Personal health records and hypertension control: a randomized trial

Purpose

To examine the impact of a personal health record (PHR) in patients with hypertension measured by changes in biological outcomes, patient empowerment, patient perception of quality of care, and use of medical services.

Methods

A cluster-randomized effectiveness trial with PHR and no PHR groups was conducted in two ambulatory clinics. 453 of 1686 (26.4%) patients approached were included in the analyses. A PHR tethered to the patient''s electronic medical record (EMR) was the primary intervention and included security measures, patient control of access, limited transmission of EMR data, blood pressure (BP) tracking, and appointment assistance. BP was the main outcome measure. Patient empowerment was assessed using the Patient Activation Measure and Patient Empowerment Scale. Quality of care was assessed using the Clinician and Group Assessment Score (CAHPS) and the Patient Assessment of Chronic Illness Care. Frequency of use of medical services was self-reported.

Results

No impact of the PHR was observed on BP, patient activation, patient perceived quality, or medical utilization in the intention-to-treat analysis. Sub-analysis of intervention patients self-identified as active PHR users (25.7% of those with available information) showed a 5.25-point reduction in diastolic BP. Younger age, self-reported computer skills, and more positive provider communication ratings were associated with frequency of PHR use.

Conclusions

Few patients provided with a PHR actually used the PHR with any frequency. Thus simply providing a PHR may have limited impact on patient BP, empowerment, satisfaction with care, or use of health services without additional education or clinical intervention designed to increase PHR use.

Clinical trial registration number

http://ClinicalTrials.gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT01317537","term_id":"NCT01317537"}}NCT01317537.     

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 However, problem lists are often incomplete or out of date.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.     

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.     

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.     

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.     

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.     

The effectiveness of a new generation of computerized drug alerts in reducing the risk of injury from drug side effects: a cluster randomized trial

Context

Computerized drug alerts for psychotropic drugs are expected to reduce fall-related injuries in older adults. However, physicians over-ride most alerts because they believe the benefit of the drugs exceeds the risk.

Objective

To determine whether computerized prescribing decision support with patient-specific risk estimates would increase physician response to psychotropic drug alerts and reduce injury risk in older people.

Design

Cluster randomized controlled trial of 81 family physicians and 5628 of their patients aged 65 and older who were prescribed psychotropic medication.

Intervention

Intervention physicians received information about patient-specific risk of injury computed at the time of each visit using statistical models of non-modifiable risk factors and psychotropic drug doses. Risk thermometers presented changes in absolute and relative risk with each change in drug treatment. Control physicians received commercial drug alerts.

Main outcome measures

Injury risk at the end of follow-up based on psychotropic drug doses and non-modifiable risk factors. Electronic health records and provincial insurance administrative data were used to measure outcomes.

Results

Mean patient age was 75.2 years. Baseline risk of injury was 3.94 per 100 patients per year. Intermediate-acting benzodiazepines (56.2%) were the most common psychotropic drug. Intervention physicians reviewed therapy in 83.3% of visits and modified therapy in 24.6%. The intervention reduced the risk of injury by 1.7 injuries per 1000 patients (95% CI 0.2/1000 to 3.2/1000; p=0.02). The effect of the intervention was greater for patients with higher baseline risks of injury (p<0.03).

Conclusion

Patient-specific risk estimates provide an effective method of reducing the risk of injury for high-risk older people.

Trial registration number

clinicaltrials.gov Identifier: NCT00818285.     

A classification approach to coreference in discharge summaries: 2011 i2b2 challenge

Objective

To create a highly accurate coreference system in discharge summaries for the 2011 i2b2 challenge. The coreference categories include Person, Problem, Treatment, and Test.

Design

An integrated coreference resolution system was developed by exploiting Person attributes, contextual semantic clues, and world knowledge. It includes three subsystems: Person coreference system based on three Person attributes, Problem/Treatment/Test system based on numerous contextual semantic extractors and world knowledge, and Pronoun system based on a multi-class support vector machine classifier. The three Person attributes are patient, relative and hospital personnel. Contextual semantic extractors include anatomy, position, medication, indicator, temporal, spatial, section, modifier, equipment, operation, and assertion. The world knowledge is extracted from external resources such as Wikipedia.

Measurements

Micro-averaged precision, recall and F-measure in MUC, BCubed and CEAF were used to evaluate results.

Results

The system achieved an overall micro-averaged precision, recall and F-measure of 0.906, 0.925, and 0.915, respectively, on test data (from four hospitals) released by the challenge organizers. It achieved a precision, recall and F-measure of 0.905, 0.920 and 0.913, respectively, on test data without Pittsburgh data. We ranked the first out of 20 competing teams. Among the four sub-tasks on Person, Problem, Treatment, and Test, the highest F-measure was seen for Person coreference.

Conclusions

This system achieved encouraging results. The Person system can determine whether personal pronouns and proper names are coreferent or not. The Problem/Treatment/Test system benefits from both world knowledge in evaluating the similarity of two mentions and contextual semantic extractors in identifying semantic clues. The Pronoun system can automatically detect whether a Pronoun mention is coreferent to that of the other four types. This study demonstrates that it is feasible to accomplish the coreference task in discharge summaries.     

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.     

Guided medication dosing for elderly emergency patients using real-time, computerized decision support

Objective

To evaluate the impact of a real-time computerized decision support tool in the emergency department that guides medication dosing for the elderly on physician ordering behavior and on adverse drug events (ADEs).

Design

A prospective controlled trial was conducted over 26 weeks. The status of the decision support tool alternated OFF (7/17/06–8/29/06), ON (8/29/06–10/10/06), OFF (10/10/06–11/28/06), and ON (11/28/06–1/16/07) in consecutive blocks during the study period. In patients ≥65 who were ordered certain benzodiazepines, opiates, non-steroidals, or sedative-hypnotics, the computer application either adjusted the dosing or suggested a different medication. Physicians could accept or reject recommendations.

Measurements

The primary outcome compared medication ordering consistent with recommendations during ON versus OFF periods. Secondary outcomes included the admission rate, emergency department length of stay for discharged patients, 10-fold dosing orders, use of a second drug to reverse the original medication, and rate of ADEs using previously validated explicit chart review.

Results

2398 orders were placed for 1407 patients over 1548 visits. The majority (49/53; 92.5%) of recommendations for alternate medications were declined. More orders were consistent with dosing recommendations during ON (403/1283; 31.4%) than OFF (256/1115; 23%) periods (p≤0.0001). 673 (43%) visits were reviewed for ADEs. The rate of ADEs was lower during ON (8/237; 3.4%) compared with OFF (31/436; 7.1%) periods (p=0.02). The remaining secondary outcomes showed no difference.

Limitations

Single institution study, retrospective chart review for ADEs.

Conclusion

Though overall agreement with recommendations was low, real-time computerized decision support resulted in greater acceptance of medication recommendations. Fewer ADEs were observed when computerized decision support was active.     

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.     

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.     

Clinical decision support with automated text processing for cervical cancer screening

Objective

To develop a computerized clinical decision support system (CDSS) for cervical cancer screening that can interpret free-text Papanicolaou (Pap) reports.

Materials and Methods

The CDSS was constituted by two rulebases: the free-text rulebase for interpreting Pap reports and a guideline rulebase. The free-text rulebase was developed by analyzing a corpus of 49 293 Pap reports. The guideline rulebase was constructed using national cervical cancer screening guidelines. The CDSS accesses the electronic medical record (EMR) system to generate patient-specific recommendations. For evaluation, the screening recommendations made by the CDSS for 74 patients were reviewed by a physician.

Results and Discussion

Evaluation revealed that the CDSS outputs the optimal screening recommendations for 73 out of 74 test patients and it identified two cases for gynecology referral that were missed by the physician. The CDSS aided the physician to amend recommendations in six cases. The failure case was because human papillomavirus (HPV) testing was sometimes performed separately from the Pap test and these results were reported by a laboratory system that was not queried by the CDSS. Subsequently, the CDSS was upgraded to look up the HPV results missed earlier and it generated the optimal recommendations for all 74 test cases.

Limitations

Single institution and single expert study.

Conclusion

An accurate CDSS system could be constructed for cervical cancer screening given the standardized reporting of Pap tests and the availability of explicit guidelines. Overall, the study demonstrates that free text in the EMR can be effectively utilized through natural language processing to develop clinical decision support tools.     

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.     

Factors contributing to an increase in duplicate medication order errors after CPOE implementation

Objective

To evaluate the incidence of duplicate medication orders before and after computerized provider order entry (CPOE) with clinical decision support (CDS) implementation and identify contributing factors.

Design

CPOE with duplicate medication order alerts was implemented in a 400-bed Northeastern US community tertiary care teaching hospital. In a pre-implementation post-implementation design, trained nurses used chart review, computer-generated reports of medication orders, provider alerts, and staff reports to identify medication errors in two intensive care units (ICUs).

Measurement

Medication error data were adjudicated by a physician and a human factors engineer for error stage and type. A qualitative analysis of duplicate medication ordering errors was performed to identify contributing factors.

Results

Data were collected for 4147 patient-days pre-implementation and 4013 patient-days post-implementation. Duplicate medication ordering errors increased after CPOE implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001). Most post-implementation duplicate orders were either for the identical order or the same medication. Contributing factors included: (1) provider ordering practices and computer availability, for example, two orders placed within minutes by different providers on rounds; (2) communication and hand-offs, for example, duplicate orders around shift change; (3) CDS and medication database design, for example confusing alert content, high false-positive alert rate, and CDS algorithms missing true duplicates; (4) CPOE data display, for example, difficulty reviewing existing orders; and (5) local CDS design, for example, medications in order sets defaulted as ordered.

Conclusions

Duplicate medication order errors increased with CPOE and CDS implementation. Many work system factors, including the CPOE, CDS, and medication database design, contributed to their occurrence.