA, Zhang F, Bates DW, Simon SR. Massachusetts e-Health Project increased physicians' ability to use registries, and signals progress toward better care. Health Aff (Millwood) 2011; 30:1256-64. [PMID: 21734198 DOI: 10.1377/hlthaff.2010.1020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The ability to generate and use registries--lists of patients with specific conditions, medications, or test results--is considered a measure of physicians' engagement with electronic health record systems and a proxy for high-quality health care. We conducted a pre-post survey of registry capability among physicians participating in the Massachusetts eHealth Collaborative, a four-year, $50 million health information technology program. Physicians who participated in the program increased their ability to generate some types of registries--specifically, for laboratory results and medication use. Our analysis also suggested that physicians who used their electronic health records more intensively were more likely to use registries, particularly in caring for patients with diabetes, compared to physicians reporting less avid use of electronic health records. This statewide project may be a viable model for regional efforts to expand health information technology and improve the quality of care.
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Affiliation(s)
- Marshall Fleurant
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, and Brigham and Women's Hospital, Boston, MA, USA.
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Rudin RS, Salzberg CA, Szolovits P, Volk LA, Simon SR, Bates DW. Care transitions as opportunities for clinicians to use data exchange services: how often do they occur? J Am Med Inform Assoc 2011; 18:853-8. [PMID: 21531703 DOI: 10.1136/amiajnl-2010-000072] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The electronic exchange of health information among healthcare providers has the potential to produce enormous clinical benefits and financial savings, although realizing that potential will be challenging. The American Recovery and Reinvestment Act of 2009 will reward providers for 'meaningful use' of electronic health records, including participation in clinical data exchange, but the best ways to do so remain uncertain. METHODS We analyzed patient visits in one community in which a high proportion of providers were using an electronic health record and participating in data exchange. Using claims data from one large private payer for individuals under age 65 years, we computed the number of visits to a provider which involved transitions in care from other providers as a percentage of total visits. We calculated this 'transition percentage' for individual providers and medical groups. RESULTS On average, excluding radiology and pathology, approximately 51% of visits involved care transitions between individual providers in the community and 36%-41% involved transitions between medical groups. There was substantial variation in transition percentage across medical specialties, within specialties and across medical groups. Specialists tended to have higher transition percentages and smaller ranges within specialty than primary care physicians, who ranged from 32% to 95% (including transitions involving radiology and pathology). The transition percentages of pediatric practices were similar to those of adult primary care, except that many transitions occurred among pediatric physicians within a single medical group. CONCLUSIONS Care transition patterns differed substantially by type of practice and should be considered in designing incentives to foster providers' meaningful use of health data exchange services.
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Affiliation(s)
- Robert S Rudin
- Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA.
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Linder JA, Schnipper JL, Tsurikova R, Volk LA, Middleton B. Self-reported familiarity with acute respiratory infection guidelines and antibiotic prescribing in primary care. Int J Qual Health Care 2010; 22:469-75. [PMID: 20935008 PMCID: PMC3003551 DOI: 10.1093/intqhc/mzq052] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2010] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Familiarity with guidelines is generally thought to be associated with guideline implementation, adherence and improved quality of care. We sought to determine if self-reported familiarity with acute respiratory infection (ARI) antibiotic treatment guidelines was associated with reduced or more appropriate antibiotic prescribing for ARIs in primary care. DESIGN SETTING PARTICIPANTS and MAIN OUTCOME MEASURES We surveyed primary care clinicians about their familiarity with ARI antibiotic treatment guidelines and linked responses to administrative diagnostic and prescribing data for non-pneumonia ARI visits. RESULTS Sixty-five percent of clinicians responded to the survey question about guideline familiarity. There were 208 survey respondents who had ARI patient visits during the study period. Respondents reported being 'not at all' (7%), 'somewhat' (30%), 'moderately' (45%) or 'extremely' (18%) familiar with the guidelines. After dichotomizing responses, compared with clinicians who reported being less familiar with the guidelines, clinicians who reported being more familiar with the guidelines had higher rates of antibiotic prescribing for all ARIs combined (46% versus 38%; n = 11 164; P < 0.0001), for antibiotic-appropriate diagnoses (69% versus 59%; n = 3213; P < 0.0001) and for non-antibiotic appropriate diagnoses (38% versus 28%; n = 7951; P < 0.0001). After adjusting for potential confounders, self-reported guideline familiarity was an independent predictor of increased antibiotic prescribing (odds ratio, 1.36; 95% confidence interval, 1.25-1.48). CONCLUSIONS Self-reported familiarity with an ARI antibiotic treatment guideline was, seemingly paradoxically, associated with increased antibiotic prescribing. Self-reported familiarity with guidelines should not be assumed to be associated with consistent guideline adherence or higher quality of care.
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Affiliation(s)
- Jeffrey A Linder
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA 02120, USA.
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Schnipper JL, Linder JA, Palchuk MB, Yu DT, McColgan KE, Volk LA, Tsurikova R, Melnikas AJ, Einbinder JS, Middleton B. Effects of documentation-based decision support on chronic disease management. Am J Manag Care 2010; 16:SP72-SP81. [PMID: 21314226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To evaluate whether a new documentation-based clinical decision support system (CDSS) is effective in addressing deficiencies in the care of patients with coronary artery disease (CAD) and diabetes mellitus (DM). STUDY DESIGN Controlled trial randomized by physician. METHODS We assigned primary care physicians (PCPs) in 10 ambulatory practices to usual care or the CAD/DM Smart Form for 9 months. The primary outcome was the proportion of deficiencies in care that were addressed within 30 days after a patient visit. RESULTS The Smart Form was used for 5.6% of eligible patients. In the intention-to-treat analysis, patients of intervention PCPs had a greater proportion of deficiencies addressed within 30 days of a visit compared with controls (11.4% vs 10.1%, adjusted and clustered odds ratio =1.14; 95% confidence interval, 1.02-1.28; P = .02). Differences were more pronounced in the "on-treatment" analysis: 17.0% of deficiencies were addressed after visits in which the Smart Form was used compared with 10.6% of deficiencies after visits in which it was not used (P <.001). Measures that improved included documentation of smoking status and prescription of antiplatelet agents when appropriate. CONCLUSIONS Overall use of the CAD/DM Smart Form was low, and improvements in management were modest. When used, documentation-based decision support shows promise, and future studies should focus on refining such tools, integrating them into current electronic health record platforms, and promoting their use, perhaps through organizational changes to primary care practices.
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Affiliation(s)
- Jeffrey L Schnipper
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA 02120, USA.
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Linder JA, Schnipper JL, Tsurikova R, Yu DT, Volk LA, Melnikas AJ, Palchuk MB, Olsha-Yehiav M, Middleton B. Electronic health record feedback to improve antibiotic prescribing for acute respiratory infections. Am J Manag Care 2010; 16:e311-e319. [PMID: 21322301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To examine whether the Acute Respiratory Infection (ARI) Quality Dashboard, an electronic health record (EHR)-based feedback system, changed antibiotic prescribing. STUDY DESIGN Cluster randomized, controlled trial. METHODS We randomly assigned 27 primary care practices to receive the ARI Quality Dashboard or usual care. The primary outcome was the intent-to-intervene antibiotic prescribing rate for ARI visits. We also compared antibiotic prescribing between ARI Quality Dashboard users and nonusers. RESULTS During the 9-month intervention, there was no difference between intervention and control practices in antibiotic prescribing for all ARI visits (47% vs 47%; P = .87), antibiotic-appropriate ARI visits (65% vs 64%; P = .68), or non–antibiotic-appropriate ARI visits (38% vs 40%; P = .70). Among the 258 intervention clinicians, 72 (28%) used the ARI Quality Dashboard at least once. These clinicians had a lower overall ARI antibiotic prescribing rate (42% vs 50% for nonusers; P = .02). This difference was due to less antibiotic prescribing for non-antibiotic-appropriate ARIs (32% vs 43%; P = .004), including nonstreptococcal pharyngitis (31% vs 41%; P = .01) and nonspecific upper respiratory infections (19% vs 34%; P = .01). CONCLUSIONS The ARI Quality Dashboard was not associated with an overall change in antibiotic prescribing for ARIs, although when used, it was associated with improved antibiotic prescribing. EHR-based quality reporting, as part of "meaningful use," may not improve care in the absence of other changes to primary care practice.
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Affiliation(s)
- Jeffrey A Linder
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA 02120, USA.
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Wald JS, Businger A, Gandhi TK, Grant RW, Poon EG, Schnipper JL, Volk LA, Middleton B. Implementing practice-linked pre-visit electronic journals in primary care: patient and physician use and satisfaction. J Am Med Inform Assoc 2010; 17:502-6. [PMID: 20819852 DOI: 10.1136/jamia.2009.001362] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Electronic health records (EHRs) and EHR-connected patient portals offer patient-provider collaboration tools for visit-based care. During a randomized controlled trial, primary care patients completed pre-visit electronic journals (eJournals) containing EHR-based medication, allergies, and diabetes (study arm 1) or health maintenance, personal history, and family history (study arm 2) topics to share with their provider. Assessment with surveys and usage data showed that among 2027 patients invited to complete an eJournal, 70.3% submitted one and 71.1% of submitters had one opened by their provider. Surveyed patients reported they felt more prepared for the visit (55.9%) and their provider had more accurate information about them (58.0%). More arm 1 versus arm 2 providers reported that eJournals were visit-time neutral (100% vs 53%; p<0.013), helpful to patients in visit preparation (66% vs 20%; p=0.082), and would recommend them to colleagues (78% vs 22%; p=0.0143). eJournal integration into practice warrants further study.
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Panjamapirom A, Burkhardt JH, Volk LA, Rothschild JM, Bates DW, Glandon GL, Berner ES. Physician opinions of the importance, accessibility, and quality of health information and their use of the information. AMIA Annu Symp Proc 2010; 2010:46-50. [PMID: 21346938 PMCID: PMC3041432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This study compared physicians' perceptions of the importance, accessibility, and quality of different types of patient information that could potentially be available with Health Information Exchange (HIE) with how they use patient information. The results showed that while the physicians rated the majority of 11 data types as very important, accessible, and of high quality, they regularly used only a few data types before having access to a new HIE system. The three major types of information regularly used by the physicians were diagnoses, current medication lists, and allergy information. This study provides new data about how opinions on the importance of information relate to reported information use. Our findings suggest that having important, accessible, and high quality information does not necessarily lead to routine use, but that much of the early value of HIE may lie in improving access to a few data areas.
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Linder JA, Schnipper JL, Tsurikova R, Yu T, Volk LA, Melnikas AJ, Palchuk MB, Olsha-Yehiav M, Middleton B. Documentation-based clinical decision support to improve antibiotic prescribing for acute respiratory infections in primary care: a cluster randomised controlled trial. Inform Prim Care 2010; 17:231-40. [PMID: 20359401 DOI: 10.14236/jhi.v17i4.742] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVE Clinical guidelines discourage antibiotic prescribing for many acute respiratory infections (ARIs), especially for non-antibiotic appropriate diagnoses. Electronic health record (EHR)-based clinical decision support has the potential to improve antibiotic prescribing for ARIs. METHODS We randomly assigned 27 primary care clinics to receive an EHR-integrated, documentation-based clinical decision support system for the care of patients with ARIs - the ARI Smart Form - or to offer usual care. The primary outcome was the antibiotic prescribing rate for ARIs in an intent-to-intervene analysis based on administrative diagnoses. RESULTS During the intervention period, patients made 21 961 ARI visits to study clinics. Intervention clinicians used the ARI Smart Form in 6% of 11 954 ARI visits. The antibiotic prescribing rate in the intervention clinics was 39% versus 43% in the control clinics (odds ratio (OR), 0.8; 95% confidence interval (CI), 0.6-1.2, adjusted for clustering by clinic). For antibiotic appropriate ARI diagnoses, the antibiotic prescribing rate was 54% in the intervention clinics and 59% in the control clinics (OR, 0.8; 95% CI, 0.5-1.3). For non-antibiotic appropriate diagnoses, the antibiotic prescribing rate was 32% in the intervention clinics and 34% in the control clinics (OR, 0.9; 95% CI, 0.6-1.4). When the ARI Smart Form was used, based on diagnoses entered on the form, the antibiotic prescribing rate was 49% overall, 88% for antibiotic appropriate diagnoses and 27% for non-antibiotic appropriate diagnoses. In an as-used analysis, the ARI Smart Form was associated with a lower antibiotic prescribing rate for acute bronchitis (OR, 0.5; 95% CI, 0.3-0.8). CONCLUSIONS The ARI Smart Form neither reduced overall antibiotic prescribing nor significantly improved the appropriateness of antibiotic prescribing for ARIs, but it was not widely used. When used, the ARI Smart Form may improve diagnostic accuracy compared to administrative diagnoses and may reduce antibiotic prescribing for certain diagnoses.
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Affiliation(s)
- Jeffrey A Linder
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, BC-3-2X, Boston, MA 02120, USA.
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Wright A, Soran C, Jenter CA, Volk LA, Bates DW, Simon SR. Physician attitudes toward health information exchange: results of a statewide survey. J Am Med Inform Assoc 2010; 17:66-70. [PMID: 20064804 DOI: 10.1197/jamia.m3241] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To assess physicians' attitudes toward health information exchange (HIE) and physicians' willingness to pay to participate in HIE. DESIGN We conducted a cross-sectional mail survey of 1296 licensed physicians (77% response rate) in Massachusetts in 2007. MEASUREMENTS Perceptions of the potential effects of HIE on healthcare costs, quality of care, clinicians' time, patients' privacy concerns, and willingness to pay for HIE. RESULTS After excluding 253 physicians who did not see any outpatients, we analyzed 1043 responses. Overall, 70% indicated that HIE would reduce costs, while 86% said it would improve quality and 76% believed that it would save time. On the other hand, 16% reported being very concerned about HIE's effect on privacy, while 55.0% were somewhat concerned and 29% not at all concerned. Slightly more than half of the physicians (54%) said they would be willing to pay an unspecified monthly fee to participate in HIE, but only 37% said they would be willing to pay $150 per month for it. Primary care physicians and those in larger practices tended to have more positive attitudes toward HIE. CONCLUSIONS Physicians perceive that HIE will have generally positive effects, though a considerable fraction harbor concerns about privacy. While physicians may be willing to participate in HIE, they are not consistently willing to pay to participate. HIE business models that require substantial physician subscription fees may face significant challenges.
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Affiliation(s)
- Adam Wright
- Brigham & Women's Hospital, Boston, Massachusetts 02120, USA.
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Wald JS, Grant RW, Schnipper JL, Gandhi TK, Poon EG, Businger AC, Orav EJ, Williams DH, Volk LA, Middleton B. Survey analysis of patient experience using a practice-linked PHR for type 2 diabetes mellitus. AMIA Annu Symp Proc 2009; 2009:678-682. [PMID: 20351940 PMCID: PMC2815456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Patient experience was assessed by survey as part of a large, randomized controlled trial of a secure, practice-linked personal health record called Patient Gateway at Partners HealthCare in Boston, MA. The subjects were patients with Type 2 diabetes who prepared for their upcoming primary care visit using a previsit electronic journal. The journal generated a diabetes care plan using patient chart information and patient responses to questions in preparation for a scheduled office visit. Review of 37 surveys revealed that a diabetes care plan took 5-9 minutes (modal) to be created by the patient and helped many patients to feel more prepared for their visit (60%) and give more accurate information to their provider (53%). Study limitations included small numbers of survey participants and a bias toward white, better educated patients with better controlled diabetes. Nevertheless, the electronic journal is a promising tool for visit preparation and process improvement.
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Affiliation(s)
- Jonathan S Wald
- Clinical Informatics Research and Development, Partners HealthCare; Boston, MA, USA
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Kaushal R, Bates DW, Jenter CA, Mills SA, Volk LA, Burdick E, Tripathi M, Simon SR. Imminent adopters of electronic health records in ambulatory care. Inform Prim Care 2009; 17:7-15. [PMID: 19490768 DOI: 10.14236/jhi.v17i1.709] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although evidence suggests electronic health records (EHRs) can improve quality and efficiency, provider adoption rates in the US ambulatory setting are relatively low. Prior studies have identified factors correlated with EHR use, but less is known about characteristics of physicians on the verge of adoption. OBJECTIVE To compare characteristics of physicians who are imminent adopters of EHRs with EHR users and non-users. DESIGN AND PARTICIPANTS A survey was mailed (June - November 2005) to a stratified random sample of all medical practices in Massachusetts. One physician from each practice (n=1884) was randomly selected to participate. Overall, 1345 physicians (71.4%) responded to the survey, with 1082 eligible for analysis due to exclusion criteria. 'Imminent adopters' were those planning to adopt EHRs within 12 months. MEASUREMENTS We assessed physician and practice characteristics, availability of technology, barriers to adoption or expansion of health information technology (HIT), computer proficiency, and financial considerations. RESULTS Compared to non-users, imminent adopters were younger, more experienced with technology, and more often in practices engaged in quality improvement. More imminent adopters owned or partly owned their practices (57.4%) than users (33.5%; p<0.001), but fewer imminent adopters owned their practices than non-users (65.7%; p<0.001). Additionally, more imminent adopters (26.0%) reported personal financial incentives for HIT use than users (14.8%; p<0.001) and non-users (10.8%; p<0.001). CONCLUSIONS Imminent adopters of EHRs differed from users and non-users. Financial considerations appear to play a major role in adoption decisions. Knowledge of these differences may assist policy-makers and healthcare leaders as they work to increase EHR adoption rates.
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Affiliation(s)
- Rainu Kaushal
- Department of Pediatrics, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY, USA.
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Zhou L, Soran CS, Jenter CA, Volk LA, Orav EJ, Bates DW, Simon SR. The relationship between electronic health record use and quality of care over time. J Am Med Inform Assoc 2009; 16:457-64. [PMID: 19390094 PMCID: PMC2705247 DOI: 10.1197/jamia.m3128] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 04/09/2009] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Electronic health records (EHRs) have the potential to advance the quality of care, but studies have shown mixed results. The authors sought to examine the extent of EHR usage and how the quality of care delivered in ambulatory care practices varied according to duration of EHR availability. METHODS The study linked two data sources: a statewide survey of physicians' adoption and use of EHR and claims data reflecting quality of care as indicated by physicians' performance on widely used quality measures. Using four years of measurement, we combined 18 quality measures into 6 clinical condition categories. While the survey of physicians was cross-sectional, respondents indicated the year in which they adopted EHR. In an analysis accounting for duration of EHR use, we examined the relationship between EHR adoption and quality of care. RESULTS The percent of physicians reporting adoption of EHR and availability of EHR core functions more than doubled between 2000 and 2005. Among EHR users in 2005, the average duration of EHR use was 4.8 years. For all 6 clinical conditions, there was no difference in performance between EHR users and non-users. In addition, for these 6 clinical conditions, there was no consistent pattern between length of time using an EHR and physicians performance on quality measures in both bivariate and multivariate analyses. CONCLUSIONS In this cross-sectional study, we found no association between duration of using an EHR and performance with respect to quality of care, although power was limited. Intensifying the use of key EHR features, such as clinical decision support, may be needed to realize quality improvement from EHRs. Future studies should examine the relationship between the extent to which physicians use key EHR functions and their performance on quality measures over time.
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Affiliation(s)
- Li Zhou
- Clinical Informatics Research & Development, Partners HealthCare System, Inc., Wellesley, MA, USA.
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