Electronic Medical Record Availability and Primary Care Depression Treatment

Background

Electronic medical records (EMR) are commonly believed to improve quality of care. Primary care patients with multiple chronic conditions have potentially greater opportunity to benefit from receiving care at practices with EMRs if these systems help coordinate complex care.

Objective

To examine how chronic conditions impact the odds that depressed patients receive depression treatment in primary care practices with EMRs compared to practices without EMRs.

Design

The study uses logistic regression to analyze cross-sectional data of primary care physician office visits in freestanding, office-based practices from the 2006?C2008 National Ambulatory Medical Care Surveys.

Patients

All visits to primary care providers made by patients ages 18 and older with physician-identified depression (N?=?3,467).

Main Measures

Outcomes include depression treatment which is defined as receipt or ordering of antidepressant medication and/or mental health counseling.

Key Results

EMRs were associated with significantly lowered odds that depressed patients received depression treatment (OR?=?0.75, p?=?0.009, 95% CI: 0.61-0.93); however when stratified by the number of chronic conditions, this association was observed only in patients with three or more chronic conditions (OR?=?0.50, p?>?0.001, 95% CI: 0.36-0.70). EMRs did not have a significant association with depression treatment for patients with two or fewer chronic conditions.

Conclusions

EMRs appear to have an unintended negative association with depression care provided during visits made by primary care patients with multiple chronic conditions.     

Trends in Primary Care Clinician Perceptions of a New Electronic Health Record

Background  Clinician perceptions of a newly implemented electronic health record play an important role in its success or failure. Objective  To measure changes in primary care clinician attitudes toward an electronic health record during the first year following implementation. Design  Longitudinal survey. Participants  86 primary care clinicians surveyed between December 2006 and January 2008. Measurements  Perceived impact on overall quality of care, patient safety, communication, and efficiency at 1, 3, 6, and 12 months following implementation. Results  Response rates for months 1, 3, 6, and 12 were 92%, 95%, 90%, and 82%, respectively. The proportion of clinicians agreeing that the EHR improved the overall quality of care (63% to 86%; p < 0.001), reduced medication-related errors (72% to 81%; p = 0.03), improved follow-up of test results (62% to 87%; p < 0.001), and improved communication among clinicians (72% to 93%; p < 0.001) increased from month 1 to month 12. During the same time period, a decreasing proportion of clinicians agreed that the EHR reduced the quality of patient interactions (49% to 33%; p = 0.001), resulted in longer patient visits (68% to 51%; p = 0.001), and increased time spent on medical documentation (78% to 68%; p = 0.006). Significant improvements in perceptions related to test result follow-up were first detected at 6 months, while those related to overall quality, efficiency, and communication were first identified at 12 months. Conclusions  Primary care clinicians report increasingly positive perceptions of a new electronic health record within 1 year of implementation across a spectrum of domains of care. This study was funded by grants from the Agency for Healthcare Research and Quality (1 R01 HS 015226-01) and the National Library of Medicine (2 T15 LM 07092-16).     

The Policy Context of Patient Centered Medical Homes: Perspectives of Primary Care Providers

BACKGROUND

Interest in the patient centered medical home (PCMH) model has increased significantly in recent years. Despite this attention, information is limited regarding the influence of policy context on implementation of the PCMH model. Using comparative, qualitative data, we identify several key policy impediments to PCMH implementation, and propose practical guidelines for addressing these issues.

RESEARCH DESIGN

Qualitative, semi-structured in-person interviews with representatives of physician organizations and primary care practices pursuing PCMH.

PARTICIPANTS

Practitioners and staff at 16 physician practices in Michigan, as well as key leaders of physician organizations.

KEY RESULTS

We identified five primary policy issues cited by physicians and physician organization leaders as most impactful on their efforts to adopt PCMH: misalignment of current reimbursement schemes, administrative burden, conflicting criteria for PCMH designation, workforce policy issues, and uncertainty of health care reform. These policies were largely seen as barriers to their ability to implement PCMH.

CONCLUSIONS

Providers’ motivation to embrace PCMH, and their level of confidence regarding the results of such change, are greatly influenced by their perception of the external environment and the control they believe they have over this environment. Having policies in place that shape the path to PCMH in a manner that makes it as easy as possible for providers to accomplish the desired changes could well make the difference in whether successful transformation is achieved.     

Use of an Electronic Problem List by Primary Care Providers and Specialists

BACKGROUND

Accurate patient problem lists are valuable tools for improving the quality of care, enabling clinical decision support, and facilitating research and quality measurement. However, problem lists are frequently inaccurate and out-of-date and use varies widely across providers.

OBJECTIVE

Our goal was to assess provider use of an electronic problem list and identify differences in usage between medical specialties.

DESIGN

Chart review of a random sample of 100,000 patients who had received care in the past two years at a Boston-based academic medical center.

PARTICIPANTS

Counts were collected of all notes and problems added for each patient from 1/1/2002 to 4/30/2010. For each entry, the recording provider and the clinic in which the entry was recorded was collected. We used the Healthcare Provider Taxonomy Code Set to categorize each clinic by specialty.

MAIN MEASURES

We analyzed the problem list use across specialties, controlling for note volume as a proxy for visits.

KEY RESULTS

A total of 2,264,051 notes and 158,105 problems were recorded in the electronic medical record for this population during the study period. Primary care providers added 82.3% of all problems, despite writing only 40.4% of all notes. Of all patients, 49.1% had an assigned primary care provider (PCP) affiliated with the hospital; patients with a PCP had an average of 4.7 documented problems compared to 1.5 problems for patients without a PCP.

CONCLUSIONS

Primary care providers were responsible for the majority of problem documentation; surgical and medical specialists and subspecialists recorded a disproportionately small number of problems on the problem list.     

Implementation of a CKD Checklist for Primary Care Providers

Background and objectives

CKD is associated with significant morbidity, mortality, and financial burden. Practice guidelines outlining CKD management exist, but there is limited application of these guidelines. Interventions to improve CKD guideline adherence have been limited. This study evaluated a new CKD checklist (a tool outlining management guidelines for CKD) to determine whether implementation in an academic primary care clinic improved adherence to guidelines.

Design, setting, participants, & measurements

During a 1-year period (August 2012–August 2013), a prospective study was conducted among 13 primary care providers (PCPs), four of whom were assigned to use a CKD checklist incorporated into the electronic medical record during visits with patients with CKD stages 1–4. All providers received education regarding CKD guidelines. The intervention and control groups consisted of 105 and 263 patients, respectively. Adherence to CKD management guidelines was measured.

Results

A random-effects logistic regression analysis was performed to account for intra-group correlation by PCP assignment and adjusted for age and CKD stage. CKD care improved among patients whose PCPs were assigned to the checklist intervention compared with controls. Patients in the CKD checklist group were more likely than controls to have appropriate annual laboratory testing for albuminuria (odds ratio [OR], 7.9; 95% confidence interval [95% CI], 3.6 to 17.2), phosphate (OR, 3.5; 95% CI, 1.5 to 8.3), and parathyroid hormone (OR, 8.1; 95% CI, 4.8 to 13.7) (P<0.001 in all cases). Patients in the CKD checklist group had higher rates of achieving a hemoglobin A1c target<7% (OR, 2.7; 95% CI, 1.4 to 5.1), use of an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker (OR, 2.1; 95% CI, 1.0 to 4.2), documentation of avoidance of nonsteroidal anti-inflammatory drugs (OR, 41.7; 95% CI, 17.8 to 100.0), and vaccination for annual influenza (OR, 2.1; 95% CI, 1.1 to 4.0) and pneumococcus (OR, 4.7; 95% CI, 2.6 to 8.6) (P<0.001 in all cases).

Conclusions

Implementation of a CKD checklist significantly improved adherence to CKD management guidelines and delivery of CKD care.     

Association of Communication Between Hospital-based Physicians and Primary Care Providers with Patient Outcomes

BACKGROUND  Patients admitted to general medicine inpatient services are increasingly cared for by hospital-based physicians rather than their primary care providers (PCPs). This separation of hospital and ambulatory care may result in important care discontinuities after discharge. We sought to determine whether communication between hospital-based physicians and PCPs influences patient outcomes. METHODS  We approached consecutive patients admitted to general medicine services at six US academic centers from July 2001 to June 2003. A random sample of the PCPs for consented patients was contacted 2 weeks after patient discharge and surveyed about communication with the hospital medical team. Responses were linked with the 30-day composite patient outcomes of mortality, hospital readmission, and emergency department (ED) visits obtained through follow-up telephone survey and National Death Index search. We used hierarchical multi-variable logistic regression to model whether communication with the patient’s PCP was associated with the 30-day composite outcome. RESULTS  A total of 1,772 PCPs for 2,336 patients were surveyed with 908 PCPs responses and complete patient follow-up available for 1,078 patients. The PCPs for 834 patients (77%) were aware that their patient had been admitted to the hospital. Of these, direct communication between PCPs and inpatient physicians took place for 194 patients (23%), and a discharge summary was available within 2 weeks of discharge for 347 patients (42%). Within 30 days of discharge, 233 (22%) patients died, were readmitted to the hospital, or visited an ED. In adjusted analyses, no relationship was seen between the composite outcome and direct physician communication (adjusted odds ratio 0.87, 95% confidence interval 0.56 – 1.34), the presence of a discharge summary (0.84, 95% CI 0.57–1.22), or PCP awareness of the index hospitalization (1.08, 95% CI 0.73–1.59). CONCLUSION  Analysis of communication between PCPs and inpatient medical teams revealed much room for improvement. Although communication during handoffs of care is important, we were not able to find a relationship between several aspects of communication and associated adverse clinical outcomes in this multi-center patient sample. This paper was presented at the Society for General Internal Medicine Annual Meeting in April 2006.     

Electronic Health Record Use,Intensity of Hospital Care,and Patient Outcomes

Objective

Previous studies have suggested that weekend hospital care is inferior to weekday care and that this difference may be related to diminished care intensity. The purpose of this study was to determine whether a metric for measuring intensity of hospital care based on use of the electronic health record was associated with patient-level outcomes.

Methods

We performed a cohort study of hospitalizations at an academic medical center. Intensity of care was defined as the hourly number of provider accessions of the electronic health record, termed “electronic health record interactions.” Hospitalizations were categorized on the basis of the mean difference in electronic health record interactions between the first Friday and the first Saturday of hospitalization. We used regression models to determine the association of these categories with patient outcomes after adjusting for covariates.

Results

Electronic health record interactions decreased from Friday to Saturday in 77% of the 9051 hospitalizations included in the study. Compared with hospitalizations with no change in Friday to Saturday electronic health record interactions, the relative lengths of stay for hospitalizations with a small, moderate, and large decrease in electronic health record interactions were 1.05 (95% confidence interval [CI], 1.00-1.10), 1.11 (95% CI, 1.05-1.17), and 1.25 (95% CI, 1.15-1.35), respectively. Although a large decrease in electronic health record interactions was associated with in-hospital mortality, these findings were not significant after risk adjustment (odds ratio 1.74, 95% CI, 0.93-3.25).

Conclusions

Intensity of inpatient care, measured by electronic health record interactions, significantly diminished from Friday to Saturday, and this decrease was associated with length of stay. Hospitals should consider monitoring and correcting temporal fluctuations in care intensity.     

End-of-Life Care from the Perspective of Primary Care Providers

PURPOSE

To explore the factors influencing primary care providers?? ability to care for their dying patients in Michigan.

METHODS

We conducted 16 focus groups to explore the provision of end-of-life care by 7 diverse primary care practices in southeast Michigan. Twenty-eight primary care providers and 22 clinical support staff participated in the study. Interviews were analyzed using thematic analysis.

RESULTS

Primary care providers (PCPs) wanted to care for their dying patients and felt largely competent to provide end-of-life care. They and their staff reported the presence of five structural factors that influenced their ability to do so: (1) continuity of care to help patients make treatment decisions and plan for the end of life; (2) scheduling flexibility and time with patients to address emergent needs, provide emotional support, and conduct meaningful end-of-life discussions; (3) information-sharing with outside providers and within the primary care practice; (4) coordination of care to address patients?? needs quickly; and (5) authority to act on behalf of their patients.

CONCLUSIONS

In order to provide end-of-life care, PCPs need structural supports within primary care for continuity of care, flexible scheduling, information-sharing, coordination of primary care, and protection of their authority.     

Electronic Medical Record Documentation of Driving Safety for Veterans with Diagnosed Dementia

Objectives: Many older adults continue to drive following dementia diagnosis, with medical providers increasingly likely to be involved in addressing such safety concerns. This study examined electronic medical record (EMR) documentation of driving safety for veterans with dementia (N = 118) seen in Veterans Affairs primary care and interdisciplinary geriatrics clinics in one geographic region over a 10-year period.

Methods: Qualitative directed content analysis of retrospective EMR data.

Results: Assessment of known risk factors or subjective concerns for unsafe driving were documented in fewer than half of observed cases; specific recommendations for driving safety were evident for a minority of patients, with formal driving evaluation the most frequently documented recommendation by providers.

Conclusion: Utilizing data from actual clinical encounters provides a unique snapshot of how driving risk and safety concerns are addressed for veterans with dementia. This information provides a meaningful frame of reference for understanding potential strengths and possible gaps in how this important topic area is being addressed in the course of clinical care.

Clinical Implications: The EMR is an important forum for interprofessional communication, with documentation of driving risk and safety concerns an essential element for continuity of care and ensuring consistency of information delivered to patients and caregivers.     

Perceptions of Electronic Health Record Implementation: A Statewide Survey of Physicians in Rhode Island

ObjectivesAlthough electronic health record use improves healthcare delivery, adoption into clinical practice is incomplete. We sought to identify the extent of adoption in Rhode Island and the characteristics of physicians and electronic health records associated with positive experience.MethodsWe performed a cross-sectional study of data collected by the Rhode Island Department of Health for the Health Information Technology Survey 2009 to 2013. Survey questions included provider and practice demographics, health record information, and Likert-type scaled questions regarding how electronic health record use affected clinical practice.ResultsThe survey response rate ranged from 50% to 65%, with 62% in 2013. Increasing numbers of physicians in Rhode Island use an electronic health record. In 2013, 81% of physicians used one, and adoption varied by clinical subspecialty. Most providers think that electronic health record use improves billing and quality improvement but has not improved job satisfaction. Physicians with longer and more sophisticated electronic health record use report positive effects of introduction on all aspects of practice examined (P < .001). Older physician age is associated with worse opinion of electronic health record introduction (P < .001). Of the 18 electronic health record vendors most frequently used in Rhode Island, 5 were associated with improved job satisfaction.ConclusionsWe report the largest statewide study of electronic health record adoption to date. We found increasing physician use in Rhode Island, and the extent of adoption varies by subspecialty. Although older physicians are less likely to be positive about electronic health record adoption, longer and more sophisticated use are associated with more positive opinions, suggesting acceptance will grow over time.     

A Comparison of Electronic Patient-Portal Use Among Patients with Resident and Attending Primary Care Providers

Background

Electronic patient-portals offer the potential to enhance patient-physician communication and health outcomes but differential use may create or worsen disparities. While prior studies identified patient characteristics associated with patient-portal use, the role of physician factors is less known. We investigated differences in overall and patterns of portal use for patients with resident and attending primary care providers (PCPs).

Methods

Cross-sectional study of all established patients with a resident or attending PCP seen at an academic internal medicine practice (two sites) between May 1, 2014, and April 30, 2015. We defined patient-portal use as having accessed any “active” (secure messaging, medication refill request), or “passive” (viewing labs, after visit summaries, or appointments) patient-portal function more than once over the study period. We used generalized linear models clustered on PCP to examine the odds of patient-portal use by PCP type, adjusted for patient age, gender, preferred language, race/ethnicity, insurance, and visits. Among patient-portal users, we examined the association of PCP type with “active use” utilizing the same method.

Results

The mean patient age (n =?17,699) was 54.2 (SD 17.5), with 47.2% White, 23.6% Asian, 8.8% Black, 8.4% Latino, and 12% other/unknown. The majority (61.8%) had private insurance, and attending PCPs (76.9%). Although 72.3% enrolled in the patient-portal, only 53.4% were portal users; 40.0% were active users. There were 47 attending and 62 resident physicians. Patients with resident PCPs had lower odds of using the portal compared to those with attending PCPs (OR?=?0.54, 95% CI 0.50–0.59). Similarly, among portal users, residents’ patients had lower odds of being active users of the portal (OR?=?0.76, 95% CI 0.68–0.87).

Conclusion

Given the lower patient-portal use among residents’ patients, residency programs should develop curricula to bolster trainee competence in using the patient-portal for communication and to enhance the patient-physician relationship. Future research should explore additional physician factors that impact portal use.

     

Implementation of an Electronic Health Record-Based Care Management System to Improve Tobacco Treatment

BACKGROUND

Tobacco treatment is underused in primary care. We designed a Tobacco Care Management system to increase the delivery of treatment and reduce the burden on primary care providers (PCPs). A one-click functionality added to the electronic health record (EHR) allowed PCPs to refer smokers to a centralized tobacco treatment coordinator (TTC) who called smokers, provided brief counseling, connected them to ongoing treatment and gave feedback to PCPs.

OBJECTIVE

To study the system??s feasibility and acceptability among PCPs, and its utilization by smokers.

DESIGN

Using a mixed methods design, we documented system utilization quantitatively from February 1, 2010 to July 31, 2011, and conducted two focus groups with PCPs in June 2011.

PARTICIPANTS

Thirty-six PCPs and 2,894 smokers from two community health centers in Massachusetts.

MAIN MEASURES

Quantitative: One-click referral utilization by PCPs, proportion of smokers referred and connected to treatment. Qualitative: PCPs?? reasons for use, barriers to use, and experiences with feedback.

KEY RESULTS

Twenty-nine PCPs (81?%) used the functionality more than once, generating 466 referrals for 15?% of known smokers seen during the study. The TTC reached 260 (56?%) of the referrals and connected 135 (29?%) to additional treatment. The director of one center sent PCPs monthly feedback about their utilization compared to peers. These PCPs referred a greater proportion of their known smokers (18?% vs. 9?%, p?<?0.0001) and reported that monthly feedback motivated referrals. PCPs attending focus groups (n?=?24) appreciated the system??s simplicity, access to updated resources, and time-efficient way to address smoking, and wanted more feedback about cessation outcomes. They collectively supported the system??s continuation.

CONCLUSIONS

A novel EHR-based Tobacco Care Management system was adopted by PCPs, especially those receiving performance feedback, and connected one-third of referred smokers to treatment. The model has the potential to improve the delivery and outcomes of evidence-based tobacco treatment in primary care.     

A Patient Safety and Transitions of Care Curriculum for Third-Year Medical Students

The elderly are the most vulnerable to adverse events during and after hospitalization. This study sought to evaluate the effectiveness of a curriculum on patient safety and transitions of care for medical students during an Internal Medicine-Geriatrics Clerkship on students’ knowledge, skills, and attitudes. The curriculum included didactics on patient safety, health literacy, discharge planning and transitions of care, and postdischarge visits to patients. Analysis of pre- and postassessments showed afterwards students were significantly more comfortable assessing a patient’s health literacy and confident performing a medication reconciliation, providing education regarding medications, and identifying barriers during transitions. More students were able to identify the most common source of adverse events after discharge (86% vs. 62% before), risk factors for low health literacy (28% vs. 14%), and ways to assess a patient’s health literacy (14% vs. 2%). It was feasible to implement a postdischarge visit assignment in an urban tertiary care setting and only required on average of approximately an one and one half hours for students to complete.     

A Failure to Communicate: A Qualitative Exploration of Care Coordination Between Hospitalists and Primary Care Providers Around Patient Hospitalizations

BackgroundCare coordination between adult hospitalists and primary care providers (PCPs) is a critical component of successful transitions of care from hospital to home, yet one that is not well understood.ObjectiveThe purpose of this study was to understand the challenges in coordination of care, as well as potential solutions, from the perspective of hospitalists and PCPs in North Carolina.ApproachInterview guides included questions about care coordination, information exchange, follow-up care, accountability, and medication management. Focus group sessions were recorded, transcribed verbatim, and analyzed in ATLAS.ti. The constant comparative method was used to evaluate differences between hospitalists and PCPs.ConclusionsHospitalists and PCPs encounter similar challenges in care coordination, yet have important experiential differences related to sending and receiving roles for hospital discharges. Efforts to improve coordination of care between hospitalists and PCPs should aim to understand perspectives of clinicians in each setting.KEY WORDS: care transitions, care coordination, accountability     

Patient Use of Secure Electronic Messaging Within a Shared Medical Record: A Cross-sectional Study

BACKGROUND  Most patients would like to be able to exchange electronic messages with personal physicians. Few patients and providers are exchanging electronic communications. OBJECTIVE  To evaluate patient characteristics associated with the use of secure electronic messaging between patients and health care providers. DESIGN, SETTING, AND PATIENTS  Cross-sectional cohort study of enrollees over 18 years of age who were enrolled in an integrated delivery system in 2005. MEASUREMENTS AND MAIN RESULTS  Among eligible enrollees, 14% (25,075) exchanged one or more secure messages with a primary or specialty care provider between January 1, 2004 and March 31, 2005. Higher secure messaging use by enrollees was associated with female gender (OR, 1.15; 95% CI, 1.10–1.19), greater overall morbidity (OR, 5.64; 95% CI, 5.07–6.28, comparing high or very high to very low overall morbidity), and the primary care provider’s use of secure messaging with other patients (OR, 1.94; 95% CI, 1.67–2.26, comparing 20–50% vs. ≤10% encounters through secure messaging). Less secure messaging use was associated with enrollee age over 65 years (OR, 0.65; CI, 0.59–0.71) and Medicaid insurance vs. commercial insurance (OR, 0.81; 95% CI, 0.68–0.96). CONCLUSIONS  In this integrated group practice, use of patient–provider secure messaging varied according to individual patient clinical and sociodemographic characteristics. Future studies should clarify variation in the use of electronic patient–provider messaging and its impact on the quality and cost of care received. Funding Sources  This study was funded by the Agency for Health Care Research and Quality (Grant No. R03 HS014625–01). Human Subjects Protections Review and Approval  This study was reviewed and approved by the Group Health Center for Health Studies Institutional Review Board.