Electronic health records: which practices have them,and how are clinicians using them?

Background Limited data exist to estimate the use of electronic health records (EHRs) in ambulatory care practices in the United States. Methods We surveyed a stratified random sample of 1829 office practices in Massachusetts in 2005. The one‐page survey measured use of health information technology, plans for EHR adoption and perceived barriers to adoption. Results A total of 847 surveys were returned, for a response rate of 46%. Overall, 18% of office practices reported having an EHR. Primary‐care‐only and mixed practices reported similar adoption rates (23% and 25%, respectively, P = 0.70). The adoption rate in specialty practices (14%) was lower compared with both primary‐care‐only (P < 0.01) and mixed (P < 0.05) practices. The number of clinicians in the practice strongly correlated with EHR adoption (P < 0.001), with fewer small practices adopting EHRs. Among practices that have EHRs with laboratory and radiology result retrieval capabilities, at least 87% of practices report that a majority of their clinicians actively use these functionalities, while 74% of practices with electronic decision support report that the majority of clinicians actively use it. Among the practices without an EHR, 13% plan to implement one within the next 12 months, 24% within the next 1–2 years, 11% within the next 3–5 years, and 52% reported having no plans to implement an EHR in the foreseeable future. The most frequently reported barrier to implementation was lack of adequate funding (42%). Conclusions Overall, fewer than 1 in 5 medical practices in Massachusetts have an EHR. Even among adopters, though, doctor usage of EHR functions varied considerably by functionality and across practices. Many clinicians are not actively using functionalities that are necessary to improve health care quality and patient safety. Furthermore, among practices that do not have EHRs, more than half have no plan for adoption. Inadequate funding remains an important barrier to EHR adoption in ambulatory care practices in the United States.     

Electronic Health Records: Upsides,Downsides, and Inside-Outsides on the Way Toward Their Use in Clinical Practice

Background: The author reviews his personal history learning to use Electronic Health Records (EHRs) and examination room computers. He asks key questions that pertain to the use of EHRs in practice and discusses the current state of knowledge regarding EHRs and doctor–patient communication. Summary: He notes that—regardless of the ubiquity of computers in our society and the recognition that they are a part of current medical practice—one cannot just plop down a computer in the examination room, click “on,” and anticipate that communication between doctors and patients will flow smoothly. Conclusions: He recommends the accompanying article by Duke, Frankel, and Reis (see p. 358 in this issue) as an excellent step-by-step guide for framing how to teach the basics of EHR use in clinical practice.     

Satisfaction after the transition between electronic health record systems at six ambulatory practices

Rationale, aims and objectives Early adopters of electronic health records (EHRs) are transitioning from older to newer EHRs to satisfy meaningful use requirements. Facilitators and barriers to satisfaction after transitioning are important to understand as provider satisfaction is linked with improvement in health care. Method We conducted a cross‐sectional survey of providers who transitioned from an older to a newer EHR at six academic, urban ambulatory medical practices. A novel survey was developed to assess: (1) satisfaction with the EHR implementation; (2) patterns of information technology use; (3) work perceptions; (4) methods for completing clinical tasks; and (5) demographic characteristics. We analysed the results using bivariate and multivariate analyses. Results The response rate was 64% (n = 197). A small majority were satisfied with the new EHR (64%, n = 120). Providers who reported satisfaction with overall quality of work life, their workload and the transition were more likely to be satisfied with the new EHR (P < 0.01). Providers who reported using the Internet at least daily were also more likely to be satisfied with the new EHR (P < 0.05). In a multivariate model, satisfaction with the transition was a strong predictor of satisfaction with the new EHR (P < 0.01). Barriers to satisfaction include dissatisfaction with: maintaining problem and medication lists, tracking health maintenance information, referring to clinical practice guidelines and ordering laboratory and radiology tests (P < 0.01). Conclusion This study provides groundwork for understanding the facilitators and barriers to provider satisfaction after the transition between EHRs and provides insight into areas requiring attention by entities undergoing similar transitions.     

Development and evaluation of a checklist assessing communication skills of oncologists: the COM-ON-Checklist

Objectives Communication skills training (CST) has to be proven effective, and therefore reliable instruments to evaluate CST are required. Most instruments assessing medical consultations do not take individual aspects of CST into consideration. Such assessment tools should naturally also be closely associated with the communication skills taught to the participants. Thus, we developed a new instrument which evaluates the effects of specific CST. Methods Development: Based on a literature review, we developed a checklist with questions (‘items’) which assess the behaviour of a doctor in a special doctor–patient consultation (The COM‐ON‐Checklist, COM‐ON = communication in oncology). First, we developed items for general communication skills that are a requirement of every doctor–patient consultation, and in addition to this, we developed items for specific situations which present a particular challenge for doctors in terms of communication skills, namely: the situation in which the doctor is required to discuss the shift from curative to palliative care, and the disclosure of information about clinical trials. For assessment, a 5‐point rating scale with anchor points was used. Evaluation: Blinded raters were trained to use the COM‐ON‐Checklist. The intra‐class correlation (ICC) was used to calculate the agreement between raters. Results The COM‐ON‐Checklist consists of two parts: the first part evaluates general communication skills; the second part evaluates content‐specific aspects of the consultation. The ICC ranged from 0.5 to 0.8, which demonstrates moderate to very good results of inter‐rater reliability. Discussion The COM‐ON‐Checklist can be used to evaluate specific CST. It is also a feedback source for clinicians because it assesses their personal communication skills in different settings. In conclusion, the COM‐ON‐Checklist provides a reliable, structured method for assessing communication skills in oncological settings.     

Electronic Health Records in Danish Home Care and Nursing Homes: Inadequate Documentation of Care,Medication, and Consent

Background  Electronic health records (EHRs) are used in long-term care to document the patients'' condition, medication, and care, thereby supporting communication among caregivers and counteracting adverse drug events. However, the use of EHRs in long-term care has lagged behind EHR use in hospitals. In addition, most EHR research focuses on hospitals. Objective  This study gives a countrywide status of the documentation-related risks to patient safety in Danish home care and nursing homes, which are the two main providers of long-term care. Such a status provides a basis for national improvement efforts and international comparisons. Method  The study is based on the reports from 893 inspections of home care and nursing homes by the Danish Patient Safety Authority (Styrelsen for Patientsikkerhed [STPS]). Results  As much as 69% of the inspected institutions document inadequately to an extent that has led to demands (i.e., issues the institution is legally obliged to rectify) or requests (i.e., issues the institution is merely asked to rectify) from STPS. Documentation issues about the patients'' condition and care are present in nearly all institutions that receive demands (97%) and in the majority of those that receive requests (68%). Documentation issues about medication and consent to care are also common, but less so. The predominant risk to patient safety is incomplete documentation. It covers 72% of the documentation issues identified in the institutions that received demands; the remaining risks concern inconsistent (11%), nonexistent (7%), inaccessible (5%), and noncompliant (5%) documentation. The documentation inadequacies are similar for home care and nursing homes. Conclusion  Inadequate EHR documentation is a widespread problem in Danish long-term care. While previous research mainly focuses on how EHR documentation affects patient medication, this study finds that documentation issues about the patients'' condition and care are more prevalent and that issues about their consent are also common.     

Clinician Perceptions of Pediatric Growth Chart Use and Electronic Health Records in Kentucky

Background

Growth chart recording is a key component of pediatric care. EHR systems could provide several growth charting functionalities compared to paper methods. To our knowledge, there has been no U.S. study exploring clinicians’ perceptions and practices related to recording of growth parameters as they adapt to electronic methods.

Objectives

To explore clinician practices regarding recording growth parameters as they adapt to electronic health records (EHR) and to investigate clinician perceptions of electronic growth charting using EHR.

Methods

An online survey of pediatricians and family practitioners in Kentucky inquiring about EHR usage, specifically use of growth charting with EHR, was conducted.

Results

Forty-six percent of respondents utilized EHRs, with pediatricians lagging family practitioners, and academic pediatricians lagging non-academicians. There was no consensus on EHR platforms being used. Almost a third of those who used EHR did not utilize electronic growth charting. Clinicians using EHR reported that electronic growth charts would improve clinician satisfaction and clinical efficiency as well as parent satisfaction and parent education. Only 12% of respondents provided copies of growth charts to parents at the end of their visit and discussed growth parameters with parents, with clinicians using EHR more likely to engage in these activities than non-EHR users.

Conclusion

Although Kentucky clinicians continue to slowly adopt EHRs, clinician perceptions and practices reflect enduring barriers to widespread use of electronic growth charting in pediatric and family practice. However, our results suggest that electronic growth charting has important benefits for both clinicians and patients, and greater adoption is expected as EHRs become standard across health care systems.     

Electronic Health Record Adoption – Maybe It’s not about the Money: Physician Super-Users,Electronic Health Records and Patient Care

Objective

The slow adoption of electronic health record (EHR) systems has been linked to physician resistance to change and the expense of EHR adoption. This qualitative study was conducted to evaluate benefits, and clarify limitations of two mature, robust, comprehensive EHR Systems by tech-savvy physicians where resistance and expense are not at issue.

Methods

Two EHR systems were examined – the paperless VistA / Computerized Patient Record System used at the Veterans’ Administration, and the General Electric Centricity Enterprise system used at an academic medical center. A series of interviews was conducted with 20 EHR-savvy multiinstitutional internal medicine (IM) faculty and house staff. Grounded theory was used to analyze the transcribed data and build themes. The relevance and importance of themes were constructed by examining their frequency, convergence, and intensity.

Results

Despite eliminating resistance to both adoption and technology as drivers of acceptance, these two robust EHR’s are still viewed as having an adverse impact on two aspects of patient care, physician workflow and team communication. Both EHR’s had perceived strengths but also significant limitations and neither were able to satisfactorily address all of the physicians’ needs.

Conclusion

Difficulties related to physician acceptance reflect real concerns about EHR impact on patient care. Physicians are optimistic about the future benefits of EHR systems, but are frustrated with the non-intuitive interfaces and cumbersome data searches of existing EHRs.     

Awareness of the Care Team in Electronic Health Records

OBJECTIVE: To support collaboration and clinician-targeted decision support, electronic health records (EHRs) must contain accurate information about patients' care providers. The objective of this study was to evaluate two approaches for care provider identification employed within a commercial EHR at a large academic medical center. METHODS: We performed a retrospective review of EHR data for 121 patients in two cardiology wards during a four-week period. System audit logs of chart accesses were analyzed to identify the clinicians who were likely participating in the patients' hospital care. The audit log data were compared with two functions in the EHR for documenting care team membership: 1) a vendor-supplied module called "Care Providers", and 2) a custom "Designate Provider" order that was created primarily to improve accuracy of the attending physician of record documentation. RESULTS: For patients with a 3-5 day hospital stay, an average of 30.8 clinicians accessed the electronic chart, including 10.2 nurses, 1.4 attending physicians, 2.3 residents, and 5.4 physician assistants. The Care Providers module identified 2.7 clinicians/patient (1.8 attending physicians and 0.9 nurses). The Designate Provider order identified 2.1 clinicians/patient (1.1 attending physicians, 0.2 resident physicians, and 0.8 physician assistants). Information about other members of patients' care teams (social workers, dietitians, pharmacists, etc.) was absent. CONCLUSIONS: The two methods for specifying care team information failed to identify numerous individuals involved in patients' care, suggesting that commercial EHRs may not provide adequate tools for care team designation. Improvements to EHR tools could foster greater collaboration among care teams and reduce communication-related risks to patient safety.     

Satisfaction of health‐care providers with electronic health records and perceived barriers to its implementation in the United Arab Emirates

The integration of electronic health records (EHRs) has shown promise in improving health‐care quality. In the United Arab Emirates, EHRs have been recently adopted to improve the quality and safety of patient care. A cross‐sectional survey of 680 health‐care providers (HCPs) was conducted to assess the satisfaction of HCPs in the United Arab Emirates with EHRs' impact on access/viewing, documentation and medication administration and to explore the barriers encountered in their use. Data were collected over 6 months from April to September 2014. High overall satisfaction with EHRs was reported by HCPs, suggesting their acceptance. Physicians reported the greatest overall satisfaction with EHRs, although nurses showed significantly higher satisfaction with the impact on medication administration compared with other HCPs. The most significant barriers reported by nurses were lack of belief in the value of EHRs for patients and lack of adequate computer skills. Given the large investment in technology, additional research is necessary to promote the full utilization of EHRs. Nurses need to be aware of the value of EHRs for patient care and be involved in all stages of EHR implementations to maximize its meaningful use for better clinical outcomes.     

Electronic health record adoption and health information exchange among hospitals in New York State

Rationale, aims and objectives Unprecedented national and state initiatives are underway to promote adoption and meaningful use of electronic health records (EHRs) with health information exchange (HIE). New York State leads the nation in state initiatives and is conducting ongoing surveillance of its investments. Lessons learned from studying states like New York can inform federal policies and will be essential to evaluate the effectiveness of these initiatives. We undertook this first in a series of planned surveys to assess EHR adoption and HIE activities by New York State hospitals. METHODS: Between May and December 2009, we surveyed all New York State hospitals to determine rates of EHR adoption, participation in HIE and implementation of functionalities associated with nine core meaningful use criteria. Results We received responses from 148 (72.2%) of 205 hospitals surveyed and found that 23 (15.5%) had adopted an EHR and 29 (23.2%) were participating in HIE. Two hospitals (1.4%) reported full implementation of the meaningful use functionalities surveyed. Public hospitals were ahead of private hospitals and notable regional differences were found. Discussion EHR adoption rates and participation in HIE are higher among New York hospitals than hospitals nationwide, suggesting that state initiatives funding community EHR implementation may influence these efforts by hospitals. However, overall rates of adoption and preparedness to meet meaningful use remain low. Direct support for hospitals, such as that provided through the national EHR Incentive Program, will likely be critical for rates of EHR adoption and HIE to significantly rise, even in advanced states.     

Promoting Responsible Electronic Documentation: Validity Evidence for a Checklist to Assess Progress Notes in the Electronic Health Record

Construct: We aimed to develop an instrument to measure the quality of inpatient electronic health record– (EHR–) generated progress notes without requiring raters to review the detailed chart or know the patient. Background: Notes written in EHRs have generated criticism for being unnecessarily long and redundant, perpetuating inaccuracy and obscuring providers' clinical reasoning. Available assessment tools either focus on outpatient progress notes or require chart review by raters to develop familiarity with the patient. Approach: We used medical literature, local expert review, and attending focus groups to develop and refine an instrument to evaluate inpatient progress notes. We measured interrater reliability and scored the selected-response elements of the checklist for a sample of 100 progress notes written by PGY-1 trainees on the general medicine service. Results: We developed an instrument with 18 selected-response items and four open-ended items to measure the quality of inpatient progress notes written in the EHR. The mean Cohen's kappa coefficient demonstrated good agreement at .67. The mean note score was 66.9% of maximum possible points (SD = 10.6, range = 34.4%–93.3%). Conclusions: We present validity evidence in the domains of content, internal structure, and response process for a new checklist for rating inpatient progress notes. The scored checklist can be completed in approximately 7 minutes by a rater who is not familiar with the patient and can be done without extensive chart review. We further demonstrate that trainee notes show substantial room for improvement.     

Implementation of a Postoperative Electronic Health Record Alert for Cardiac Implantable Electronic Device Patients

PurposeApproximately 2% of surgical patients have an existing cardiac implantable electronic device (CIED). Perioperative device reprogramming requires postoperative care to ensure that device settings are restored. Electronic health record (EHR) alerts have been shown to improve communication between providers and decrease time to necessary interventions in other areas of medicine. The aim of this quality improvement project was to create an EHR alert for postoperative CIED patients who require device reprogramming to help clinicians track, remember, and document the timely and safe restoration of device settings.DesignThis project used a pre-post observational design.MethodsThis project was conducted at a major academic medical center using a pre-post observational design. To prevent anesthesia providers from closing an encounter in the EHR before postoperative restoration of device settings, an alert was developed and embedded within the intraoperative EHR to track preoperative device reprogramming, and alert anesthesia providers to perform and document postoperative restoration of safe settings.FindingsThe postimplementation group (n = 272) had fewer unknown or undocumented preoperative CIED interventions (12.9% vs 30.9%), a 7.3% shorter device suspension time (median = 165 minutes vs 178 minutes), 6.8% improvement in documentation of postoperative re-enabling of device therapies (78.8% vs 72.0%), and a 72.48% decrease in length of stay (median = 625 hours vs 172 hours) when compared with the preimplementation group (n = 132).ConclusionElectronic prompts effectively captured patients who received preoperative CIED reprogramming and provided a process for reprogramming devices to safe settings, both significant steps in preventing negative patient outcomes associated with undocumented CIED interventions. Perioperative CIED documentation improved, and length of stay decreased after project implementation.     

Meaningful Use of Electronic Health Records

The concerns on patient safety and quality improvement in health care are increasing. There is growing use of technology in health care, particularly use of the electronic health record (EHR). As this occurs, the health care system is transforming. The federal government has become involved in EHR implementation, encouraging improved health care. The Centers for Medicare & Medicaid Services are implementing the Meaningful Use (MU) Incentive Program for Medicare- and Medicaid-eligible providers. As EHR implementation and MU Programs grow, it is important for the nurse practitioner (NP) to be aware of the MU Program. As NPs become engaged in using EHRs, MU will have an impact on changing health care systems and implications related to clinical practice and improved outcomes.     

Consultation in the emergency department: a qualitative analysis and review

Background

No studies have evaluated the consultation process or attempted to define a standardized approach that could improve communication and patient outcomes.

Objective

To perform a qualitative analysis of emergency medicine (EM) consultation to reveal its complexity and elucidate strategies and frameworks for physician-to-physician communication.

Methods

Data were collected in three phases: informal interviews conducted in an emergency department (ED), 10-question surveys given to a subset of EM and specialty physicians, and semi-structured 1-h group interviews using open-ended questions to further explore issues and trends elicited from the survey responses. In addition, we conducted an extensive literature search focused on health care and business consultation and communication.

Results

Seventy-six percent (29 of 38) of emergency and specialty physicians completed the 10-question survey in its entirety. Three themes were identified from the survey responses: organizational skills, interpersonal and communication skills, and medical knowledge. Of 95 total comments, 41 (43%) focused on organizational skills, 26 (27%) on interpersonal and communication skills, and 28 (30%) on medical knowledge. There were 29 comments regarding poor consultations: 15 issues with organization, 6 with interpersonal and communication skills, and 8 with medical knowledge. The literature search revealed several models and types of consultation, but no standard algorithm currently exists.

Conclusions

We recommend focusing on organizational skills, interpersonal and communication skills, and medical knowledge when teaching ED consultation and present a conceptual framework of the Five Cs Consultation Model: contact, communication, core question, collaboration, and closing the loop.     

Assessing Advanced Communication Skills via Objective Structured Clinical Examination: A Comparison of Faculty Versus Self,Peer, and Standardized Patient Assessors

Abstract

Construct: The construct addressed in this study is assessment of advanced communication skills among senior medical students. Background: The question of who should assess participants during objective structured clinical examinations (OSCEs) has been debated, and options discussed in the literature have included peer, self, standardized patient, and faculty assessment models. What is not known is whether same-level peer assisted learning can be utilized for formative assessment of advanced communication skills when no faculty, standardized patients, or other trained assessors are involved in providing feedback. If successful, such an educational model would optimize resource utilization and broaden the scope of topics that could be covered in formative OSCEs. Approach: The investigators developed a 4-station formative OSCE focused on advanced communication skills for senior medical students, and evaluated the concordance of assessment done by same-level peers, self, standardized patients, and faculty for 45 students. After each station, examinees completed a self-assessment checklist and received checklist-based assessment and verbal feedback from same-level peers only. Standardized patients completed checklist-based assessments outside the room, and faculty did so after the OSCE via video review; neither group provided direct feedback to examinees. The investigators assessed inter-rater agreement and mean difference scores on the checklists using faculty score as the gold standard. Findings: There was fair to good overall agreement among self, same-level peer, standardized patient, and faculty-assessment of advanced communication skills. Relative to faculty, peer and standardized patient assessors overestimated advanced communication skills, while self-assessments underestimated skills. Conclusions: Self and same-level peer-assessment may be a viable alternative to faculty assessment for a formative OSCE on advanced communication skills for senior medical students.     

Use,Impact, Weaknesses,and Advanced Features of Search Functions for Clinical Use in Electronic Health Records: A Scoping Review

Objective  Although vast amounts of patient information are captured in electronic health records (EHRs), effective clinical use of this information is challenging due to inadequate and inefficient access to it at the point of care. The purpose of this study was to conduct a scoping review of the literature on the use of EHR search functions within a single patient''s record in clinical settings to characterize the current state of research on the topic and identify areas for future study. Methods  We conducted a literature search of four databases to identify articles on within-EHR search functions or the use of EHR search function in the context of clinical tasks. After reviewing titles and abstracts and performing a full-text review of selected articles, we included 17 articles in the analysis. We qualitatively identified themes in those articles and synthesized the literature for each theme. Results  Based on the 17 articles analyzed, we delineated four themes: (1) how clinicians use search functions, (2) impact of search functions on clinical workflow, (3) weaknesses of current search functions, and (4) advanced search features. Our review found that search functions generally facilitate patient information retrieval by clinicians and are positively received by users. However, existing search functions have weaknesses, such as yielding false negatives and false positives, which can decrease trust in the results, and requiring a high cognitive load to perform an inclusive search of a patient''s record. Conclusion  Despite the widespread adoption of EHRs, only a limited number of articles describe the use of EHR search functions in a clinical setting, despite evidence that they benefit clinician workflow and productivity. Some of the weaknesses of current search functions may be addressed by enhancing EHR search functions with collaborative filtering.     

EHR adoption among doctors who treat the elderly

Objectives The purpose of this study is to examine Electronic Health Record (EHR) adoption among Florida doctors who treat the elderly. This analysis contributes to the EHR adoption literature by determining if doctors who disproportionately treat the elderly differ from their counterparts with respect to the utilization of an important quality‐enhancing health information technology application. Methods This study is based on a primary survey of a large, statewide sample of doctors practising in outpatient settings in Florida. Logistic regression analysis was used to determine whether doctors who treat a high volume of elderly (HVE) patients were different with respect to EHR adoption. Results Our analyses included responses from 1724 doctors. In multivariate analyses controlling for doctor age, training, computer sophistication, practice size and practice setting, HVE doctors were significantly less likely to adopt EHR. Specifically, compared with their counterparts, HVE doctors were observed to be 26.7% less likely to be utilizing an EHR system (OR = 0.733, 95% CI 0.547–0.982). We also found that doctor age is negatively related to EHR adoption, and practice size and doctor computer savvy‐ness is positively associated. Conclusions Despite the fact that EHR adoption has improved in recent years, doctors in Florida who serve the elderly are less likely to adopt EHRs. As long as HVE doctors are adopting EHR systems at slower rates, the elderly patients treated by these doctors will be at a disadvantage with respect to potential benefits offered by this technology.