Primary Care Physicians’ Use of an Electronic Medical Record System: A Cognitive Task Analysis

OBJECTIVE  To describe physicians’ patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient–doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular. DESIGN  Cognitive task analysis using semi-structured interviews and field observations. PARTICIPANTS  Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel. RESULTS  The comprehensiveness, organization, and readability of data in the EMR system reduced physicians’ need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient’s chart. EMR use interfered with patient–doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians’ communication skills also helped. CONCLUSIONS  There is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians’ offices and by enhancing physicians’ computer and communication skills.     

Validating Measures of Third Year Medical Students’ Use of Interpreters by Standardized Patients and Faculty Observers

Background

Increasing prevalence of limited English proficiency patient encounters demands effective use of interpreters. Validated measures for this skill are needed.

Objective

We describe the process of creating and validating two new measures for rating student skills for interpreter use.

Setting

Encounters using standardized patients (SPs) and interpreters within a clinical practice examination (CPX) at one medical school.

Measurements

Students were assessed by SPs using the interpreter impact rating scale (IIRS) and the physician patient interaction (PPI) scale. A subset of 23 encounters was assessed by 4 faculty raters using the faculty observer rating scale (FORS). Internal consistency reliability was assessed by Cronbach’s coefficient alpha (α). Interrater reliability of the FORS was examined by the intraclass correlation coefficient (ICC). The FORS and IIRS were compared and each was correlated with the PPI.

Results

Cronbach’s α was 0.90 for the 7-item IIRS and 0.88 for the 11-item FORS. ICC among 4 faculty observers had a mean of 0.61 and median of 0.65 (0.20, 0.86). Skill measured by the IIRS did not significantly correlate with FORS but correlated with the PPI.

Conclusions

We developed two measures with good internal reliability for use by SPs and faculty observers. More research is needed to clarify the reasons for the lack of concordance between these measures and which may be more valid for use as a summative assessment measure.

     

Perceived Helpfulness of Physicians’ Communication Behavior and Breast Cancer Patients’ Level of Trust Over Time

OBJECTIVE  We evaluated the association between physicians’ communication behavior and breast cancer patients’ trust in their physicians. DESIGN  Longitudinal survey conducted at baseline, 2-month, and 5-month follow-up during first year of diagnosis. PARTICIPANTS  Newly diagnosed breast cancer patients (N = 246). MEASUREMENTS  We collected data on patient perceptions of the helpfulness of informational, emotional, and decision-making support provided by physicians and patients’ trust. Linear regression models evaluated the association of concurrent and prior levels of physician support with patients’ trust. RESULTS  At baseline, patients who received helpful informational, emotional, and decision-making support from physicians reported greater trust (p < 0.05, p < 0.001, and p < 0.01, respectively). At the 2-month assessment, baseline informational support and informational and emotional support at 2-months were associated with greater trust (p < 0.05, p < 0.01, and p < 0.05, respectively). At the 5-month assessment, only helpful emotional support from physicians at 5 months was associated with greater trust (p < 0.01). Interestingly, while perceived helpfulness of all three types of physician support decreased significantly over time, patient trust remained high and unchanged. CONCLUSIONS  Findings suggest that while informational and decision-making support may be more important to patient trust early in the course of treatment, emotional support from physicians may be important to maintain trust throughout the initial year of diagnosis.     

Quality Monitoring of Physicians: Linking Patients’ Experiences of Care to Clinical Quality and Outcomes

Background  Physicians are increasingly asked to improve the delivery of clinical services and patient experiences of care. Objective  We evaluated the association between clinical performance and patient experiences in a statewide sample of physician practice sites and a sample of physicians within a large physician group. Design, Setting, Participants  We separately identified 373 practice sites and 119 individual primary care physicians in Massachusetts. Measurements  Using Health Plan Employer Data and Information Set data, we produced two composites addressing processes of care (prevention, disease management) and one composite addressing outcomes. Using Ambulatory Care Experiences Survey data, we produced seven composite measures summarizing the quality of clinical interactions and organizational features of care. For each sample (practice site and individual physician), we calculated adjusted Spearman correlation coefficients to assess the relationship between the composites summarizing patient experiences of care and those summarizing clinical performance. Results  Among 42 possible correlations (21 correlations involving practice sites and 21 involving individual physicians), the majority were positive in site level (71%) and physician level (67%) analyses. For the 28 possible correlations involving patient experiences and clinical process composites, 8 (29%) were significant and positive, and only 2 (7%) were significant and negative. The magnitude of the significant positive correlations ranged from 0.13 to 0.19 at the site level and from 0.28 to 0.51 at the physician level. There were no significant correlations between patient experiences and the clinical outcome composite. Conclusions  The modest correlations suggest that clinical quality and patient experience are distinct, but related domains that may require separate measurement and improvement initiatives. Acknowledgements: This study was funded by the Commonwealth Fund and the William Randolph Hearst Foundation. Dr. Sequist had full access to all the data in the study and takes responsibility for the integrity and the accuracy of the data analysis. This work was presented in abstract form at the 2007 Society for General Internal Medicine Annual Conference. We would like to thank Massachusetts Health Quality Partners for allowing us use of statewide data for these analyses; Jo-Anne Foley at HVMA for helping to obtain physician-level data; and Angela Li, Angie Rodday, and Hong Chang at Tufts-New England Medical Center for analytic support. Dr. Sequist has served as a consultant on the Aetna External Advisory Committee for Racial and Ethnic Equality.     

Primary Care Physicians’ Decisions About Discharging Patients from Their Practices

Objective There are few data available about factors which influence physicians’ decisions to discharge patients from their practices. To study general internists’ and family medicine physicians’ attitudes and experiences in discharging patients from their practices. Design A cross-sectional mailed survey was used. Participants One thousand general internists and family medicine physicians participated in this study. Measurements and Main Results We studied the likelihood physicians would discharge 12 hypothetical patients from their practices, and whether they had actually discharged such patients. The effect of demographic data on the number of scenarios in which patients were likely to be discharged, and the number of patients actually discharged were analyzed via ANOVA and multiple logistic regression analysis. Of 977 surveys received by subjects, 526 (54%) were completed and returned. A majority of respondents were willing to discharge patients in 5 of 12 hypothetical scenarios. Eighty-five percent had actually discharged at least one patient from their practices. Most respondents (71%) had discharged 10 or fewer patients, but 14% had discharged 11 to 200 patients. Respondents who were in private practice (p < 0.000001) were more likely to discharge both hypothetical and actual patients from their practices. Older physicians (≥48 years old) were more likely to discharge actual patients from their practices (p = 0.005) as were physicians practicing in rural settings (p = 0.003). Conclusions Most physicians in our sample were willing to discharge actual and hypothetical patients from their practices. This tendency may have significant implications for the initiation of pay-for-performance programs. Physicians should be educated about the importance of the patient–physician relationship and their fiduciary obligations to the patient.     

Family Physicians’ Attitudes and Practices Regarding Assessments of Medical Fitness to Drive in Older Persons

Background Higher crash rates per mile driven in older drivers have focused attention on the assessment of older drivers. Objective To examine the attitudes and practices of family physicians regarding fitness-to-drive issues in older persons. Design Survey questionnaire. Participants The questionnaire was sent to 1,000 randomly selected Canadian family physicians. Four hundred sixty eligible physicians returned completed questionnaires. Measurements Self-reported attitudes and practices towards driving assessments and the reporting of medically unsafe drivers. Results Over 45% of physicians are not confident in assessing driving fitness and do not consider themselves to be the most qualified professionals to do so. The majority (88.6%) feel that they would benefit from further education in this area. About 75% feel that reporting a patient as an unsafe driver places them in a conflict of interest and negatively impacts on the patient and the physician–patient relationship. Nevertheless, most (72.4%) agree that physicians should be legally responsible for reporting unsafe drivers to the licensing authorities. Physicians from provinces with mandatory versus discretionary reporting requirements are more likely to report unsafe drivers (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.58 to 4.91), but less likely to perform driving assessments (OR, 0.58; 95% CI, 0.39 to 0.85). Most driving assessments take between 10 and 30 minutes, with much variability in the components included. Conclusions Family physicians lack confidence in performing driving assessments and note many negative consequences of reporting unsafe drivers. Education about assessing driving fitness and approaches that protect the physician–patient relationship when reporting occurs are needed.     

Physicians’ Opinions of Stress Ulcer Prophylaxis: Survey Results from a Large Urban Medical Center

Background

Stress ulcer prophylaxis (SUP) has been increasingly prescribed for patients admitted to medical wards. The knowledge, attitudes, and practices of those in the healthcare profession regarding use of SUP in medical wards are understudied.

Methods

A survey consisting of closed-ended questions and multiple-choice queries was handed out during grand rounds.

Results

One hundred people (39 attending physicians, 61 residents) completed the survey. More attending physicians (41 vs. 30 %) believed SUP was indicated for patients treated in a non-intensive-care medical ward (P = 0.2357). All residents preferred a proton-pump inhibitor (PPI) for SUP compared with 85 % of attending physicians (P < 0.05). Despite equal agreement that PPIs were not harmless, more attending physicians than residents agreed that using PPIs increased the risk of community-acquired pneumonia (P < 0.05). More residents than attending physicians agreed on the use of SUP for patients suffering from major burns and for those with liver failure. In situations of respiratory distress not requiring intubation and in cases of steroid treatment for a chronic obstructive pulmonary disease flare, more attending physicians than residents felt SUP was required. Approaching a statistically significant difference, more attending physicians than residents felt that being too busy to question SUP indication and the perception of PPIs as harmless affected decision making.

Conclusion

Despite the publication of guidelines, misuse of gastric acid suppressants continues to occur, even by attending physicians. More complete understanding of the need and occasion for SUP use should result in more cautious use.     

Factors Influencing Physicians’ Screening Behavior for Liver Cancer Among High-risk Patients

BACKGROUND Little is known about physicians’ screening patterns for liver cancer despite its rising incidence. OBJECTIVE Describe physician factors associated with liver cancer screening. DESIGN Mailed survey. PARTICIPANTS Physicians practicing in family practice, internal medicine, gastroenterology, or nephrology in 3 northern California counties in 2004. MEASUREMENTS Sociodemographic and practice measures, liver cancer knowledge, attitudes, and self-reported screening behaviors. RESULTS The response rate was 61.8% (N = 459). Gastroenterologists (100%) were more likely than Internists (88.4%), family practitioners (84.2%), or nephrologists (75.0%) to screen for liver cancer in high-risk patients (p = 0.016). In multivariate analysis, screeners were more likely than nonscreeners to think that screening for liver cancer reduced mortality (odds ratio [OR] 1.60, CI 1.09–2.34) and that not screening was a malpractice risk (OR 1.88, CI 1.29–2.75). Screeners were more likely than nonscreeners to order any screening test if it was a quality of care measure (OR 4.39, CI 1.79–10.81). CONCLUSIONS Despite debate about screening efficacy, many physicians screen for liver cancer. Their screening behavior is influenced by malpractice and quality control concerns. More research is needed to develop better screening tests for liver cancer, to evaluate their effectiveness, and to understand how physicians behave when there is insufficient evidence.     

Does a Reduction of Adhesion Molecules by LDL‐Apheresis Have a Role in the Treatment of Sudden Hearing Loss?

Sudden hearing loss (SHL) is a highly disabling affliction that can severely affect the subject's social and relational life. Although the etiology of the complaint is still debated, it is thought that microcirculation disturbances conditioned by an endothelial dysfunction might be the main pathogenetic mechanism. Adhesion molecules favoring interaction between leukocytes and endothelial cells are early markers of endothelial damage. In the present report, we describe a case of SHL that derived evident benefit from a single session of LDL/fibrinogen apheresis, with complete hearing recovery. In this patient, in addition to reducing LDL cholesterol and fibrinogen, the circulating adhesion molecules (sE-selectin, sVCAM-1 and sICAM-1), previously present in higher than normal concentrations, were reduced by the treatment.     

Studies of Physician‐Patient Communication with Older Patients: How Often is Hearing Loss Considered? A Systematic Literature Review

Hearing loss is remarkably prevalent in the geriatric population: one‐quarter of adults aged 60–69 and 80% of adults aged 80 years and older have bilateral disabling loss. Only about one in five adults with hearing loss wears a hearing aid, leaving many vulnerable to poor communication with healthcare providers. We quantified the extent to which hearing loss is mentioned in studies of physician‐patient communication with older patients, and the degree to which hearing loss is incorporated into analyses and findings. We conducted a structured literature search within PubMed for original studies of physician‐patient communication with older patients that were published since 2000, using the natural language phrase “older patient physician communication.” We identified 409 papers in the initial search, and included 67 in this systematic review. Of the 67 papers, only 16 studies (23.9%) included any mention of hearing loss. In six of the 16 studies, hearing loss was mentioned only; in four studies, hearing loss was used as an exclusion criterion; and in two studies, the extent of hearing loss was measured and reported for the sample, with no further analysis. Three studies examined or reported on an association between hearing loss and the quality of physician‐patient communication. One study included an intervention to temporarily mitigate hearing loss to improve communication. Less than one‐quarter of studies of physician‐elderly patient communication even mention that hearing loss may affect communication. Methodologically, this means that many studies may have omitted an important potential confounder. Perhaps more importantly, research in this field has largely overlooked a highly prevalent, important, and remediable influence on the quality of communication.     

Disparities in Service Quality Among Insured Adult Patients Seen in Physicians’ Offices

Objective  

To examine racial disparities in health care service quality.     

Medical therapy of Crohn’s disease

Opinion statement There is no medical or surgical treatment that provides a permanent cure for Crohn’s disease (CD). However, an evolving understanding of the pathogenesis of CD has provided clinicians with a diversity of medical treatment options for the disease. The goal of therapy is to induce and maintain clinical remission. The efficacy of immune-modifying agents such as azathioprine/6-mercaptopurine and infliximab have supported a paradigm shift in CD treatment in which maintenance agents are introduced earlier in the disease course. At the same time, it is imperative to balance the efficacy, safety, and tolerability of medical therapy. Given the variable and relapsing clinical course of CD, the physician and patient should ideally develop an ongoing relationship that allows for individualization of treatment regimens, monitoring of response and side effects, and modification of the therapeutic strategy in the absence of improvement.     

Physicians’ reports of focused expertise in clinical practice

Little is known about the prevalence of focused expertise (special areas of expertise within a clinical field) among physicians, yet such expertise may influence how care is delivered. We surveyed general internists, pediatricians, cardiologists, infectious disease specialists, and orthopedic surgeons to describe the prevalence of focused expertise and identify associated physician and practice characteristics. About one quarter of generalists and three quarters of specialists reported a focused expertise within their primary specialty. Hospital-based physicians more often reported such expertise, and physicians reimbursed by capitation less often reported expertise. Learning how focused expertise affects processes and outcomes of care will contribute to decisions about physician training and staffing of medical groups. Dr. Keating was the recipient of a National Research Service Award from the Agency for Healthcare Research and Quality, Rockville, MD, Dr. Ayanian was a Generalist Physician Faculty Scholar of the Robert Wood Johnson Foundation, Princeton, NJ. This study was supported by the Primary Care Research and Education Fund of Brigham and Women’s Hospital.     

Financial Responsibility of Hospitalized Patients Who Left Against Medical Advice: Medical Urban Legend?

BACKGROUND

Physicians may counsel patients who leave against medical advice (AMA) that insurance will not pay for their care. However, it is unclear whether insurers deny payment for hospitalization in these cases.

OBJECTIVE

To review whether insurers denied payment for patients discharged AMA and assess physician beliefs and counseling practices when patients leave AMA.

DESIGN

Retrospective cohort of medical inpatients from 2001 to 2010; cross-sectional survey of physician beliefs and counseling practices for AMA patients in 2010.

PARTICIPANTS

Patients who left AMA from 2001 to 2010, internal medicine residents and attendings at a single academic institution, and a convenience sample of residents from 13 Illinois hospitals in June 2010.

MAIN MEASURES

Percent of AMA patients for which insurance denied payment, percent of physicians who agreed insurance denies payment for patients who leave AMA and who counsel patients leaving AMA they are financially responsible.

KEY RESULTS

Of 46,319 patients admitted from 2001 to 2010, 526 (1.1%) patients left AMA. Among insured patients, payment was refused in 4.1% of cases. Reasons for refusal were largely administrative (wrong name, etc.). No cases of payment refusal were because patient left AMA. Nevertheless, most residents (68.6%) and nearly half of attendings (43.9%) believed insurance denies payment when a patient leaves AMA. Attendings who believed that insurance denied payment were more likely to report informing AMA patients they may be held financially responsible (mean 4.2 vs. 1.7 on a Likert 1–5 scale, in which 5 is “always” inform, p < 0.001). This relationship was not observed among residents. The most common reason for counseling patients was “so they will reconsider staying in the hospital” (84.8% residents, 66.7% attendings, p = 0.008)

CONCLUSIONS

Contrary to popular belief, we found no evidence that insurance denied payment for patients leaving AMA. Residency programs and hospitals should ensure that patients are not misinformed.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-012-1984-x) contains supplementary material, which is available to authorized users.KEY WORDS: patient discharge, financial responsibility, hospital reimbursement     

Medical students’ perceptions of the elements of effective inpatient teaching by attending physicians and housestaff

BACKGROUND: Most studies of effective inpatient teaching have focused on teaching by attending physicians. OBJECTIVE: To identify and compare medical students' perceptions of behaviors associated with teaching effectiveness of attending physicians and housestaff (residents and interns). DESIGN AND PARTICIPANTS: Third-year students who spent 4 weeks on a general internal medicine inpatient service during academic year 2003-2004 completed surveys using a 5-point Likert-type scale. Students evaluated numerous teaching behaviors of attendings and housestaff and then evaluated their overall teaching effectiveness. MEASUREMENTS: Each behavior was correlated with the perceived teaching effectiveness in univariate and regression analyses. RESULTS: Seventy-two students were taught by 23 attendings and 73 housestaff. Of 144 possible teaching evaluations, they completed 142 (98.6%) for attendings and 128 (88.9%) for housestaff. The mean rating for perceived teaching effectiveness was 4.48 (SD 0.82) for attendings and 4.39 (SD 0.80) for housestaff. For attending physicians, teaching effectiveness correlated most strongly with enthusiasm for teaching (R(2)=63.6%) but was also associated with inspiring confidence in knowledge and skills, providing feedback, and encouraging students to accept increasing responsibility. Housestaff teaching effectiveness correlated most strongly with providing a role model (R(2)=61.8%) but was also associated with being available to students, performing effective patient education, inspiring confidence in knowledge and skills, and showing enthusiasm for teaching. Regression models explained 79.7% and 73.6% of the variance in evaluations of attendings and housestaff, respectively. CONCLUSIONS: Students' perceptions of effective teaching behaviors differ for attending physicians and housestaff, possibly reflecting differences in teaching roles or methods.     

Patients’ perceptions of physicians’ recommendations for comfort care differ by patient age and gender

OBJECTIVE: To determine patient characteristics associated with patient and proxy perceptions of physicians’ recommendations for life-prolonging care versus comfort care, and with acceptance of such recommendations. DESIGN: Cross-sectional. SETTING: Five teaching hospitals in Denver, Colo. PATIENTS: We studied 239 hospitalized adults believed by physicians to have a high likelihood of dying within 6 months. MEASUREMENTS AND MAIN RESULTS: Interviews with patients or proxies were conducted to determine perceptions of physicians’ recommended goal of care and roles in decision making. RESULTS: Patients’ mean age was 66.6 years; 44% were women. In adjusted analysis, age greater than 70 years and female gender were associated with a higher likelihood of believing that comfort care had been recommended by the physician (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.89 to 7.24; OR, 1.99; 95% CI, 1.04 to 3.84, respectively). Patients and proxies gave substantial decision-making authority to physicians: 29% responded that physicians dominate decision making, 55% that decision making is equally shared by physicians and patients, and only 16% that patients make decisions, Increasing age was associated with an increased likelihood of believing that physicians should dominate decision making (P<.005). CONCLUSIONS: Among patients with advanced illness, perceived comfort care recommendations were related to patient age and gender, raising concern about possible gender and age bias in physicians’ recommendations. Although all patients and proxies gave significant decision-making authority to physicians, older individuals were more likely to give physicians decision-making authority, making them more vulnerable to possible physician bias. Presented at the annual meeting of the American Geriatrics Society, May 19, 1999. Financial support for this work was received from the Hartford/Jahnigen Center of Excellence in Geriatrics at the University of Colorado and the Colorado Collective for Medical Decisions, a nonprofit organization to improve care of the dying in the state of Colorado.