CD4 testing at clinics to assess eligibility for Antiretroviral therapy

Background

In 2011, the Ministry of Health raised the CD4 threshold for antiretroviral therapy (ART) eligibility from <250 cells/µl and <350 cells/µl, but at the same time only 8.8% of facilities in Malawi with HIV services provided CD4 testing. We conducted a record review at 10 rural clinics in Thyolo District to assess the impact of introducing CD4 testing on identifying patients eligible for ART.

Methods

We abstracted CD4 counts of all ART-naïve, HIV-infected patients with WHO clinical stages 1 and 2 and an initial CD4 test between May 2008 and June 2009. At four clinics, we also abstracted CD4 counts of patients not initially eligible for ART who were retested before April 2010.

Results

Of 1,113 patients tested, the initial CD4 was “≤250 cells/µl” and “≤350 cells/µl” in 534 (48.0%). Of 203 patients with follow-up results, the most recent CD4 was ≤250 cells/µl in 34 (24.5%), and ≤350 cells/µl in 64 (46.0%).

Conclusions

CD4 testing in rural clinics is feasible and identifies many patients eligible for ART who would not be identified without CD4 testing. CD4 testing needs to be scaled-up to identify patients eligible for ART. ART services need to be scaled-up concurrently to meet the resulting increased demand.     

Design and evaluation of a wireless electronic health records system for field care in mass casualty settings

Background

There is growing interest in the use of technology to enhance the tracking and quality of clinical information available for patients in disaster settings. This paper describes the design and evaluation of the Wireless Internet Information System for Medical Response in Disasters (WIISARD).

Materials and methods

WIISARD combined advanced networking technology with electronic triage tags that reported victims'' position and recorded medical information, with wireless pulse-oximeters that monitored patient vital signs, and a wireless electronic medical record (EMR) for disaster care. The EMR system included WiFi handheld devices with barcode scanners (used by front-line responders) and computer tablets with role-tailored software (used by managers of the triage, treatment, transport and medical communications teams). An additional software system provided situational awareness for the incident commander. The WIISARD system was evaluated in a large-scale simulation exercise designed for training first responders. A randomized trial was overlaid on this exercise with 100 simulated victims, 50 in a control pathway (paper-based), and 50 in completely electronic WIISARD pathway. All patients in the electronic pathway were cared for within the WIISARD system without paper-based workarounds.

Results

WIISARD reduced the rate of the missing and/or duplicated patient identifiers (0% vs 47%, p<0.001). The total time of the field was nearly identical (38:20 vs 38:23, IQR 26:53–1:05:32 vs 18:55–57:22).

Conclusion

Overall, the results of WIISARD show that wireless EMR systems for care of the victims of disasters would be complex to develop but potentially feasible to build and deploy, and likely to improve the quality of information available for the delivery of care during disasters.     

Is the quality of data in an electronic medical record sufficient for assessing the quality of primary care?

Objective

Quality indicators for the treatment of type 2 diabetes are often retrieved from a chronic disease registry (CDR). This study investigates the quality of recording in a general practitioner''s (GP) electronic medical record (EMR) compared to a simple, web-based CDR.

Methods

The GPs entered data directly in the CDR and in their own EMR during the study period (2011). We extracted data from 58 general practices (8235 patients) with type 2 diabetes and compared the occurrence and value of seven process indicators and 12 outcome indicators in both systems. The CDR, specifically designed for monitoring type 2 diabetes and reporting to health insurers, was used as the reference standard. For process indicators we examined the presence or absence of recordings on the patient level in both systems, for outcome indicators we examined the number of compliant or non-compliant values of recordings present in both systems. The diagnostic OR (DOR) was calculated for all indicators.

Results

We found less concordance for process indicators than for outcome indicators. HbA1c testing was the process indicator with the highest DOR. Blood pressure measurement, urine albumin test, BMI recorded and eye assessment showed low DOR. For outcome indicators, the highest DOR was creatinine clearance <30 mL/min or mL/min/1.73 m² and the lowest DOR was systolic blood pressure <140 mm Hg.

Conclusions

Clinical items are not always adequately recorded in an EMR for retrieving indicators, but there is good concordance for the values of these items. If the quality of recording improves, indicators can be reported from the EMR, which will reduce the workload of GPs and enable GPs to maintain a good patient overview.     

Leveraging informatics for genetic studies: use of the electronic medical record to enable a genome-wide association study of peripheral arterial disease

Background

There is significant interest in leveraging the electronic medical record (EMR) to conduct genome-wide association studies (GWAS).

Methods

A biorepository of DNA and plasma was created by recruiting patients referred for non-invasive lower extremity arterial evaluation or stress ECG. Peripheral arterial disease (PAD) was defined as a resting/post-exercise ankle-brachial index (ABI) less than or equal to 0.9, a history of lower extremity revascularization, or having poorly compressible leg arteries. Controls were patients without evidence of PAD. Demographic data and laboratory values were extracted from the EMR. Medication use and smoking status were established by natural language processing of clinical notes. Other risk factors and comorbidities were ascertained based on ICD-9-CM codes, medication use and laboratory data.

Results

Of 1802 patients with an abnormal ABI, 115 had non-atherosclerotic vascular disease such as vasculitis, Buerger''s disease, trauma and embolism (phenocopies) based on ICD-9-CM diagnosis codes and were excluded. The PAD cases (66±11 years, 64% men) were older than controls (61±8 years, 60% men) but had similar geographical distribution and ethnic composition. Among PAD cases, 1444 (85.6%) had an abnormal ABI, 233 (13.8%) had poorly compressible arteries and 10 (0.6%) had a history of lower extremity revascularization. In a random sample of 95 cases and 100 controls, risk factors and comorbidities ascertained from EMR-based algorithms had good concordance compared with manual record review; the precision ranged from 67% to 100% and recall from 84% to 100%.

Conclusion

This study demonstrates use of the EMR to ascertain phenocopies, phenotype heterogeneity and relevant covariates to enable a GWAS of PAD. Biorepositories linked to EMR may provide a relatively efficient means of conducting GWAS.     

Enrollment into a time sensitive clinical study in the critical care setting: results from computerized septic shock sniffer implementation

Objective

Recruitment of patients into time sensitive clinical trials in intensive care units (ICU) poses a significant challenge. Enrollment is limited by delayed recognition and late notification of research personnel. The objective of the present study was to evaluate the effectiveness of the implementation of electronic screening (septic shock sniffer) regarding enrollment into a time sensitive (24 h after onset) clinical study of echocardiography in severe sepsis and septic shock.

Design

We developed and tested a near-real time computerized alert system, the septic shock sniffer, based on established severe sepsis/septic shock diagnostic criteria. A sniffer scanned patients'' data in the electronic medical records and notified the research coordinator on call through an institutional paging system of potentially eligible patients.

Measurement

The performance of the septic shock sniffer was assessed.

Results

The septic shock sniffer performed well with a positive predictive value of 34%. Electronic screening doubled enrollment, with 68 of 4460 ICU admissions enrolled during the 9 months after implementation versus 37 of 4149 ICU admissions before sniffer implementation (p<0.05). Efficiency was limited by study coordinator availability (not available at nights or weekends).

Conclusions

Automated electronic medical records screening improves the efficiency of enrollment and should be a routine tool for the recruitment of patients into time sensitive clinical trials in the ICU setting.     

Point-of-care clinical documentation: assessment of a bladder cancer informatics tool (eCancerCareBladder): a randomized controlled study of efficacy,efficiency and user friendliness compared with standard electronic medical records

Objective

To compare the use of structured reporting software and the standard electronic medical records (EMR) in the management of patients with bladder cancer. The use of a human factors laboratory to study management of disease using simulated clinical scenarios was also assessed.

Design

eCancerCare^Bladder and the EMR were used to retrieve data and produce clinical reports. Twelve participants (four attending staff, four fellows, and four residents) used either eCancerCare^Bladder or the EMR in two clinical scenarios simulating cystoscopy surveillance visits for bladder cancer follow-up.

Measurements

Time to retrieve and quality of review of the patient history; time to produce and completeness of a cystoscopy report. Finally, participants provided a global assessment of their computer literacy, familiarity with the two systems, and system preference.

Results

eCancerCare^Bladder was faster for data retrieval (scenario 1: 146 s vs 245 s, p=0.019; scenario 2: 306 vs 415 s, NS), but non-significantly slower to generate a clinical report. The quality of the report was better in the eCancerCare^Bladder system (scenario 1: p<0.001; scenario 2: p=0.11). User satisfaction was higher with the eCancerCare^Bladder system, and 11/12 participants preferred to use this system.

Limitations

The small sample size affected the power of our study to detect differences.

Conclusions

Use of a specific data management tool does not appear to significantly reduce user time, but the results suggest improvement in the level of care and documentation and preference by users. Also, the use of simulated scenarios in a laboratory setting appears to be a valid method for comparing the usability of clinical software.     

Development and evaluation of an ensemble resource linking medications to their indications

Objective

To create a computable MEDication Indication resource (MEDI) to support primary and secondary use of electronic medical records (EMRs).

Materials and methods

We processed four public medication resources, RxNorm, Side Effect Resource (SIDER) 2, MedlinePlus, and Wikipedia, to create MEDI. We applied natural language processing and ontology relationships to extract indications for prescribable, single-ingredient medication concepts and all ingredient concepts as defined by RxNorm. Indications were coded as Unified Medical Language System (UMLS) concepts and International Classification of Diseases, 9th edition (ICD9) codes. A total of 689 extracted indications were randomly selected for manual review for accuracy using dual-physician review. We identified a subset of medication–indication pairs that optimizes recall while maintaining high precision.

Results

MEDI contains 3112 medications and 63 343 medication–indication pairs. Wikipedia was the largest resource, with 2608 medications and 34 911 pairs. For each resource, estimated precision and recall, respectively, were 94% and 20% for RxNorm, 75% and 33% for MedlinePlus, 67% and 31% for SIDER 2, and 56% and 51% for Wikipedia. The MEDI high-precision subset (MEDI-HPS) includes indications found within either RxNorm or at least two of the three other resources. MEDI-HPS contains 13 304 unique indication pairs regarding 2136 medications. The mean±SD number of indications for each medication in MEDI-HPS is 6.22±6.09. The estimated precision of MEDI-HPS is 92%.

Conclusions

MEDI is a publicly available, computable resource that links medications with their indications as represented by concepts and billing codes. MEDI may benefit clinical EMR applications and reuse of EMR data for research.     

Late-stage disease at presentation to an HIV clinic in eastern Tanzania: A retrospective cross-sectional study

Background

Late presentation and delayed treatment initiation is associated with poor outcomes in patients with HIV. Little is known about the stage at which HIV patients present at HIV clinics in Tanzania.

Aim

This study aimed at determining the proportion of HIV patients presenting with WHO clinical stages 3 and 4 disease, and the level of immunity at the time of enrollment at the care and treatment center.

Methods

A retrospective cross-sectional study was conducted among 366 HIV-infected adults attending HIV clinic at Mwananyamala Hospital in Dar es Salaam, Tanzania. Data were obtained from the care and treatment clinic database.

Results

Late stage disease at the time of presentation was found in 276 (75.4%) of the patients; out of whom 153 (41.8%) presented with CD4 count <200 cells/ul and 229 (62.6%) presented with WHO clinical stage 3 or 4 at the time of clinic enrollment. Strategies to improve early diagnosis and treatment initiation should be improved.     

The feasibility of automating audit and feedback for ART guideline adherence in Malawi

Objective

To determine the feasibility of using electronic medical record (EMR) data to provide audit and feedback of antiretroviral therapy (ART) clinical guideline adherence to healthcare workers (HCWs) in Malawi.

Materials and methods

We evaluated recommendations from Malawi''s ART guidelines using GuideLine Implementability Appraisal criteria. Recommendations that passed selected criteria were converted into ratio-based performance measures. We queried representative EMR data to determine the feasibility of generating feedback for each performance measure, summed clinical encounters representing each performance measure''s denominator, and then measured the distribution of encounter frequency for individual HCWs across nurse and clinical officer groups.

Results

We analyzed 423 831 encounters in the EMR data and generated automated feedback for 21 recommendations (12%) from Malawi''s ART guidelines. We identified 11 nurse recommendations and eight clinical officer recommendations. Individual nurses and clinical officers had an average of 45 and 59 encounters per month, per recommendation, respectively. Another 37 recommendations (21%) would support audit and feedback if additional routine EMR data are captured and temporal constraints are modeled.

Discussion

It appears feasible to implement automated guideline adherence feedback that could potentially improve HCW performance and supervision. Feedback reports may support workplace learning by increasing HCWs'' opportunities to reflect on their performance.

Conclusion

A moderate number of recommendations from Malawi''s ART guidelines can be used to generate automated guideline adherence feedback using existing EMR data. Further study is needed to determine the receptivity of HCWs to peer comparison feedback and barriers to implementation of automated audit and feedback in low-resource settings.     

ICU nurses' acceptance of electronic health records

Objective

To assess intensive care unit (ICU) nurses'' acceptance of electronic health records (EHR) technology and examine the relationship between EHR design, implementation factors, and nurse acceptance.

Design

The authors analyzed data from two cross-sectional survey questionnaires distributed to nurses working in four ICUs at a northeastern US regional medical center, 3 months and 12 months after EHR implementation.

Measurements

Survey items were drawn from established instruments used to measure EHR acceptance and usability, and the usefulness of three EHR functionalities, specifically computerized provider order entry (CPOE), the electronic medication administration record (eMAR), and a nursing documentation flowsheet.

Results

On average, ICU nurses were more accepting of the EHR at 12 months as compared to 3 months. They also perceived the EHR as being more usable and both CPOE and eMAR as being more useful. Multivariate hierarchical modeling indicated that EHR usability and CPOE usefulness predicted EHR acceptance at both 3 and 12 months. At 3 months postimplementation, eMAR usefulness predicted EHR acceptance, but its effect disappeared at 12 months. Nursing flowsheet usefulness predicted EHR acceptance but only at 12 months.

Conclusion

As the push toward implementation of EHR technology continues, more hospitals will face issues related to acceptance of EHR technology by staff caring for critically ill patients. This research suggests that factors related to technology design have strong effects on acceptance, even 1 year following the EHR implementation.     

Research and applications: Impact of an electronic medication management system on hospital doctors’ and nurses’ work: a controlled pre–post,time and motion study

Objective

To quantify and compare the time doctors and nurses spent on direct patient care, medication-related tasks, and interactions before and after electronic medication management system (eMMS) introduction.

Methods

Controlled pre–post, time and motion study of 129 doctors and nurses for 633.2 h on four wards in a 400-bed hospital in Sydney, Australia. We measured changes in proportions of time on tasks and interactions by period, intervention/control group, and profession.

Results

eMMS was associated with no significant change in proportions of time spent on direct care or medication-related tasks relative to control wards. In the post-period control ward, doctors spent 19.7% (2 h/10 h shift) of their time on direct care and 7.4% (44.4 min/10 h shift) on medication tasks, compared to intervention ward doctors (25.7% (2.6 h/shift; p=0.08) and 8.5% (51 min/shift; p=0.40), respectively). Control ward nurses in the post-period spent 22.1% (1.9 h/8.5 h shift) of their time on direct care and 23.7% on medication tasks compared to intervention ward nurses (26.1% (2.2 h/shift; p=0.23) and 22.6% (1.9 h/shift; p=0.28), respectively). We found intervention ward doctors spent less time alone (p=0.0003) and more time with other doctors (p=0.003) and patients (p=0.009). Nurses on the intervention wards spent less time with doctors following eMMS introduction (p=0.0001).

Conclusions

eMMS introduction did not result in redistribution of time away from direct care or towards medication tasks. Work patterns observed on these intervention wards were associated with previously reported significant reductions in prescribing error rates relative to the control wards.     

Electronic medical record use in pediatric primary care

Objectives

To characterize patterns of electronic medical record (EMR) use at pediatric primary care acute visits.

Design

Direct observational study of 529 acute visits with 27 experienced pediatric clinician users.

Measurements

For each 20 s interval and at each stage of the visit according to the Davis Observation Code, we recorded whether the physician was communicating with the family only, using the computer while communicating, or using the computer without communication. Regression models assessed the impact of clinician, patient and visit characteristics on overall visit length, time spent interacting with families, and time spent using the computer while interacting.

Results

The mean overall visit length was 11:30 (min:sec) with 9:06 spent in the exam room. Clinicians used the EMR during 27% of exam room time and at all stages of the visit (interacting, chatting, and building rapport; history taking; formulation of the diagnosis and treatment plan; and discussing prevention) except the physical exam. Communication with the family accompanied 70% of EMR use. In regression models, computer documentation outside the exam room was associated with visits that were 11% longer (p=0.001), and female clinicians spent more time using the computer while communicating (p=0.003).

Limitations

The 12 study practices shared one EMR.

Conclusions

Among pediatric clinicians with EMR experience, conversation accompanies most EMR use. Our results suggest that efforts to improve EMR usability and clinician EMR training should focus on use in the context of doctor–patient communication. Further study of the impact of documentation inside versus outside the exam room on productivity is warranted.     

Population informatics-based system to improve osteoporosis screening in women in a primary care practice

Objective

To study the effects of using a population-based informatics system for osteoporosis screening and treatment in women aged 65 years or older.

Design

A population-based informatics system (PRECARES: PREventive CAre REminder System) was implemented to meet the needs of the workflow of a primary care practice. Patients treated in either of two sections of a primary care internal medicine department were selected for the intervention, and patients of a comparable third section served as the control group. PRECARES identified women in the intervention group who were due for osteoporosis screening on the basis of age and who had no record of previous screening in our clinical system. If these eligible patients did not have an upcoming outpatient appointment, appointment secretaries sent a letter requesting that they call to make an appointment for a dual-energy x-ray absorptiometry scan.

Measurements

At baseline and 3 months after the letters were sent, a database was used to determine the rate of osteoporosis screening in the intervention and control groups.

Results

A total of 689 patients in the intervention group were sent the letter. Three months after the letters were sent, the rate of osteoporosis screening was 76.4% (2409/3152) in the intervention group vs 69% (928/1344) in the control group (p<0.001). In the intervention group, 25% of the 689 patients responded to the letter and completed osteoporosis screening. Patients who had osteoporosis screening received appropriate treatment.

Conclusion

A population-based informatics system for primary care practice significantly improved the rate of osteoporosis screening.     

Prevalence of HIV infection and the correlates among homeless in Tehran,Iran

Objective

To determine the prevalence of HIV infection among homeless men and women and the related risk behaviors in Tehran, Iran.

Methods

In 2007-2008, Tehran municipality stacked up 10 657 homeless men and women for assessment of HIV and began collaboration with Iranian Research Center for HIV/AIDS (IRCHA) departments to conduct HIV infection prevalence surveys in homeless populations. The results were analyzed for associations with demographic information, family support, status of drug abuse and relation with family and friends.

Results

Overall HIV prevalence was 1.7% (95% confidence interval 1.4-1.9). Factors independently associated with HIV infection included history of using drugs [AOR 8.15 (4.86-13.67)], older age [AOR 1.80 (1.08-2.99) for 40- 55 yr], occupation [AOR 1.64 (1.19-2.24) for unemployed], and no relation with family [AOR 1.82 (1.30-2.54)].

Conclusions

This study supports the idea that injection drug use is contributing to the increased spread of HIV among Iranian homeless. Harm reduction programs should be expanded, particularly among homeless injection drug users.     

Computer-based Insulin Infusion Protocol Improves Glycemia Control over Manual Protocol

Objective

Hyperglycemia worsens clinical outcomes in critically ill patients. Precise glycemia control using intravenous insulin improves outcomes. To determine if we could improve glycemia control over a previous paper-based, manual protocol, authors implemented, in a surgical intensive care unit (SICU), an intravenous insulin protocol integrated into a care provider order entry (CPOE) system.

Design

Retrospective before-after study of consecutive adult patients admitted to a SICU during pre (manual protocol, 32 days) and post (computer-based protocol, 49 days) periods.

Measurements

Percentage of glucose readings in ideal range of 70–109 mg/dl, and minutes spent in ideal range of control during the first 5 days of SICU stay.

Results

The computer-based protocol reduced time from first glucose measurement to initiation of insulin protocol, improved the percentage of all SICU glucose readings in the ideal range, and improved control in patients on IV insulin for ≥24 hours. Hypoglycemia (<40 mg/dl) was rare in both groups.

Conclusion

The CPOE-based intravenous insulin protocol improved glycemia control in SICU patients compared to a previous manual protocol, and reduced time to insulin therapy initiation. Integrating a computer-based insulin protocol into a CPOE system achieved efficient, safe, and effective glycemia control in SICU patients.     

Tuberculosis Drug Resistance and Outcomes among Tuberculosis Inpatients in Lilongwe,Malawi

Setting/Objective

We evaluated clinical characteristics, yield of solid vs. liquid culture, polymerase chain reaction (PCR)-based drug-resistance profiles, and clinical outcomes of tuberculosis (TB) inpatients in Lilongwe, Malawi.

Design

We enrolled adult patients admitted to the Bwaila TB Ward from Jan-Aug/2010. Evaluations included questionnaires, clinical exam, chest radiograph, HIV status, CD4 lymphocyte count, plasma HIVRNA and sputum analysis including Auramine-O stain, Lowenstein-Jensen (LJ) and Mycobacterial Growth Indicator Tube (MGIT) culture, and susceptibility testing using the HAIN GenoType® MTBDRplus.

Results

Eighty-eight patients were enrolled (88% re-treatment, 42% smear positive, 93% pulmonary TB, 74% HIV co-infected). At baseline, 44/88 (50%) MGIT and 28 (32%) LJ cultures were positive with a mean time to positivity of 12.1 (Range 1–42) and 21.5 (Range 7–58) days, respectively. Four percent (3/77) of retreatment patients or 8% of the 38 MGIT+ PCR-confirmed retreatment cases had multi-drug resistant tuberculosis (MDR TB). One MDR TB patient was smear negative and only one MDR patient was identified with LJ. Lower mean hemoglobin at admission was associated with mortality (10.5 vs. 7.5; p<0.01; CI 101 9.8–11.0).

Conclusions

The MDR TB burden among the retreatment population in Lilongwe, Malawi is similar to regional estimates by the WHO (7.7% 95% CI 0–18.1). MDR TB patients are not routinely identified with sputum smear or LJ, suggesting more efficient technology should be adopted.     

A Survey of the Pain Management of Acute Painful Crisis among Patients with Sickle Cell Disease at Two Centres in Jamaica

Objectives:

The aim of this survey was to establish the pain management approaches to acute painful crisis (APC) in sickle cell patients at two healthcare facilities and to compare with available guidelines.

Methods:

A multi-centre observational survey of the management of APC in sickle cell patients was conducted. Data were collected at the Sickle Cell Unit (SCU), Tropical Medicine Research Institute (TMRI) and Accident and Emergency Department (A&E), University Hospital of the West Indies.

Results:

One hundred episodes of uncomplicated APC involving 81 patients managed at the SCU clinic and 64 episodes at the A&E in a total of 28 patients were included in the data set. Drugs used at the SCU included oral morphine, codeine and paracetamol and intramuscular diclofenac. At the A&E, parenteral morphine and pethidine were most commonly used. At the SCU, the mean time to initiation of analgesics was 38 minutes (IQR 25 to 50 minutes); at the A&E, this was 111 minutes (IQR 50 to 150 minutes). At the SCU, the mean duration of stay (DOS) was 2.9 hours (IQR 1.9 to 3.8 hours) with 94% of the patients being discharged home. At the A&E, the mean DOS was 13.0 hours (IQR 8.3 to 16.9 hours) with 93% of the patients being discharged home. The A&E patient group contained multiple high frequency presenters. Documentation of pain severity scores was inconsistent.

Conclusion

The findings of the survey indicate that the management of APC at the two centres is substantially different. Further study is required to investigate patient satisfaction, centre preference and analgesic therapy efficacy.     

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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