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Shah M, De Arrigunaga S, Forman LS, West M, Rowe SG, Mishuris RG. Cumulated time to chart closure: a novel electronic health record-derived metric associated with clinician burnout. JAMIA Open 2024; 7:ooae009. [PMID: 38333109 PMCID: PMC10852987 DOI: 10.1093/jamiaopen/ooae009] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/02/2024] [Indexed: 02/10/2024] Open
Abstract
Objective We sought to determine whether average cumulated time to chart closure (CTCC), a novel construct to measure clinician workload burden, and electronic health record (EHR) measures were associated with a validated measure of burnout. Materials and methods Physicians at a large academic institution participated in a well-being survey that was linked to their EHR use data. CTCC was defined as the average time from the start of patient encounters to chart closure over a set of encounters. Established EHR use measures including daily total time in the EHR (EHR-Time8), time in the EHR outside scheduled hours, work outside of work (WOW8), and time spent on inbox (IB-Time8) were calculated. We examined the relationship between CTCC, EHR use metrics, and burnout using descriptive statistics and adjusted logistic regression models. Results We included data from 305 attendings, encompassing 242 432 ambulatory encounters (2021). Among them, 42% (128 physicians) experienced burnout. The median CTCC for all clinicians was 32.5 h. Unadjusted analyses revealed significant associations between CTCC, WOW8, IB-Time8, and burnout. In a final adjusted model, only CTCC remained statistically significant with an odds ratio estimate of 1.42 (95% CI, 1.00-2.01). Discussion These results suggest that CTCC is predictive of burnout and that purely measuring duration of interaction with the EHR itself is not sufficient to capture burnout. Conclusion Workload burden as manifested by average CTCC has the potential to be a practical, quantifiable measure that will allow for identification of clinicians at risk of burnout and to assess the success of interventions designed to address burnout.
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Affiliation(s)
- Madhura Shah
- Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, Boston, MA 02118, United States
| | - Sofia De Arrigunaga
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Medical School, Miami, FL 33136, United States
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA 02118, United States
| | - Matthew West
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, United States
| | - Susannah G Rowe
- Office of Equity, Vitality and Inclusion, Boston University Medical Group, Boston, MA 02118, United States
- Wellness and Professional Vitality, Boston Medical Center, Boston, MA 02118, United States
- Department of Ophthalmology, Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, Boston, MA 02118, United States
| | - Rebecca G Mishuris
- Digital, Mass General Brigham, Somerville, MA 02145, United States
- Department of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA 02115, United States
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Tang M, Mishuris RG, Payvandi L, Stern AD. Differences in Care Team Response to Patient Portal Messages by Patient Race and Ethnicity. JAMA Netw Open 2024; 7:e242618. [PMID: 38497963 PMCID: PMC10949096 DOI: 10.1001/jamanetworkopen.2024.2618] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/24/2024] [Indexed: 03/19/2024] Open
Abstract
Importance The COVID-19 pandemic was associated with substantial growth in patient portal messaging. Higher message volumes have largely persisted, reflecting a new normal. Prior work has documented lower message use by patients who belong to minoritized racial and ethnic groups, but research has not examined differences in care team response to messages. Both have substantial ramifications on resource allocation and care access under a new care paradigm with portal messaging as a central channel for patient-care team communication. Objective To examine differences in how care teams respond to patient portal messages sent by patients from different racial and ethnic groups. Design, Setting, and Participants In a cross-sectional design in a large safety-net health system, response outcomes from medical advice message threads sent from January 1, 2021, through November 24, 2021, from Asian, Black, Hispanic, and White patients were compared, controlling for patient and message thread characteristics. Asian, Black, Hispanic, and White patients with 1 or more adult primary care visits at Boston Medical Center in calendar year 2020 were included. Data analysis was conducted from June 23, 2022, through December 21, 2023. Exposure Patient race and ethnicity. Main Outcomes and Measures Rates at which medical advice request messages were responded to by care teams and the types of health care professionals that responded. Results A total of 39 043 patients were included in the sample: 2006 were Asian, 21 600 were Black, 7185 were Hispanic, and 8252 were White. A total of 22 744 (58.3%) patients were women and mean (SD) age was 50.4 (16.7) years. In 2021, these patients initiated 57 704 medical advice request message threads. When patients who belong to minoritized racial and ethnic groups sent these messages, the likelihood of receiving any care team response was similar, but the types of health care professionals that responded differed. Black patients were 3.95 percentage points (pp) less likely (95% CI, -5.34 to -2.57 pp; P < .001) to receive a response from an attending physician, and 3.01 pp more likely (95% CI, 1.76-4.27 pp; P < .001) to receive a response from a registered nurse, corresponding to a 17.4% lower attending response rate. Similar, but smaller, differences were observed for Asian and Hispanic patients. Conclusions and Relevance The findings of this study suggest lower prioritization of patients who belong to minoritized racial and ethnic groups during triaging. Understanding and addressing these disparities will be important for improving care equity and informing health care delivery support algorithms.
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Affiliation(s)
- Mitchell Tang
- Harvard Graduate School of Arts and Sciences, Cambridge, Massachusetts
- Harvard Business School, Boston, Massachusetts
| | - Rebecca G. Mishuris
- Digital, Mass General Brigham, Somerville, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lily Payvandi
- Department of Family Medicine, Boston Medical Center, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Ariel D. Stern
- Harvard Business School, Boston, Massachusetts
- Harvard-MIT Center for Regulatory Science, Boston, Massachusetts
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Levy DR, Moy AJ, Apathy N, Adler-Milstein J, Rotenstein L, Nath B, Rosenbloom ST, Kannampallil T, Mishuris RG, Alexanian A, Sieja A, Hribar MR, Patel JS, Sinsky CA, Melnick ER. Identifying and Addressing Barriers to Implementing Core Electronic Health Record Use Metrics for Ambulatory Care: Virtual Consensus Conference Proceedings. Appl Clin Inform 2023; 14:944-950. [PMID: 37802122 PMCID: PMC10686750 DOI: 10.1055/a-2187-3243] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023] Open
Abstract
Precise, reliable, valid metrics that are cost-effective and require reasonable implementation time and effort are needed to drive electronic health record (EHR) improvements and decrease EHR burden. Differences exist between research and vendor definitions of metrics. PROCESS: We convened three stakeholder groups (health system informatics leaders, EHR vendor representatives, and researchers) in a virtual workshop series to achieve consensus on barriers, solutions, and next steps to implementing the core EHR use metrics in ambulatory care. CONCLUSION: Actionable solutions identified to address core categories of EHR metric implementation challenges include: (1) maintaining broad stakeholder engagement, (2) reaching agreement on standardized measure definitions across vendors, (3) integrating clinician perspectives, and (4) addressing cognitive and EHR burden. Building upon the momentum of this workshop's outputs offers promise for overcoming barriers to implementing EHR use metrics.
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Affiliation(s)
- Deborah R Levy
- Department of Veterans Affairs, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Section of Biomedical Informatics and Data Sciences, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Amanda J Moy
- Department of Biomedical Informatics, Columbia University, New York, New York, United States
| | - Nate Apathy
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Iowa, United States
| | - Julia Adler-Milstein
- Department of Medicine, Center for Clinical Informatics and Improvement Research, University of California, San Francisco, California, United States
| | - Lisa Rotenstein
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
| | - S Trent Rosenbloom
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, United States
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, United States
- Institute for Informatics, Data Science, and Biostatistics (I2DB), Washington University School of Medicine, St. Louis, Missouri, United States
| | - Rebecca G Mishuris
- Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
- Digital, Mass General Brigham, Boston, Massachusetts, United States
| | | | - Amber Sieja
- Department of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Michelle R Hribar
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, United States
| | - Jigar S Patel
- Oracle Corporation, Kansas City, Missouri, United States
| | | | - Edward R Melnick
- Section of Biomedical Informatics and Data Sciences, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
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You JG, Samal L, Leung TI, Dharod A, Zhang HM, Kaelber DC, Mishuris RG. A Call to Support Informatics Curricula in U.S.-Based Residency Education. Appl Clin Inform 2023; 14:992-995. [PMID: 37879358 PMCID: PMC10733056 DOI: 10.1055/a-2198-7788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/23/2023] [Indexed: 10/27/2023] Open
Affiliation(s)
- Jacqueline G. You
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, United States
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Lipika Samal
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Tiffany I. Leung
- Department of Internal Medicine (adjunct), Southern Illinois University School of Medicine, Springfield, Illinois, United States
- Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Ajay Dharod
- Department of Internal Medicine, Wake Forest School of Medicine, Informatics and Analytics, Winston Salem, North Carolina, United States
- Department of Internal Medicine, Wake Forest School of Medicine, Section on General Internal Medicine, Winston Salem, North Carolina, United States
| | - Haipeng M. Zhang
- Department of Psychosocial Oncology and Palliative Care, Division of Adult Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - David C. Kaelber
- Department of Internal Medicine, Pediatrics and Population, and Quantitative Health Sciences, The Center for Clinical Informatics Research and Education, MetroHealth System, Case Western Reserve University, Cleveland, Ohio, United States
| | - Rebecca G. Mishuris
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Digital, Mass General Brigham, Somerville, Massachusetts, United States
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Chen A, Ayub MH, Mishuris RG, Rodriguez JA, Gwynn K, Lo MC, Noronha C, Henry TL, Jones D, Lee WW, Varma M, Cuevas E, Onumah C, Gupta R, Goodson J, Lu AD, Syed Q, Suen LW, Heiman E, Salhi BA, Khoong EC, Schmidt S. Telehealth Policy, Practice, and Education: a Position Statement of the Society of General Internal Medicine. J Gen Intern Med 2023; 38:2613-2620. [PMID: 37095331 PMCID: PMC10124932 DOI: 10.1007/s11606-023-08190-8] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/23/2023] [Indexed: 04/26/2023]
Abstract
Telehealth services, specifically telemedicine audio-video and audio-only patient encounters, expanded dramatically during the COVID-19 pandemic through temporary waivers and flexibilities tied to the public health emergency. Early studies demonstrate significant potential to advance the quintuple aim (patient experience, health outcomes, cost, clinician well-being, and equity). Supported well, telemedicine can particularly improve patient satisfaction, health outcomes, and equity. Implemented poorly, telemedicine can facilitate unsafe care, worsen disparities, and waste resources. Without further action from lawmakers and agencies, payment will end for many telemedicine services currently used by millions of Americans at the end of 2024. Policymakers, health systems, clinicians, and educators must decide how to support, implement, and sustain telemedicine, and long-term studies and clinical practice guidelines are emerging to provide direction. In this position statement, we use clinical vignettes to review relevant literature and highlight where key actions are needed. These include areas where telemedicine must be expanded (e.g., to support chronic disease management) and where guidelines are needed (e.g., to prevent inequitable offering of telemedicine services and prevent unsafe or low-value care). We provide policy, clinical practice, and education recommendations for telemedicine on behalf of the Society of General Internal Medicine. Policy recommendations include ending geographic and site restrictions, expanding the definition of telemedicine to include audio-only services, establishing appropriate telemedicine service codes, and expanding broadband access to all Americans. Clinical practice recommendations include ensuring appropriate telemedicine use (for limited acute care situations or in conjunction with in-person services to extend longitudinal care relationships), that the choice of modality be done through patient-clinician shared decision-making, and that health systems design telemedicine services through community partnerships to ensure equitable implementation. Education recommendations include developing telemedicine-specific educational strategies for trainees that align with accreditation body competencies and providing educators with protected time and faculty development resources.
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Affiliation(s)
- Anders Chen
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Box 356421, Seattle, WA, 98195, USA.
| | - Mariam H Ayub
- Division of General Internal Medicine, MedStar Georgetown University Hospital, Georgetown University Medical Center, Washington, DC, USA
| | - Rebecca G Mishuris
- Digital, Mass General Brigham, Somerville, MA, USA
- Division of General Internal Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Jorge A Rodriguez
- Division of General Internal Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Kendrick Gwynn
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Baltimore, MD, USA
| | - Margaret C Lo
- Division of General Internal Medicine, Department of Medicine, University of Florida College of Medicine, Malcom Randall VAMC, Gainesville, FL, USA
| | - Craig Noronha
- Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Tracey L Henry
- Division of General Internal Medicine, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Danielle Jones
- Division of General Internal Medicine, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Wei Wei Lee
- Section of General Internal Medicine, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Malvika Varma
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- New England VA GRECC, Boston VA Medical Center, Boston, MA, USA
| | - Elizabeth Cuevas
- Division of Academic Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Chavon Onumah
- Division or General Internal Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Reena Gupta
- Division of General Internal Medicine at San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - John Goodson
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy D Lu
- Division of General Internal Medicine, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Quratulain Syed
- Birmingham-Atlanta VA GRECC, Atlanta VA Medical Center, Atlanta, GA, USA
| | - Leslie W Suen
- Division of General Internal Medicine at San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Erica Heiman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Bisan A Salhi
- Department of Emergency Medicine, Drexel University College of Medicine, Reading, PA, USA
| | - Elaine C Khoong
- Division of General Internal Medicine at San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Stacie Schmidt
- Division of General Internal Medicine, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
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Hu Y, Huerta J, Cordella N, Mishuris RG, Paschalidis IC. Personalized hypertension treatment recommendations by a data-driven model. BMC Med Inform Decis Mak 2023; 23:44. [PMID: 36859187 PMCID: PMC9979505 DOI: 10.1186/s12911-023-02137-z] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 02/09/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Hypertension is a prevalent cardiovascular disease with severe longer-term implications. Conventional management based on clinical guidelines does not facilitate personalized treatment that accounts for a richer set of patient characteristics. METHODS Records from 1/1/2012 to 1/1/2020 at the Boston Medical Center were used, selecting patients with either a hypertension diagnosis or meeting diagnostic criteria (≥ 130 mmHg systolic or ≥ 90 mmHg diastolic, n = 42,752). Models were developed to recommend a class of antihypertensive medications for each patient based on their characteristics. Regression immunized against outliers was combined with a nearest neighbor approach to associate with each patient an affinity group of other patients. This group was then used to make predictions of future Systolic Blood Pressure (SBP) under each prescription type. For each patient, we leveraged these predictions to select the class of medication that minimized their future predicted SBP. RESULTS The proposed model, built with a distributionally robust learning procedure, leads to a reduction of 14.28 mmHg in SBP, on average. This reduction is 70.30% larger than the reduction achieved by the standard-of-care and 7.08% better than the corresponding reduction achieved by the 2nd best model which uses ordinary least squares regression. All derived models outperform following the previous prescription or the current ground truth prescription in the record. We randomly sampled and manually reviewed 350 patient records; 87.71% of these model-generated prescription recommendations passed a sanity check by clinicians. CONCLUSION Our data-driven approach for personalized hypertension treatment yielded significant improvement compared to the standard-of-care. The model implied potential benefits of computationally deprescribing and can support situations with clinical equipoise.
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Affiliation(s)
- Yang Hu
- Department of Electrical and Computer Engineering, Division of Systems Engineering, Boston University, 8 Saint Mary's St., Boston, MA, 02215, USA
| | - Jasmine Huerta
- Department of Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, MA, USA
| | - Nicholas Cordella
- Department of Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, MA, USA
| | - Rebecca G Mishuris
- Department of Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, MA, USA
| | - Ioannis Ch Paschalidis
- Department of Electrical and Computer Engineering, Division of Systems Engineering, Boston University, 8 Saint Mary's St., Boston, MA, 02215, USA.
- Department of Biomedical Engineering, Faculty of Computing & Data Sciences, Hariri Institute for Computing and Computational Science & Engineering, Boston University, 8 Saint Mary's St., Boston, MA, 02215, USA.
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Levy DR, Sloss EA, Chartash D, Corley ST, Mishuris RG, Rosenbloom ST, Tiase VL. Reflections on the Documentation Burden Reduction AMIA Plenary Session through the Lens of 25 × 5. Appl Clin Inform 2023; 14:11-15. [PMID: 36356593 PMCID: PMC9812582 DOI: 10.1055/a-1976-2052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/06/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Deborah R. Levy
- Department of Veterans Affairs, Pain Research, Multimorbidities, and Education (PRIME) Center, VA-Connecticut, United States
- Yale University School of Medicine, New Haven, Connecticut, United States
| | - Elizabeth A. Sloss
- College of Nursing, University of Utah, Salt Lake City, Utah, United States
| | - David Chartash
- Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Sarah T. Corley
- MITRE Corporation, Center for Government Effectiveness and Modernization, Center Office, McLean, Virginia, United States
| | - Rebecca G. Mishuris
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States
| | - S. Trent Rosenbloom
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Victoria L. Tiase
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States
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Hao B, Hu Y, Sotudian S, Zad Z, Adams WG, Assoumou SA, Hsu H, Mishuris RG, Paschalidis IC. OUP accepted manuscript. J Am Med Inform Assoc 2022; 29:1253-1262. [PMID: 35441692 PMCID: PMC9129120 DOI: 10.1093/jamia/ocac062] [Citation(s) in RCA: 6] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/13/2022] [Accepted: 04/14/2022] [Indexed: 01/08/2023] Open
Abstract
Objective To develop predictive models of coronavirus disease 2019 (COVID-19) outcomes, elucidate the influence of socioeconomic factors, and assess algorithmic racial fairness using a racially diverse patient population with high social needs. Materials and Methods Data included 7,102 patients with positive (RT-PCR) severe acute respiratory syndrome coronavirus 2 test at a safety-net system in Massachusetts. Linear and nonlinear classification methods were applied. A score based on a recurrent neural network and a transformer architecture was developed to capture the dynamic evolution of vital signs. Combined with patient characteristics, clinical variables, and hospital occupancy measures, this dynamic vital score was used to train predictive models. Results Hospitalizations can be predicted with an area under the receiver-operating characteristic curve (AUC) of 92% using symptoms, hospital occupancy, and patient characteristics, including social determinants of health. Parsimonious models to predict intensive care, mechanical ventilation, and mortality that used the most recent labs and vitals exhibited AUCs of 92.7%, 91.2%, and 94%, respectively. Early predictive models, using labs and vital signs closer to admission had AUCs of 81.1%, 84.9%, and 92%, respectively. Discussion The most accurate models exhibit racial bias, being more likely to falsely predict that Black patients will be hospitalized. Models that are only based on the dynamic vital score exhibited accuracies close to the best parsimonious models, although the latter also used laboratories. Conclusions This large study demonstrates that COVID-19 severity may accurately be predicted using a score that accounts for the dynamic evolution of vital signs. Further, race, social determinants of health, and hospital occupancy play an important role.
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Affiliation(s)
- Boran Hao
- Center for Information and Systems Engineering, Boston University, Boston, Massachusetts, USA
- Department of Electrical and Computer Engineering, Boston University, Boston, Massachusetts, USA
| | - Yang Hu
- Center for Information and Systems Engineering, Boston University, Boston, Massachusetts, USA
- Department of Electrical and Computer Engineering, Boston University, Boston, Massachusetts, USA
| | - Shahabeddin Sotudian
- Center for Information and Systems Engineering, Boston University, Boston, Massachusetts, USA
- Division of Systems Engineering, Boston University, Boston, Massachusetts, USA
| | - Zahra Zad
- Center for Information and Systems Engineering, Boston University, Boston, Massachusetts, USA
- Division of Systems Engineering, Boston University, Boston, Massachusetts, USA
| | - William G Adams
- Department of Pediatrics, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sabrina A Assoumou
- Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Heather Hsu
- Department of Pediatrics, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Rebecca G Mishuris
- Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ioannis C Paschalidis
- Corresponding Author: Ioannis C. Paschalidis, Division of Systems Engineering, Department of Electrical and Computer Engineering, Department of Biomedical Engineering, and Faculty of Computing & Data Sciences, Boston University, 8 Saint Mary’s St., Boston, MA 02215, USA; http://sites.bu.edu/paschalidis
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Kathuria H, Herbst N, Seth B, Clark K, Helm ED, Zhang M, O’Donnell C, Fitzgerald C, Itchapurapu IS, Waite M, Wong C, Swamy L, Olson J, Mishuris RG, Wiener RS. Rapid Cycle Evaluation and Adaptation of an Inpatient Tobacco Treatment Service at a U.S. Safety-Net Hospital. Implementation Research and Practice 2021; 2:26334895211041295. [PMID: 37089992 PMCID: PMC9981890 DOI: 10.1177/26334895211041295] [Citation(s) in RCA: 1] [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] [Indexed: 12/21/2022] Open
Abstract
Background To address disparities in smoking rates, our safety-net hospital implemented an inpatient tobacco treatment intervention: an “opt-out” electronic health record (EHR)-based Best Practice Alert + order-set, which triggers consultation to a Tobacco Treatment Consult (TTC) service for all hospitalized patients who smoke cigarettes. We report on development, implementation, and adaptation of the intervention, informed by a pre-implementation needs assessment and two rapid-cycle evaluations guided by the Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementing Change (ERIC) compilation. Methods We identified stakeholders affected by implementation and conducted a local needs assessment starting 6 months-pre-launch. We then conducted two rapid-cycle evaluations during the first 6 months post-implementation. The CFIR informed survey and interview guide development, data collection, assessment of barriers and facilitators, and selection of ERIC strategies to implement and adapt the intervention. Results Key themes were: (1) Understanding the hospital's priority to improving tobacco performance metrics was critical in gaining leadership buy-in (CFIR Domain: Outer setting; Construct: External Policy and Incentives). (2) CFIR-based rapid-cycle evaluations allowed us to recognize implementation challenges early and select ERIC strategies clustering into 3 broad categories (conducting needs assessment; developing stakeholder relationships; training and educating stakeholders) to make real-time adaptations, creating an acceptable clinical workflow. (3) Minimizing clinician burden allowed the successful implementation of the TTC service. (4) Demonstrating improved 6-month quit rates and tobacco performance metrics were key to sustaining the program. Conclusions Rapid-cycle evaluations to gather pre-implementation and early-implementation data, focusing on modifiable barriers and facilitators, allowed us to develop and refine the intervention to improve acceptability, adoption, and sustainability, enabling us to improve tobacco performance metrics in a short timeline. Future directions include spreading rapid-cycle evaluations to promote implementation of inpatient tobacco treatment programs to other settings and assessing long-term sustainability and return on investment of these programs.
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Affiliation(s)
- Hasmeena Kathuria
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Nicole Herbst
- Division of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Bhavna Seth
- Division of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Kristopher Clark
- Division of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Eric D. Helm
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Michelle Zhang
- Division of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Charles O’Donnell
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Carmel Fitzgerald
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | | | - Meg Waite
- Analytics and Public Reporting, Boston Medical Center, Boston, MA, USA
| | - Carolina Wong
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Lakshmana Swamy
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Jen Olson
- Epic Patient Access Systems, ITS, Boston Medical Center, Boston, MA, USA
| | - Rebecca G. Mishuris
- Division of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Renda Soylemez Wiener
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA, USA
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10
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Hsu HE, Ashe EM, Silverstein M, Hofman M, Lange SJ, Razzaghi H, Mishuris RG, Davidoff R, Parker EM, Penman-Aguilar A, Clarke KEN, Goldman A, James TL, Jacobson K, Lasser KE, Xuan Z, Peacock G, Dowling NF, Goodman AB. Race/Ethnicity, Underlying Medical Conditions, Homelessness, and Hospitalization Status of Adult Patients with COVID-19 at an Urban Safety-Net Medical Center - Boston, Massachusetts, 2020. MMWR Morb Mortal Wkly Rep 2020; 69:864-869. [PMID: 32644981 PMCID: PMC7727597 DOI: 10.15585/mmwr.mm6927a3] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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11
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Herbst N, Wiener RS, Helm ED, O'Donnell C, Fitzgerald C, Wong C, Bulekova K, Waite M, Mishuris RG, Kathuria H. Effectiveness of an Opt-Out Electronic Heath Record-Based Tobacco Treatment Consult Service at an Urban Safety Net Hospital. Chest 2020; 158:1734-1741. [PMID: 32428510 DOI: 10.1016/j.chest.2020.04.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 10/31/2019] [Revised: 04/06/2020] [Accepted: 04/17/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND To address the burden of tobacco use in underserved populations, our safety net hospital developed a tobacco treatment intervention consisting of an "opt-out" electronic health record-based best practice alert + order set, which triggers consultation to an inpatient tobacco treatment consult (TTC) service for all hospitalized smokers. RESEARCH QUESTION We sought to understand if the intervention would increase patient-level outcomes (receipt of tobacco treatment during hospitalization and at discharge; 6-month smoking abstinence) and improve hospital-wide performance on tobacco treatment metrics. DESIGN AND METHODS We conducted two retrospective quasi-experimental analyses to examine effectiveness of the TTC service. Using a pragmatic design and multivariable logistic regression, we compared patient-level outcomes of receipt of nicotine replacement therapy and 6-month quit rates between smokers seen by the service (n = 505) and eligible smokers not seen because of time constraints (n = 680) between July 2016 and December 2016. In addition, we conducted an interrupted time series analysis to examine the effect of the TTC service on hospital-level performance measures, comparing reported Joint Commission measure rates for inpatient (Tob-2) and postdischarge (Tob-3) tobacco treatment preimplementation (January 2015-June 2016) vs postimplementation (July 2016-December 2017) of the intervention. RESULTS Compared with inpatient smokers not seen by the TTC service, smokers seen by the TTC service had higher odds of receiving nicotine replacement during hospitalization (260 of 505 [51.5%] vs 244 of 680 [35.9%]; adjusted ORs [AOR], 1.93 [95% CI, 1.5-2.45]) and at discharge (164 of 505 [32.5%] vs 84 of 680 [12.4%]; AOR, 3.41 [95% CI, 2.54-4.61]), as well as higher odds of 6-month smoking abstinence (75 of 505 [14.9%] vs 68 of 680 [10%]; AOR, 1.48 [95% CI, 1.03-2.12]). Hospital-wide, the intervention was associated with a change in slope trends for Tob-3 (P < .01), but not for Tob-2. INTERPRETATION The "opt-out" electronic health record-based TTC service at our large safety net hospital was effective at improving both patient-level outcomes and hospital-level performance metrics, and could be implemented at other safety net hospitals that care for hard-to-reach smokers.
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Affiliation(s)
- Nicole Herbst
- Division of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Renda Soylemez Wiener
- Pulmonary Center, Boston University School of Medicine, Boston, MA; Center for Healthcare Organization and Implementation Research, ENRM VA Hospital, Bedford, MA
| | - Eric D Helm
- Pulmonary Center, Boston University School of Medicine, Boston, MA
| | | | | | - Carolina Wong
- Pulmonary Center, Boston University School of Medicine, Boston, MA
| | - Katia Bulekova
- Research Computing Services Group, Information Services and Technology, Boston University, Boston, MA
| | - Meg Waite
- Analytics and Public Reporting, Boston Medical Center, Boston, MA
| | - Rebecca G Mishuris
- Division of General Internal Medicine, Boston University School of Medicine, Boston, MA
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12
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Mishuris RG, Palmisano J, McCullagh L, Hess R, Feldstein DA, Smith PD, McGinn T, Mann DM. Using normalisation process theory to understand workflow implications of decision support implementation across diverse primary care settings. BMJ Health Care Inform 2019; 26:bmjhci-2019-100088. [PMID: 31630113 PMCID: PMC7062348 DOI: 10.1136/bmjhci-2019-100088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Effective implementation of technologies into clinical workflow is hampered by lack of integration into daily activities. Normalisation process theory (NPT) can be used to describe the kinds of 'work' necessary to implement and embed complex new practices. We determined the suitability of NPT to assess the facilitators, barriers and 'work' of implementation of two clinical decision support (CDS) tools across diverse care settings. METHODS We conducted baseline and 6-month follow-up quantitative surveys of clinic leadership at two academic institutions' primary care clinics randomised to the intervention arm of a larger study. The survey was adapted from the NPT toolkit, analysing four implementation domains: sense-making, participation, action, monitoring. Domains were summarised among completed responses (n=60) and examined by role, institution, and time. RESULTS The median score for each NPT domain was the same across roles and institutions at baseline, and decreased at 6 months. At 6 months, clinic managers' participation domain (p=0.003), and all domains for medical directors (p<0.003) declined. At 6 months, the action domain decreased among Utah respondents (p=0.03), and all domains decreased among Wisconsin respondents (p≤0.008). CONCLUSIONS This study employed NPT to longitudinally assess the implementation barriers of new CDS. The consistency of results across participant roles suggests similarities in the work each role took on during implementation. The decline in engagement over time suggests the need for more frequent contact to maintain momentum. Using NPT to evaluate this implementation provides insight into domains which can be addressed with participants to improve success of new electronic health record technologies. TRIAL REGISTRATION NUMBER NCT02534987.
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Affiliation(s)
| | - Joseph Palmisano
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Lauren McCullagh
- Northwell Health and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Rachel Hess
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - David A Feldstein
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Paul D Smith
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Thomas McGinn
- Northwell Health and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Devin M Mann
- New York University School of Medicine, New York City, New York, USA
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13
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Delitto A, Patterson CG, Stevans JM, Brennan GP, Wegener ST, Morrisette DC, Beneciuk JM, Freel JA, Minick KI, Hunter SJ, Ephraim PL, Friedman M, Simpson KN, George SZ, Daley KN, Albert MC, Tamasy M, Cash J, Lake DS, Freburger JK, Greco CM, Hough LJ, Jeong JH, Khoja SS, Schneider MJ, Sowa GA, Spigle WA, Wasan AD, Adams WG, Lemaster CM, Mishuris RG, Plumb DL, Williams CT, Saper RB. Study protocol for targeted interventions to prevent chronic low back pain in high-risk patients: A multi-site pragmatic cluster randomized controlled trial (TARGET Trial). Contemp Clin Trials 2019; 82:66-76. [PMID: 31136834 DOI: 10.1016/j.cct.2019.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 01/23/2019] [Revised: 05/16/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Low back pain (LBP) is one of the most prevalent and potentially disabling conditions for which people seek health care. Patients, providers, and payers agree that greater effort is needed to prevent acute LBP from transitioning to chronic LBP. METHODS AND STUDY DESIGN The TARGET (Targeted Interventions to Prevent Chronic Low Back Pain in High-Risk Patients) Trial is a primary care-based, multisite, cluster randomized, pragmatic trial comparing guideline-based care (GBC) to GBC + referral to Psychologically Informed Physical Therapy (PIPT) for patients presenting with acute LBP and identified as high risk for persistent disabling symptoms. Study sites include primary care clinics within each of five geographical regions in the United States, with clinics randomized to either GBC or GBC + PIPT. Acute LBP patients at all clinics are risk stratified (high, medium, low) using the STarT Back Tool. The primary outcomes are the presence of chronic LBP and LBP-related functional disability determined by the Oswestry Disability Index at 6 months. Secondary outcomes are LBP-related processes of health care and utilization of services over 12 months, determined through electronic medical records. Study enrollment began in May 2016 and concluded in June 2018. The trial was powered to include at least 1860 high-risk patients in the randomized controlled trial cohort. A prospective observational cohort of approximately 6900 low and medium-risk acute LBP patients was enrolled concurrently. DISCUSSION The TARGET pragmatic trial aims to establish the effectiveness of the stratified approach to acute LBP intervention targeting high-risk patients with GBC and PIPT. TRIAL REGISTRATION ClinicalTrials.govNCT02647658 Registered Jan. 6, 2016.
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Affiliation(s)
- Anthony Delitto
- School of Health and Rehabilitation Sciences (SHRS), University of Pittsburgh, 4028 Forbes Tower, Pittsburgh, PA 15260, USA.
| | - Charity G Patterson
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Joel M Stevans
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Gerard P Brennan
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Stephen T Wegener
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - David C Morrisette
- Division of Physical Therapy, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Jason M Beneciuk
- Department of Physical Therapy, College of Public Health & Health Professions, University of Florida, Box 100154, UFHSC, Gainesville, FL 32610, USA
| | - Jennifer A Freel
- Wolff Center at UPMC, 4601 Baum Blvd, Suite 228, Pittsburgh, PA 15213, USA
| | - Kate I Minick
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Stephen J Hunter
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Patti L Ephraim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E Monument Street, Baltimore, MD 21287, USA
| | - Michael Friedman
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Kit N Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Steven Z George
- Duke Clinical Research Institute and Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27705, USA
| | - Kelly N Daley
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Michael C Albert
- Johns Hopkins Community Physicians, 6225 Smith Avenue, Baltimore, MD 21209, USA
| | - Marie Tamasy
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Jewel Cash
- Boston Medical Center, Boston, MA 02118, USA
| | - D Scott Lake
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Janet K Freburger
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Carol M Greco
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
| | - Linda J Hough
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Jong-Hyeon Jeong
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, 130 De Soto Street, Pittsburgh, PA 15261, USA
| | - Samannaaz S Khoja
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Michael J Schneider
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Gwendolyn A Sowa
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 Fifth Avenue, Suite 1103, Pittsburgh, PA 15213, USA
| | - Wendy A Spigle
- Wolff Center at UPMC, 4601 Baum Blvd, Suite 228, Pittsburgh, PA 15213, USA
| | - Ajay D Wasan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | - William G Adams
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Chelsey M Lemaster
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Rebecca G Mishuris
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Dorothy L Plumb
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Charles T Williams
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Robert B Saper
- Department of Family Medicine, Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
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Abstract
Problem-oriented charting is form of medical documentation that organizes patient data by a diagnosis or problem. In this review, we discuss the history and current use of problem-oriented charting by critically evaluating the literature on the topic. We provide insights with regard to our own institutional use of problem-oriented charting and potential opportunities for research.
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Affiliation(s)
- Shilpa M Chowdhry
- Department of Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, United States.
| | - Rebecca G Mishuris
- Department of Medicine. Boston University School of Medicine, United States
| | - Devin Mann
- Department of Population Health. NYU School of Medicine, United States
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15
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Feldstein DA, Hess R, McGinn T, Mishuris RG, McCullagh L, Smith PD, Flynn M, Palmisano J, Doros G, Mann D. Design and implementation of electronic health record integrated clinical prediction rules (iCPR): a randomized trial in diverse primary care settings. Implement Sci 2017; 12:37. [PMID: 28292304 PMCID: PMC5351194 DOI: 10.1186/s13012-017-0567-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 03/06/2017] [Indexed: 11/24/2022] Open
Abstract
Background Clinical prediction rules (CPRs) represent a method of determining individual patient risk to help providers make more accurate decisions at the point of care. Well-validated CPRs are underutilized but may decrease antibiotic overuse for acute respiratory infections. The integrated clinical prediction rules (iCPR) study builds on a previous single clinic study to integrate two CPRs into the electronic health record and assess their impact on practice. This article discusses study design and implementation of a multicenter cluster randomized control trial of the iCPR clinical decision support system, including the tool adaptation, usability testing, staff training, and implementation study to disseminate iCPR at multiple clinical sites across two health care systems. Methods The iCPR tool is based on two well-validated CPRs, one for strep pharyngitis and one for pneumonia. The iCPR tool uses the reason for visit to trigger a risk calculator. Provider completion of the risk calculator provides a risk score, which is linked to an order set. Order sets guide evidence-based care and include progress note documentation, tests, prescription medications, and patient instructions. The iCPR tool was refined based on interviews with providers, medical assistants, and clinic managers, and two rounds of usability testing. “Near live” usability testing with simulated patients was used to ensure that iCPR fit into providers’ clinical workflows. Thirty-three Family Medicine and General Internal Medicine primary care clinics were recruited at two institutions. Clinics were randomized to academic detailing about strep pharyngitis and pneumonia diagnosis and treatment (control) or academic detailing plus use of the iCPR tool (intervention). The primary outcome is the difference in antibiotic prescribing rates between the intervention and control groups with secondary outcomes of difference in rapid strep and chest x-ray ordering. Use of the components of the iCPR will also be assessed. Discussion The iCPR study uses a strong user-centered design and builds on the previous initial study, to assess whether CPRs integrated in the electronic health record can change provider behavior and improve evidence-based care in a broad range of primary care clinics. Trial registration Clinicaltrials.gov (NCT02534987)
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Affiliation(s)
- David A Feldstein
- Division of General Internal Medicine, University of Wisconsin School of Medicine and Public Health, 2828 Marshall Court, Suite 100, Madison, WI, 53705, USA.
| | - Rachel Hess
- Division of Health System Innovation and Research, University of Utah School of Medicine, Williams Building, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Thomas McGinn
- Department of Medicine, Hofstra Northwell School of Medicine, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Rebecca G Mishuris
- Department of Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown 2, Boston, MA, 02118, USA
| | - Lauren McCullagh
- Department of Medicine, Hofstra Northwell School of Medicine, 600 Community Drive, Suite 300, Manhasset, NY, 11030, USA
| | - Paul D Smith
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, 1100 Delaplaine Court, Madison, WI, 53715, USA
| | - Michael Flynn
- Westridge Health Center, University of Utah School of Medicine, 3730 West 4700 South, West Valley City, UT, 84118, USA
| | - Joseph Palmisano
- Boston University School of Public Health, Fuller Building M-900C, Boston, MA, 02118, USA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University School of Public Health, Crosstown Center-CT331, Boston, MA, 02118, USA
| | - Devin Mann
- Department of Medicine, New York University School of Medicine, 227 East 30th St. 7th floor, New York, NY, 10016, USA
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16
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Freund KM, Isabelle AP, Hanchate AD, Kalish RL, Kapoor A, Bak S, Mishuris RG, Shroff SM, Battaglia TA. The impact of health insurance reform on insurance instability. J Health Care Poor Underserved 2015; 25:95-108. [PMID: 24583490 DOI: 10.1353/hpu.2014.0061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We investigated the impact of the 2006 Massachusetts health care reform on insurance coverage and stability among minority and underserved women. We examined 36 months of insurance claims among 1,946 women who had abnormal cancer screening at six community health centers pre-(2004-2005) and post-(2007-2008) insurance reform. We examined frequency of switches in insurance coverage as measures of longitudinal insurance instability. On the date of their abnormal cancer screening test, 36% of subjects were publicly insured and 31% were uninsured. Post-reform, the percent ever uninsured declined from 39% to 29% (p .001) and those consistently uninsured declined from 23% to 16%. To assess if insurance instability changed between the pre- and post-reform periods, we conducted Poisson regression models, adjusted for patient demographics and length of time in care. These revealed no significant differences from the pre- to post-reform period in annual rates of insurance switches, incident rate ratio 0.98 (95%- CI 0.88-1.09). Our analysis is limited by changes in the populations in the pre- and post-reform period and inability to capture care outside of the health system network. Insurance reform increased stability as measured by decreasing uninsured rates without increasing insurance switches.
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17
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Kapoor A, Battaglia TA, Isabelle AP, Hanchate AD, Kalish RL, Bak S, Mishuris RG, Shroff SM, Freund KM. The impact of insurance coverage during insurance reform on diagnostic resolution of cancer screening abnormalities. J Health Care Poor Underserved 2015; 25:109-21. [PMID: 24583491 DOI: 10.1353/hpu.2014.0063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
We examined the impact of Massachusetts insurance reform on the care of women at six community health centers with abnormal breast and cervical cancer screening to investigate whether stability of insurance coverage was associated with more timely diagnostic resolution. We conducted Cox proportional hazards models to predict time from cancer screening to diagnostic resolution, examining the impact of 1) insurance status at time of screening abnormality, 2) number of insurance switches over a three-year period, and 3) insurance history over a three-year period. We identified 1,165 women with breast and 781 with cervical cancer screening abnormalities. In the breast cohort, Medicaid insurance at baseline, continuous public insurance, and losing insurance predicted delayed resolution. We did not find these effects in the cervical cohort. These data provide evidence that stability of health insurance coverage with insurance reform nationally may improve timely care after abnormal cancer screening in historically underserved women.
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18
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Mishuris RG, Linder JA, Bates DW, Bitton A. Using electronic health record clinical decision support is associated with improved quality of care. Am J Manag Care 2014; 20:e445-e452. [PMID: 25414982] [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: 06/04/2023]
Abstract
OBJECTIVES To determine whether clinical decision support (CDS) is associated with improved quality indicators and whether disabling CDS negatively affects these. STUDY DESIGN/METHODS Using the 2006-2009 National Ambulatory and National Hospital Ambulatory Medical Care Surveys, we performed logistic regression to analyze adult primary care visits for the association between the use of CDS (problem lists, preventive care reminders, lab results, lab range notifications, and drug-drug interaction warnings) and quality measures (blood pressure control, cancer screening, health education, influenza vaccination, and visits related to adverse drug events). RESULTS There were an estimated 900 million outpatient primary care visits to clinics with EHRs from 2006-2009; 97% involved CDS, 77% were missing at least 1 CDS, and 15% had at least 1 CDS disabled. The presence of CDS was associated with improved blood pressure control (86% vs 82%; OR 1.3; 95% CI, 1.1-1.5) and more visits not related to adverse drug events (99.9% vs 99.8%; OR 3.0; 95% CI, 1.3-7.3); these associations were also present when comparing practices with CDS against practices that had disabled CDS. Electronic problem lists were associated with increased odds of having a visit with controlled blood pressure (86% vs 80%; OR 1.4; 95% CI, 1.3-1.6). Lab result notification was associated with increased odds of ordering cancer screening (15% vs 10%; OR 1.5; 95% CI, 1.03-2.2). CONCLUSIONS The use of CDS was associated with improvement in some quality indicators. Not having at least 1 CDS was common; disabling CDS was infrequent. This suggests that meaningful use standards may improve national quality indicators and health outcomes, once fully implemented.
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Affiliation(s)
- Rebecca G Mishuris
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St, BC-3-2X, Boston, MA 02120. E-mail:
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Mishuris RG, Stewart M, Fix GM, Marcello T, McInnes DK, Hogan TP, Boardman JB, Simon SR. Barriers to patient portal access among veterans receiving home-based primary care: a qualitative study. Health Expect 2014; 18:2296-305. [PMID: 24816246 DOI: 10.1111/hex.12199] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2014] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Electronic, or web-based, patient portals can improve patient satisfaction, engagement and health outcomes and are becoming more prevalent with the advent of meaningful use incentives. However, adoption rates are low, particularly among vulnerable patient populations, such as those patients who are home-bound with multiple comorbidities. Little is known about how these patients view patient portals or their barriers to using them. OBJECTIVE To identify barriers to and facilitators of using My HealtheVet (MHV), the United States Department of Veterans Affairs (VA) patient portal, among Veterans using home-based primary care services. DESIGN Qualitative study using in-depth semi-structured interviews. We conducted a content analysis informed by grounded theory. PARTICIPANTS Fourteen Veterans receiving home-based primary care, surrogates of two of these Veterans, and three home-based primary care (HBPC) staff members. KEY RESULTS We identified five themes related to the use of MHV: limited knowledge; satisfaction with current HBPC care; limited computer and Internet access; desire to learn more about MHV and its potential use; and value of surrogates acting as intermediaries between Veterans and MHV. CONCLUSIONS Despite their limited knowledge of MHV and computer access, home-bound Veterans are interested in accessing MHV and using it as an additional point of care. Surrogates are also potential users of MHV on behalf of these Veterans and may have different barriers to and benefits from use.
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Affiliation(s)
- Rebecca G Mishuris
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, USA.,Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Max Stewart
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, USA
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Health Services Research and Development Service, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Thomas Marcello
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, USA.,Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,Center for Healthcare Organization and Implementation Research (CHOIR), VA Health Services Research and Development Service, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - D Keith McInnes
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Health Services Research and Development Service, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA.,HIV/Hepatitis Quality Enhancement Research Initiative (QUERI) Program, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,eHealth Quality Enhancement Research Initiative (QUERI), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - Timothy P Hogan
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,Center for Healthcare Organization and Implementation Research (CHOIR), VA Health Services Research and Development Service, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Judith B Boardman
- Home Based Primary Care Program, VA Boston Healthcare System, Boston, MA, USA.,Salem State University, Salem, MA, USA
| | - Steven R Simon
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, USA.,Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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20
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Mishuris RG, Linder JA. Racial differences in cancer screening with electronic health records and electronic preventive care reminders. J Am Med Inform Assoc 2014; 21:e264-9. [PMID: 24637955 DOI: 10.1136/amiajnl-2013-002439] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Health information technology (HIT) can increase preventive care. There are hopes and fears about the impact of HIT on racial disparities in cancer screening. OBJECTIVE To determine whether electronic health records (EHRs) or electronic preventive care reminders (e-reminders) modify racial differences in cancer screening order rates. DESIGN Using the 2006-2010 National Ambulatory and National Hospital Ambulatory Medical Care Surveys, we measured (1) visit-based differences in rates of age-appropriate breast, cervical and colon cancer screening orders between white and non-white subjects at primary care visits with and without EHRs, and, at visits with EHRs, with and without e-reminders, and (2) whether EHRs or e-reminders modified these differences. MAIN OUTCOMES Mammography (N=45,380); Pap smears (N=73,348); and sigmoidoscopy/colonoscopy (N=50,955) orders. RESULTS Among an estimated 2.4 billion US adult primary care visits, orders for screening for breast, cervical or colon cancer did not differ between clinics with and without EHRs or e-reminders. There was no difference in screening orders between non-white and white patients for breast (aOR=1.1; 95% CI 0.9 to 1.4) or cervical cancer (aOR=1.2; 95% CI 1.0 to 1.3). For colon cancer, non-white patients were more likely to receive screening orders than white patients overall (aOR=1.5; 95% CI 1.1 to 2.0), at visits with EHRs (aOR=1.8; 95% CI 1.1 to 2.8) and at visits with e-reminders (aOR=2.1; 95% CI 1.2 to 3.7). EHRs or e-reminders did not modify racial differences in cancer screening rates. CONCLUSIONS In this visit-based analysis, non-white patients had higher colon cancer screening order rates than white patients. Despite hopes and fears about HIT, EHRs and e-reminders did not ameliorate or exacerbate racial differences in cancer screening order rates.
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Affiliation(s)
- Rebecca G Mishuris
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey A Linder
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA
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Affiliation(s)
- Rebecca G. Mishuris
- Division of General Medicine and Primary Care, Brigham and Women’s Hospital, 1620 Tremont Street, BC-3-2X, Boston, MA 02120 USA
| | - 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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Affiliation(s)
- Rebecca G. Mishuris
- />Division of General Medicine and Primary Care, Brigham and Women’s Hospital, 1620 Tremont Street, BC-3-2X, Boston, MA 02120 USA
- />Harvard Medical School, Boston, MA USA
| | - 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
- />Harvard Medical School, Boston, MA USA
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