Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes

BackgroundThe 21st Century Cures Act mandates patients’ access to their electronic health record (EHR) notes. To our knowledge, no previous work has systematically invited patients to proactively report diagnostic concerns while documenting and tracking their diagnostic experiences through EHR-based clinician note review.ObjectiveTo test if patients can identify concerns about their diagnosis through structured evaluation of their online visit notes.MethodsIn a large integrated health system, patients aged 18–85 years actively using the patient portal and seen between October 2019 and February 2020 were invited to respond to an online questionnaire if an EHR algorithm detected any recent unexpected return visit following an initial primary care consultation (“at-risk” visit). We developed and tested an instrument (Safer Dx Patient Instrument) to help patients identify concerns related to several dimensions of the diagnostic process based on notes review and recall of recent “at-risk” visits. Additional questions assessed patients’ trust in their providers and their general feelings about the visit. The primary outcome was a self-reported diagnostic concern. Multivariate logistic regression tested whether the primary outcome was predicted by instrument variables.ResultsOf 293 566 visits, the algorithm identified 1282 eligible patients, of whom 486 responded. After applying exclusion criteria, 418 patients were included in the analysis. Fifty-one patients (12.2%) identified a diagnostic concern. Patients were more likely to report a concern if they disagreed with statements “the care plan the provider developed for me addressed all my medical concerns” [odds ratio (OR), 2.65; 95% confidence interval [CI], 1.45–4.87) and “I trust the provider that I saw during my visit” (OR, 2.10; 95% CI, 1.19–3.71) and agreed with the statement “I did not have a good feeling about my visit” (OR, 1.48; 95% CI, 1.09–2.01).ConclusionPatients can identify diagnostic concerns based on a proactive online structured evaluation of visit notes. This surveillance strategy could potentially improve transparency in the diagnostic process.     

Assessment of the early effectiveness of a stroke unit in comparison to the general ward

Strokeisthethirdleadingcauseofdeathinmostcountries InChina ,strokeisamajorpublichealthproblemassociatedwithhighmortality ,disability ,andfinancialcost Whatisthemosteffectivetreatmentstrategyforstrokepatients?Theanswertothisquestionisimportant,becausestrokeisfrequent,lethal,andexpensive 1　Thetraditionaltherapymodelhasbeencriticizedforitsarbitrarinessanddeficiencies 2 　Estab lishingahospitalstrokeunit (SU)isonepromisingnewtherapeuticapproach METHODSTriageandsubjectsThesubjects (n =392 …     

Openness of patients' reporting with use of electronic records: psychiatric clinicians' views

Objectives

Improvements in electronic health record (EHR) system development will require an understanding of psychiatric clinicians'' views on EHR system acceptability, including effects on psychotherapy communications, data-recording behaviors, data accessibility versus security and privacy, data quality and clarity, communications with medical colleagues, and stigma.

Design

Multidisciplinary development of a survey instrument targeting psychiatric clinicians who recently switched to EHR system use, focus group testing, data analysis, and data reliability testing.

Measurements

Survey of 120 university-based, outpatient mental health clinicians, with 56 (47%) responding, conducted 18 months after transition from a paper to an EHR system.

Results

Factor analysis gave nine item groupings that overlapped strongly with five a priori domains. Respondents both praised and criticized the EHR system. A strong majority (81%) felt that open therapeutic communications were preserved. Regarding data quality, content, and privacy, clinicians (63%) were less willing to record highly confidential information and disagreed (83%) with including their own psychiatric records among routinely accessed EHR systems.

Limitations

single time point; single academic medical center clinic setting; modest sample size; lack of prior instrument validation; survey conducted in 2005.

Conclusions

In an academic medical center clinic, the presence of electronic records was not seen as a dramatic impediment to therapeutic communications. Concerns regarding privacy and data security were significant, and may contribute to reluctances to adopt electronic records in other settings. Further study of clinicians'' views and use patterns may be helpful in guiding development and deployment of electronic records systems.     

BTS质量改进模式在缺血性脑卒中患者中的应用效果评价

目的：探讨基于突破性系列（breakthrough series,BTS）质量改进模式在缺血性脑卒中患者中的应用效果。方法：采用非同期前后对照的研究方法,将2020年6月至9月未采用BTS质量改进模式56例患者作为对照组;将2021年3月至7月采用BTS质量改进模式的56例患者作为观察组。比较实施前后2组患者美国国立卫生院脑卒中量表（National Institutes of Health Stroke Scale,NIHSS）评分、Barthel指数、压疮发生率、住院天数、改良Rankin量表（modified Rankin Scale,mRS）评分、营养指标及满意度的情况。结果：应用BTS质量改进模式后,观察组NIHSS评分明显低于对照组,差异有统计学差异（P<0.05）;观察组mRS评分（2.31±0.43）低于对照组（4.68±0.85）,差异有统计学意义（P<0.05）;2组营养指标及满意度差异均有统计学意义（P<0.05）。结论：BTS质量改进模型的应用能够有效提升缺血性脑卒中患者护理质量,促进患者神经功能恢复,改善患者预后情况。     

Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient setting following implementation of a commercial electronic health record: implications for designing more effective alerts

ObjectiveTo assess the appropriateness of medication-related clinical decision support (CDS) alerts associated with renal insufficiency and the potential/actual harm from overriding the alerts.Materials and MethodsOverride rate frequency was recorded for all inpatients who had a renal CDS alert trigger between 05/2017 and 04/2018. Two random samples of 300 for each of 2 types of medication-related CDS alerts associated with renal insufficiency—“dose change” and “avoid medication”—were evaluated by 2 independent reviewers using predetermined criteria for appropriateness of alert trigger, appropriateness of override, and patient harm.ResultsWe identified 37 100 “dose change” and 5095 “avoid medication” alerts in the population evaluated, and 100% of each were overridden. Dose change triggers were classified as 12.5% appropriate and overrides of these alerts classified as 90.5% appropriate. Avoid medication triggers were classified as 29.6% appropriate and overrides 76.5% appropriate. We identified 5 adverse drug events, and, of these, 4 of the 5 were due to inappropriately overridden alerts.ConclusionAlerts were nearly always presented inappropriately and were all overridden during the 1-year period studied. Alert fatigue resulting from receiving too many poor-quality alerts may result in failure to recognize errors that could lead to patient harm. Although medication-related CDS alerts associated with renal insufficiency had previously been found to be the most clinically beneficial alerts in a legacy system, in this system they were ineffective. These findings underscore the need for improvements in alert design, implementation, and monitoring of alert performance to make alerts more patient-specific and clinically appropriate.     

Factors associated with difficult electronic health record implementation in office practice

Little is known about physicians' perception of the ease or difficulty of implementing electronic health records (EHR). This study identified factors related to the perceived difficulty of implementing EHR. 163 physicians completed surveys before and after the implementation of EHR in an externally funded pilot program in three Massachusetts communities. Ordinal hierarchical logistic regression was used to identify baseline factors that correlated with physicians' report of difficulty with EHR implementation. Compared with physicians with ownership stake in their practices, physician employees were less likely to describe EHR implementation as difficult (adjusted OR 0.5, 95% CI 0.3 to 1.0). Physicians who perceived their staff to be innovative were also less likely to view EHR implementation as difficult (adjusted OR 0.4, 95% CI 0.2 to 0.8). Physicians who own their practice may need more external support for EHR implementation than those who do not. Innovative clinical support staff may ease the EHR implementation process and contribute to its success.     

Evaluation of electronic health record-integrated digital health tools to engage hospitalized patients in discharge preparation

ObjectiveTo evaluate the effect of electronic health record (EHR)-integrated digital health tools comprised of a checklist and video on transitions-of-care outcomes for patients preparing for discharge.Materials and MethodsEnglish-speaking, general medicine patients (>18 years) hospitalized at least 24 hours at an academic medical center in Boston, MA were enrolled before and after implementation. A structured checklist and video were administered on a mobile device via a patient portal or web-based survey at least 24 hours prior to anticipated discharge. Checklist responses were available for clinicians to review in real time via an EHR-integrated safety dashboard. The primary outcome was patient activation at discharge assessed by patient activation (PAM)-13. Secondary outcomes included postdischarge patient activation, hospital operational metrics, healthcare resource utilization assessed by 30-day follow-up calls and administrative data and change in patient activation from discharge to 30 days postdischarge.ResultsOf 673 patients approached, 484 (71.9%) enrolled. The proportion of activated patients (PAM level 3 or 4) at discharge was nonsignificantly higher for the 234 postimplementation compared with the 245 preimplementation participants (59.8% vs 56.7%, adjusted OR 1.23 [0.38, 3.96], P = .73). Postimplementation participants reported 3.75 (3.02) concerns via the checklist. Mean length of stay was significantly higher for postimplementation compared with preimplementation participants (10.13 vs 6.21, P < .01). While there was no effect on postdischarge outcomes, there was a nonsignificant decrease in change in patient activation within participants from pre- to postimplementation (adjusted difference-in-difference of −16.1% (9.6), P = .09).ConclusionsEHR-integrated digital health tools to prepare patients for discharge did not significantly increase patient activation and was associated with a longer length of stay. While issues uncovered by the checklist may have encouraged patients to inquire about their discharge preparedness, other factors associated with patient activation and length of stay may explain our observations. We offer insights for using PAM-13 in context of real-world health-IT implementations.Trial RegistrationNIH US National Library of Medicine, {"type":"clinical-trial","attrs":{"text":"NCT03116074","term_id":"NCT03116074"}}NCT03116074, clinicaltrials.gov     

院前急救对急性缺血性卒中患者溶栓时间的作用与影响因素分析

ObjectiveTo explore the efficacy of prehospital emergency system in duration of thrombolysis for patients with acute ischemic stroke(AIS), and to analyze the influencing factors of arrival by ambulance.     

Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge

Serious medication errors occur commonly in the period after hospital discharge. Medication reconciliation in the postdischarge ambulatory setting may be one way to reduce the frequency of these errors. The authors describe the design and implementation of a novel tool built into an ambulatory electronic medical record (EMR) to facilitate postdischarge medication reconciliation. The tool compares the preadmission medication list within the ambulatory EMR to the hospital discharge medication list, highlights all changes, and allows the EMR medication list to be easily updated. As might be expected for a novel tool intended for use in a minority of visits, use of the tool was low at first: 20% of applicable patient visits within 30 days of discharge. Clinician outreach, education, and a pop-up reminder succeeded in increasing use to 41% of applicable visits. Review of feedback identified several usability issues that will inform subsequent versions of the tool and provide generalizable lessons for how best to design medication reconciliation tools for this setting.     

垂体腺瘤37例眼部改变及误诊分析

目的:探讨就诊于眼科的垂体腺瘤患者视功能损害和误诊原因,以期加深对垂体腺瘤的认识,促进早期诊断,尽量避免或减少误诊。方法:对37例手术后病理证实的垂体腺瘤进行临床分析。结果:视功能损害35例,视野缺损34例,以视力减退为首发症状就诊于眼科15例,误诊5例。结论:眼科医师在临床诊断中对视力、视野异常的患者需要综合分析,以避免或减少垂体腺瘤的误诊。     

浙江省县域医疗服务共同体发展现状及展望

浙江省在2017年9月为深入实施“双下沉、两提升”的举措,在11个市分别确定了1个县域医疗服务共同体建设试点,并开展了一系列的工作,形成了“基层首诊、分级诊疗、双向转诊”的良好就医格局。县域医疗服务共同体是上级医院与基层医疗卫生机构通过整合资源、实行共同管理而开展的一次医疗服务体系重构,是在当今社会面临医改困境所进行的一种改革创新。经过近两年的探索,各建设试点取得了一定的成效,统一各项资源,改革“三医联动”,提高医疗服务水平,还结合各自实际情况打磨出独属于自己的亮点。浙江省县域医疗服务共同体取得的成绩是瞩目的,但在发展进程中,县域医疗服务共同体内部成员的定位分工、基层卫生机构的人才队伍建设和服务水平的提高成了不可忽视的难题。本文阐述了浙江省医疗服务共同体建设开展后取得的成绩为医疗服务共同体建设的必要性提供依据,以及提出当前存在的问题为医疗服务共同体建设的发展方向提供思路,只有出台相应的举措来解决上述问题,医疗服务水平才能得到提高。     

加强临床服务管理在卫生服务质量改进中的实施效果评价——以卫Ⅷ/卫Ⅷ支持性项目地区为例

通过文献法和现场调查法对卫Ⅷ/卫Ⅷ支持性项目在改进农村贫困地区卫生服务质量中加强临床服务管理的效果进行评价,发现加强临床服务管理在项目地区取得了很好的效果,提高了卫生服务的可及性,改善了卫生服务的质量。同时也总结出了建立临床诊疗规范;规范医疗文书撰写;建立和完善基本药物目录,合理使用药物等干预措施。     

1989年湖北省5岁以下儿童死亡回顾调查

对湖北省８个妇幼卫生合作项目县１９８９年５岁以下儿童死亡及相关因素进行了回顾性调查，结果：８县５岁以下儿童死亡率为７４．２５‰；１～４岁儿童死亡率为３５．８８‰；婴儿死亡率为６１．１８‰；其中竹山县最高，高于全国１～２倍．婴儿死亡的前６位死因是：肺炎２６．９７％；新生儿窒息１６．３２％；意外窒息１３．３０％，早产１１．１３％，新生儿破伤风１０．７２％；先天畸形５．０４％．死前未曾就医高达５７．０３％；死于家中或途中８６．５２％．发展生产，改善贫困，加强基层卫生组织建设，推广简捷、经济、适用的急救技术是降低边远山区儿童死亡的关键．     

个性化健康教育对脑卒中患者生活质量的影响

目的研究个性化健康教育对脑卒中患者生活质量的影响。方法将70例脑卒中康复患者随机分为两组,对照组给予康复训练及常规健康教育,干预组在康复训练基础上进行有针对性和系统性的个性化健康教育。采用汉密尔顿焦虑量表(HAMA)评估患者的焦虑症状;Banthel指数量表评估日常生活能力;生活满意度指数量表评估生活满意度。比较两组患者治疗前后焦虑症状、日常生活能力和生活满意度的差异。结果两组患者治疗前的HAMA、Banthel指数和生活满意度指数评分比较差异均无统计学意义(P>0.05)。两组患者治疗后的HAMA评分显著低于治疗前,Banthel指数和生活满意度指数评分显著高于治疗前,差异均有统计学意义(P<0.05)。与对照组治疗后比较,干预组治疗后的HAMA评分更低,Banthel指数和生活满意指数评分更高,差异也均有统计学意义(P<0.05)。结论脑卒中患者在进行康复训练的基础上,早期接受有针对性和系统性的个性化健康教育能进一步提高患者的生活质量。     

Patient safety and quality improvement: Ethical principles for a regulatory approach to bias in healthcare machine learning

Accumulating evidence demonstrates the impact of bias that reflects social inequality on the performance of machine learning (ML) models in health care. Given their intended placement within healthcare decision making more broadly, ML tools require attention to adequately quantify the impact of bias and reduce its potential to exacerbate inequalities. We suggest that taking a patient safety and quality improvement approach to bias can support the quantification of bias-related effects on ML. Drawing from the ethical principles underpinning these approaches, we argue that patient safety and quality improvement lenses support the quantification of relevant performance metrics, in order to minimize harm while promoting accountability, justice, and transparency. We identify specific methods for operationalizing these principles with the goal of attending to bias to support better decision making in light of controllable and uncontrollable factors.     

卒中意识与救治研究热点及演进趋势的知识图谱

目的:展示卒中意识与救治的研究热点及演进趋势。方法:检索Web of Science数据库中有关卒中意识与救治研究的文献,用关键词词频分析和共词分析方法绘制知识图谱。结果:自1996年始,相关论文数量逐年增长,卒中意识与救治受到越来越多的关注,说明卒中意识与救治问题仍然严峻,且在该研究领域尚未取得突破性进展。结论:卒中意识与救治的研究重点在急性缺血性卒中,特别是tPA治疗;研究视角从治疗为主转为防治结合。     

卒中溶栓绿色通道优化研究及实施效果分析

目的探讨卒中溶栓绿色通道的构建、整改对发病到实施溶栓的时间（onset to treatment time,OTT）、院内溶栓时间（door to needle time，DNT）、临床疗效及预后的影响。 方法收集通过绿色通道溶栓患者118例的临床资料，以时间为界分为对照组57例和观察组61例。比较2组OTT、DNT、DNT≤60 min比率、临床疗效、并发症发生情况、美国国立卫生研究院卒中量表（the National Institutes of Health Stroke Scale,NIHSS）评分、Barthel指数（Barthel index，BI）评分、改良Rankin量表（Modified Rankin Scale,mRS）评分等。 结果观察组OTT、DNT短于对照组，DNT≤60 min比例高于对照组（P＜0.01）。经过溶栓治疗72 h后，观察组临床疗效优于对照组，总有效率高于对照组（P＜0.01）。2组总并发症发生率和病死率差异均无统计学意义（P＞0.05）。2组NIHSS评分均呈逐渐降低趋势，观察组NIHSS评分低于对照组，组间、时点间、组间·时点间交互作用差异均有统计学意义（P＜0.01）。2组BI评分均呈逐渐升高趋势，观察组BI评分高于对照组，组间、时点间、组间·时点间交互作用差异均有统计学意义（P＜0.01）。治疗3个月以后，观察组mRS评分明显低于对照组，≤2分比例高于对照组（P＜0.01）。 结论卒中溶栓绿色通道的建立，能够显著缩短OTT、DNT，提高临床疗效，减轻残障程度，取得良好的社会效益。     

Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial

Objective

To determine the effects of a personal health record (PHR)-linked medications module on medication accuracy and safety.

Design

From September 2005 to March 2007, we conducted an on-treatment sub-study within a cluster-randomized trial involving 11 primary care practices that used the same PHR. Intervention practices received access to a medications module prompting patients to review their documented medications and identify discrepancies, generating ‘eJournals’ that enabled rapid updating of medication lists during subsequent clinical visits.

Measurements

A sample of 267 patients who submitted medications eJournals was contacted by phone 3 weeks after an eligible visit and compared with a matched sample of 274 patients in control practices that received a different PHR-linked intervention. Two blinded physician adjudicators determined unexplained discrepancies between documented and patient-reported medication regimens. The primary outcome was proportion of medications per patient with unexplained discrepancies.

Results

Among 121 046 patients in eligible practices, 3979 participated in the main trial and 541 participated in the sub-study. The proportion of medications per patient with unexplained discrepancies was 42% in the intervention arm and 51% in the control arm (adjusted OR 0.71, 95% CI 0.54 to 0.94, p=0.01). The number of unexplained discrepancies per patient with potential for severe harm was 0.03 in the intervention arm and 0.08 in the control arm (adjusted RR 0.31, 95% CI 0.10 to 0.92, p=0.04).

Conclusions

When used, concordance between documented and patient-reported medication regimens and reduction in potentially harmful medication discrepancies can be improved with a PHR medication review tool linked to the provider''s medical record.

Trial registration number

This study was registered at ClinicalTrials.gov ({"type":"clinical-trial","attrs":{"text":"NCT00251875","term_id":"NCT00251875"}}NCT00251875).