Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial

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 ({"type":"clinical-trial","attrs":{"text":"NCT00251875","term_id":"NCT00251875"}}NCT00251875).     

Improving completeness of electronic problem lists through clinical decision support: a randomized, controlled trial

Background

Accurate clinical problem lists are critical for patient care, clinical decision support, population reporting, quality improvement, and research. However, problem lists are often incomplete or out of date.

Objective

To determine whether a clinical alerting system, which uses inference rules to notify providers of undocumented problems, improves problem list documentation.

Study Design and Methods

Inference rules for 17 conditions were constructed and an electronic health record-based intervention was evaluated to improve problem documentation. A cluster randomized trial was conducted of 11 participating clinics affiliated with a large academic medical center, totaling 28 primary care clinical areas, with 14 receiving the intervention and 14 as controls. The intervention was a clinical alert directed to the provider that suggested adding a problem to the electronic problem list based on inference rules. The primary outcome measure was acceptance of the alert. The number of study problems added in each arm as a pre-specified secondary outcome was also assessed. Data were collected during 6-month pre-intervention (11/2009–5/2010) and intervention (5/2010–11/2010) periods.

Results

17 043 alerts were presented, of which 41.1% were accepted. In the intervention arm, providers documented significantly more study problems (adjusted OR=3.4, p<0.001), with an absolute difference of 6277 additional problems. In the intervention group, 70.4% of all study problems were added via the problem list alerts. Significant increases in problem notation were observed for 13 of 17 conditions.

Conclusion

Problem inference alerts significantly increase notation of important patient problems in primary care, which in turn has the potential to facilitate quality improvement.

Trial Registration

ClinicalTrials.gov: {"type":"clinical-trial","attrs":{"text":"NCT01105923","term_id":"NCT01105923"}}NCT01105923.     

Improving personal health records for patient-centered care

Objective

To assess the patient-centeredness of personal health records (PHR) and offer recommendations for best practice guidelines.

Design

Semi-structured interviews were conducted in seven large early PHR adopter organizations in 2007. Organizations were purposively selected to represent a variety of US settings, including medium and large hospitals, ambulatory care facilities, insurers and health plans, government departments, and commercial sectors.

Measurements

Patient-centeredness was assessed against a framework of care that includes: (1) respect for patient values, preferences, and expressed needs; (2) information and education; (3) access to care; (4) emotional support to relieve fear and anxiety; (5) involvement of family and friends; (6) continuity and secure transition between healthcare providers; (7) physical comfort; (8) coordination of care. Within this framework we used evidence for patient preferences (where it exists) to compare existing PHR policies, and propose a best practice model.

Results

Most organizations enable many patient-centered functions such as data access for proxies and minors. No organization allows patient views of clinical progress notes, and turnaround times for PHR reporting of normal laboratory results can be up to 7 days.

Conclusion

Findings suggest patient-centeredness for personal health records can be improved, and recommendations are made for best practice guidelines.     

The SMART Platform: early experience enabling substitutable applications for electronic health records

Objective

The Substitutable Medical Applications, Reusable Technologies (SMART) Platforms project seeks to develop a health information technology platform with substitutable applications (apps) constructed around core services. The authors believe this is a promising approach to driving down healthcare costs, supporting standards evolution, accommodating differences in care workflow, fostering competition in the market, and accelerating innovation.

Materials and methods

The Office of the National Coordinator for Health Information Technology, through the Strategic Health IT Advanced Research Projects (SHARP) Program, funds the project. The SMART team has focused on enabling the property of substitutability through an app programming interface leveraging web standards, presenting predictable data payloads, and abstracting away many details of enterprise health information technology systems. Containers—health information technology systems, such as electronic health records (EHR), personally controlled health records, and health information exchanges that use the SMART app programming interface or a portion of it—marshal data sources and present data simply, reliably, and consistently to apps.

Results

The SMART team has completed the first phase of the project (a) defining an app programming interface, (b) developing containers, and (c) producing a set of charter apps that showcase the system capabilities. A focal point of this phase was the SMART Apps Challenge, publicized by the White House, using http://www.challenge.gov website, and generating 15 app submissions with diverse functionality.

Conclusion

Key strategic decisions must be made about the most effective market for further disseminating SMART: existing market-leading EHR vendors, new entrants into the EHR market, or other stakeholders such as health information exchanges.     

Impact of iron supplementation on schistosomiasis control in Zambian school children in a highly endemic area

Aim

To study impact of once weekly iron supplementation on praziquantel cure rate, Schistosoma haematobium reinfection, and haematological parameters in pupils aged between 9 and 15 years of age in Nchelenge district, Zambia.

Methods

Pupils in the intervention group received once weekly dose of ferrous sulphate at 200mg while those in the control received once weekly vitamin C at 100mg for up to 9 months. Both study groups received a single dose of praziquantel at baseline.

Results

S haematobium reinfection intensity was significantly lower in boys in the intervention group than in boys in the control group at 6 months (P<0.001) and 9 months (P<0.001) of supplementation. Significantly lower S haematobium reinfection intensity was found in girls in the intervention group than in girls in the control group only at 6 months of supplementation (P=0.018). Boys in the intervention group were 42% (Adjusted Risk Ratio =0.58, 95% confidence interval 0.39, 0.86) less likely to be reinfected with S haematobium than in the control group at 6 months follow up.

Conclusion

Once weekly iron supplementation can decrease S haematobium reinfection after 6 months and should be incorporated into school based schistosomiasis control programs in highly endemic areas.

Clinical trials.gov identifier

{"type":"clinical-trial","attrs":{"text":"NCT 00276224","term_id":"NCT00276224"}}NCT 00276224, sponsored by DBL-Institute for Health Research and Development, Denmark.     

Veterans' voices: use of the American Customer Satisfaction Index (ACSI) Survey to identify My HealtheVet personal health record users' characteristics,needs, and preferences

Background

Consumer research reveals considerable interest in the use of Personal Health Records (PHRs), yet adoption remains relatively low. Both adopters and nonadopters represent important perspectives from which to understand this paradox.

Objective

This study focuses on direct feedback from adopters obtained using the American Customer Satisfaction Index (ACSI) survey on the My HealtheVet PHR portal (http://www.myhealth.va.gov) of the Veterans Health Administration (VHA). The results represent a source of direct feedback with which to better understand veterans'' needs and preferences.

Methods

The ACSI Survey was implemented in October 2007 to measure satisfaction and elicit information about characteristics and preferences of My HealtheVet PHR adopters. The data represent a continuous random sample of site visitors who have navigated at least four pages on the site. A total of 100 617 surveys were completed (17.2%).

Results

Satisfaction with My HealtheVet is high (8.3/10.0), and users are highly likely to return to the site (8.6/10.0) and recommend the site to other veterans (9.1/10.0). The majority of system adopters are male (91%), between the ages of 51 and 70 (68%), and served in the Vietnam War (60%). Most veterans currently visit the site to utilize pharmacy-related features.

Conclusion

VHA has used the ACSI to monitor satisfaction, and to better understand the characteristics, needs, and preferences of early adopters. The data provide an important source of direct feedback to inform program development. Future research will include monitoring the impact of enhancements and new features on satisfaction, and conducting additional research with nonadopters to identify barriers to adoption and use.     

The military health system's personal health record pilot with Microsoft HealthVault and Google Health

Objective

To design, build, implement, and evaluate a personal health record (PHR), tethered to the Military Health System, that leverages Microsoft^® HealthVault and Google^® Health infrastructure based on user preference.

Materials and methods

A pilot project was conducted in 2008–2009 at Madigan Army Medical Center in Tacoma, Washington. Our PHR was architected to a flexible platform that incorporated standards-based models of Continuity of Document and Continuity of Care Record to map Department of Defense-sourced health data, via a secure Veterans Administration data broker, to Microsoft^® HealthVault and Google^® Health based on user preference. The project design and implementation were guided by provider and patient advisory panels with formal user evaluation.

Results

The pilot project included 250 beneficiary users. Approximately 73.2% of users were <65 years of age, and 38.4% were female. Of the users, 169 (67.6%) selected Microsoft^® HealthVault, and 81 (32.4%) selected Google^® Health as their PHR of preference. Sample evaluation of users reflected 100% (n=60) satisfied with convenience of record access and 91.7% (n=55) satisfied with overall functionality of PHR.

Discussion

Key lessons learned related to data-transfer decisions (push vs pull), purposeful delays in reporting sensitive information, understanding and mapping PHR use and clinical workflow, and decisions on information patients may choose to share with their provider.

Conclusion

Currently PHRs are being viewed as empowering tools for patient activation. Design and implementation issues (eg, technical, organizational, information security) are substantial and must be thoughtfully approached. Adopting standards into design can enhance the national goal of portability and interoperability.     

Openness of patients' reporting with use of electronic records: psychiatric clinicians' views

Objectives

Improvements in electronic health record (EHR) system development will require an understanding of psychiatric clinicians'' views on EHR system acceptability, including effects on psychotherapy communications, data-recording behaviors, data accessibility versus security and privacy, data quality and clarity, communications with medical colleagues, and stigma.

Design

Multidisciplinary development of a survey instrument targeting psychiatric clinicians who recently switched to EHR system use, focus group testing, data analysis, and data reliability testing.

Measurements

Survey of 120 university-based, outpatient mental health clinicians, with 56 (47%) responding, conducted 18 months after transition from a paper to an EHR system.

Results

Factor analysis gave nine item groupings that overlapped strongly with five a priori domains. Respondents both praised and criticized the EHR system. A strong majority (81%) felt that open therapeutic communications were preserved. Regarding data quality, content, and privacy, clinicians (63%) were less willing to record highly confidential information and disagreed (83%) with including their own psychiatric records among routinely accessed EHR systems.

Limitations

single time point; single academic medical center clinic setting; modest sample size; lack of prior instrument validation; survey conducted in 2005.

Conclusions

In an academic medical center clinic, the presence of electronic records was not seen as a dramatic impediment to therapeutic communications. Concerns regarding privacy and data security were significant, and may contribute to reluctances to adopt electronic records in other settings. Further study of clinicians'' views and use patterns may be helpful in guiding development and deployment of electronic records systems.     

Patient-controlled sharing of medical imaging data across unaffiliated healthcare organizations

Background

Current image sharing is carried out by manual transportation of CDs by patients or organization-coordinated sharing networks. The former places a significant burden on patients and providers. The latter faces challenges to patient privacy.

Objective

To allow healthcare providers efficient access to medical imaging data acquired at other unaffiliated healthcare facilities while ensuring strong protection of patient privacy and minimizing burden on patients, providers, and the information technology infrastructure.

Methods

An image sharing framework is described that involves patients as an integral part of, and with full control of, the image sharing process. Central to this framework is the Patient Controlled Access-key REgistry (PCARE) which manages the access keys issued by image source facilities. When digitally signed by patients, the access keys are used by any requesting facility to retrieve the associated imaging data from the source facility. A centralized patient portal, called a PCARE patient control portal, allows patients to manage all the access keys in PCARE.

Results

A prototype of the PCARE framework has been developed by extending open-source technology. The results for feasibility, performance, and user assessments are encouraging and demonstrate the benefits of patient-controlled image sharing.

Discussion

The PCARE framework is effective in many important clinical cases of image sharing and can be used to integrate organization-coordinated sharing networks. The same framework can also be used to realize a longitudinal virtual electronic health record.

Conclusion

The PCARE framework allows prior imaging data to be shared among unaffiliated healthcare facilities while protecting patient privacy with minimal burden on patients, providers, and infrastructure. A prototype has been implemented to demonstrate the feasibility and benefits of this approach.     

Glycemic Variation in Tumor Patients with Total Parenteral Nutrition

Background:Hyperglycemia is associated with poor clinical outcomes and mortality in several patients.However,studies evaluating hyperglycemia variation in tumor patients receiving total parenteral nutr...     

Efficacy and Safety of Tenofovir and Lamivudine in Combination with Efavirenz in Patients Co-infected with Human Immunodeficiency Virus and Hepatitis B Virus in China

Background:

The prevalence of hepatitis B virus (HBV) infection is high among individuals infected with human immunodeficiency virus (HIV) in China. Both HIV and HBV can be treated with tenofovir disoproxil fumarate (TDF) and lamivudine (3TC), so we evaluated the safety and efficacy of combination antiretroviral therapy (ART) that included TDF, 3TC, and efavirenz (EFV) among ART-naive individuals who were co-infected with HIV and HBV.

Methods:

One hundred HIV/HBV co-infected ARV-naive individuals were started on the regimen of TDF, 3TC, and EFV, and the levels of plasma HBV DNA, HIV RNA, and biochemical evaluation related to the function of liver and kidney were analyzed.

Results:

Concerning efficacy, this study found that by week 48, the vast majority co-infected participants receiving this ART regimen had undetectable HBV DNA levels (71%) and/or HIV RNA levels (90%). Concerning safety, this study found that the median estimated glomerular filtration rate of participants decreased from baseline (109 ml·min⁻¹·1.73 m⁻²) to week 12 (104 ml·min⁻¹·1.73 m⁻²) but was almost back to baseline at week 48 (111 ml·min⁻¹·1.73 m⁻²).

Conclusion:

This combination ART regimen is safe and effective for patients with HIV/HBV co-infection.

Trial Registration:

ClinicalTrials.gov, {"type":"clinical-trial","attrs":{"text":"NCT01751555","term_id":"NCT01751555"}}NCT01751555; https://clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT01751555","term_id":"NCT01751555"}}NCT01751555.     

Personal health records: a randomized trial of effects on elder medication safety

Purpose

To examine the impact of a personal health record (PHR) on medication-use safety among older adults.

Background

Online PHRs have potential as tools to manage health information. We know little about how to make PHRs accessible for older adults and what effects this will have.

Methods

A PHR was designed and pretested with older adults and tested in a 6-month randomized controlled trial. After completing mailed baseline questionnaires, eligible computer users aged 65 and over were randomized 3:1 to be given access to a PHR (n=802) or serve as a standard care control group (n=273). Follow-up questionnaires measured change from baseline medication use, medication reconciliation behaviors, and medication management problems.

Results

Older adults were interested in keeping track of their health and medication information. A majority (55.2%) logged into the PHR and used it, but only 16.1% used it frequently. At follow-up, those randomized to the PHR group were significantly less likely to use multiple non-steroidal anti-inflammatory drugs—the most common warning generated by the system (viewed by 23% of participants). Compared with low/non-users, high users reported significantly more changes in medication use and improved medication reconciliation behaviors, and recognized significantly more side effects, but there was no difference in use of inappropriate medications or adherence measures.

Conclusions

PHRs can engage older adults for better medication self-management; however, features that motivate continued use will be needed. Longer-term studies of continued users will be required to evaluate the impact of these changes in behavior on patient health outcomes.     

Impact of a web-based personally controlled health management system on influenza vaccination and health services utilization rates: a randomized controlled trial

Objective

To assess the impact of a web-based personally controlled health management system (PCHMS) on the uptake of seasonal influenza vaccine and primary care service utilization among university students and staff.

Materials and methods

A PCHMS called Healthy.me was developed and evaluated in a 2010 CONSORT-compliant two-group (6-month waitlist vs PCHMS) parallel randomized controlled trial (RCT) (allocation ratio 1:1). The PCHMS integrated an untethered personal health record with consumer care pathways, social forums, and messaging links with a health service provider.

Results

742 university students and staff met inclusion criteria and were randomized to a 6-month waitlist (n=372) or the PCHMS (n=370). Amongst the 470 participants eligible for primary analysis, PCHMS users were 6.7% (95% CI: 1.46 to 12.30) more likely than the waitlist to receive an influenza vaccine (waitlist: 4.9% (12/246, 95% CI 2.8 to 8.3) vs PCHMS: 11.6% (26/224, 95% CI 8.0 to 16.5); χ²=7.1, p=0.008). PCHMS participants were also 11.6% (95% CI 3.6 to 19.5) more likely to visit the health service provider (waitlist: 17.9% (44/246, 95% CI 13.6 to 23.2) vs PCHMS: 29.5% (66/224, 95% CI: 23.9 to 35.7); χ²=8.8, p=0.003). A dose–response effect was detected, where greater use of the PCHMS was associated with higher rates of vaccination (p=0.001) and health service provider visits (p=0.003).

Discussion

PCHMS can significantly increase consumer participation in preventive health activities, such as influenza vaccination.

Conclusions

Integrating a PCHMS into routine health service delivery systems appears to be an effective mechanism for enhancing consumer engagement in preventive health measures.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12610000386033. http://www.anzctr.org.au/trial_view.aspx?id=335463.     

Sociotechnical challenges to developing technologies for patient access to health information exchange data

Background

Providing patients with access to their medical data is widely expected to help educate and empower them to manage their own health. Health information exchange (HIE) infrastructures could potentially help patients access records across multiple healthcare providers. We studied three HIE organizations as they developed portals to give consumers access to HIE data previously exchanged only among healthcare organizations.

Objective

To follow the development of new consumer portal technologies, and to identify barriers and facilitators to patient access to HIE data.

Methods

Semistructured interviews of 15 key informants over a 2-year period spanning the development and early implementation of three new projects, coded according to a sociotechnical framework.

Results

As the organizations tried to develop functionality that fully served the needs of both providers and patients, plans were altered by technical barriers (primarily related to data standardization) and cultural and legal issues surrounding data access. Organizational changes also played an important role in altering project plans. In all three cases, patient access to data was significantly scaled back from initial plans.

Conclusions

This prospective study revealed how sociotechnical factors previously identified as important in health information technology success and failure helped to shape the evolution of three novel consumer informatics projects. Barriers to providing patients with seamless access to their HIE data were multifactorial. Remedies will have to address technical, organizational, cultural, and other factors.     

How is the electronic health record being used? Use of EHR data to assess physician-level variability in technology use

Background

Studies of the effects of electronic health records (EHRs) have had mixed findings, which may be attributable to unmeasured confounders such as individual variability in use of EHR features.

Objective

To capture physician-level variations in use of EHR features, associations with other predictors, and usage intensity over time.

Methods

Retrospective cohort study of primary care providers eligible for meaningful use at a network of federally qualified health centers, using commercial EHR data from January 2010 through June 2013, a period during which the organization was preparing for and in the early stages of meaningful use.

Results

Data were analyzed for 112 physicians and nurse practitioners, consisting of 430 803 encounters with 99 649 patients. EHR usage metrics were developed to capture how providers accessed and added to patient data (eg, problem list updates), used clinical decision support (eg, responses to alerts), communicated (eg, printing after-visit summaries), and used panel management options (eg, viewed panel reports). Provider-level variability was high: for example, the annual average proportion of encounters with problem lists updated ranged from 5% to 60% per provider. Some metrics were associated with provider, patient, or encounter characteristics. For example, problem list updates were more likely for new patients than established ones, and alert acceptance was negatively correlated with alert frequency.

Conclusions

Providers using the same EHR developed personalized patterns of use of EHR features. We conclude that physician-level usage of EHR features may be a valuable additional predictor in research on the effects of EHRs on healthcare quality and costs.     

The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis

Objectives

To evaluate the impact of electronic health record (EHR) implementation on nursing care processes and outcomes.

Design

Interrupted time series analysis, 2003–2009.

Setting

A large US not-for-profit integrated health care organization.

Participants

29 hospitals in Northern and Southern California.

Intervention

An integrated EHR including computerized physician order entry, nursing documentation, risk assessment tools, and documentation tools.

Main outcome measures

Percentage of patients with completed risk assessments for hospital acquired pressure ulcers (HAPUs) and falls (process measures) and rates of HAPU and falls (outcome measures).

Results

EHR implementation was significantly associated with an increase in documentation rates for HAPU risk (coefficient 2.21, 95% CI 0.67 to 3.75); the increase for fall risk was not statistically significant (0.36; −3.58 to 4.30). EHR implementation was associated with a 13% decrease in HAPU rates (coefficient −0.76, 95% CI −1.37 to −0.16) but no decrease in fall rates (−0.091; −0.29 to 0.11). Irrespective of EHR implementation, HAPU rates decreased significantly over time (−0.16; −0.20 to −0.13), while fall rates did not (0.0052; −0.01 to 0.02). Hospital region was a significant predictor of variation for both HAPU (0.72; 0.30 to 1.14) and fall rates (0.57; 0.41 to 0.72).

Conclusions

The introduction of an integrated EHR was associated with a reduction in the number of HAPUs but not in patient fall rates. Other factors, such as changes over time and hospital region, were also associated with variation in outcomes. The findings suggest that EHR impact on nursing care processes and outcomes is dependent on a number of factors that should be further explored.     

Harmonized patient-reported data elements in the electronic health record: supporting meaningful use by primary care action on health behaviors and key psychosocial factors

Background

Electronic health records (EHR) have the potential to improve patient care through efficient access to complete patient health information. This potential may not be reached because many of the most important determinants of health outcome are rarely included. Successful health promotion and disease prevention requires patient-reported data reflecting health behaviors and psychosocial issues. Furthermore, there is a need to harmonize this information across different EHR systems.

Methods

To fill this gap a three-phased process was used to conceptualize, identify and recommend patient-reported data elements on health behaviors and psychosocial factors for the EHR. Expert panels (n=13) identified candidate measures (phase 1) that were reviewed and rated by a wide range of health professionals (n=93) using the grid-enabled measures wiki social media platform (phase 2). Recommendations were finalized through a town hall meeting with key stakeholders including patients, providers, researchers, policy makers, and representatives from healthcare settings (phase 3).

Results

Nine key elements from three areas emerged as the initial critical patient-reported elements to incorporate systematically into EHR—health behaviors (eg, exercise), psychosocial issues (eg, distress), and patient-centered factors (eg, demographics). Recommendations were also made regarding the frequency of collection ranging from a single assessment (eg, demographic characteristics), to annual assessment (eg, health behaviors), or more frequent (eg, patient goals).

Conclusions

There was strong stakeholder support for this initiative reflecting the perceived value of incorporating patient-reported elements into EHR. The next steps will include testing the feasibility of incorporating these elements into the EHR across diverse primary care settings.     

Validity of electronic health record-derived quality measurement for performance monitoring

Background

Since 2007, New York City''s primary care information project has assisted over 3000 providers to adopt and use a prevention-oriented electronic health record (EHR). Participating practices were taught to re-adjust their workflows to use the EHR built-in population health monitoring tools, including automated quality measures, patient registries and a clinical decision support system. Practices received a comprehensive suite of technical assistance, which included quality improvement, EHR customization and configuration, privacy and security training, and revenue cycle optimization. These services were aimed at helping providers understand how to use their EHR to track and improve the quality of care delivered to patients.

Materials and Methods

Retrospective electronic chart reviews of 4081 patient records across 57 practices were analyzed to determine the validity of EHR-derived quality measures and documented preventive services.

Results

Results from this study show that workflow and documentation habits have a profound impact on EHR-derived quality measures. Compared with the manual review of electronic charts, EHR-derived measures can undercount practice performance, with a disproportionately negative impact on the number of patients captured as receiving a clinical preventive service or meeting a recommended treatment goal.

Conclusion

This study provides a cautionary note in using EHR-derived measurement for public reporting of provider performance or use for payment.