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ABSTRACT: Conventional wisdom holds that older, busier clinicians who see complex patients are less likely to adopt and use novel electronic health record (EHR) functionality.
To compare the characteristics of clinicians who did and did not use novel EHR functionality, we conducted a retrospective analysis of the intervention arm of a randomized trial of new EHR-based tobacco treatment functionality.
The novel functionality was used by 103 of 207 (50%) clinicians. Staff physicians were more likely than trainees to use the functionality (64% vs 37%; p<0.001). Clinicians who graduated more than 10 years previously were more likely to use the functionality than those who graduated less than 10 years previously (64% vs 42%; p<0.01). Clinicians with higher patient volumes were more likely to use the functionality (lowest quartile of number of patient visits, 25%; 2nd quartile, 38%; 3rd quartile, 65%; highest quartile, 71%; p<0.001). Clinicians who saw patients with more documented problems were more likely to use the functionality (lowest tertile of documented patient problems, 38%; 2nd tertile, 58%; highest tertile, 54%; p=0.04). In multivariable modeling, independent predictors of use were the number of patient visits (OR 1.2 per 100 additional patients; 95% CI 1.1 to 1.4) and number of documented problems (OR 2.9 per average additional problem; 95% CI 1.4 to 6.1).
Contrary to conventional wisdom, clinically busier physicians seeing patients with more documented problems were more likely to use novel EHR functionality.
Journal of the American Medical Informatics Association 09/2011; 18 Suppl 1:i87-90. · 3.61 Impact Factor
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ABSTRACT: Accurate knowledge of a patient's medical problems is critical for clinical decision making, quality measurement, research, billing and clinical decision support. Common structured sources of problem information include the patient problem list and billing data; however, these sources are often inaccurate or incomplete.
To develop and validate methods of automatically inferring patient problems from clinical and billing data, and to provide a knowledge base for inferring problems.
We identified 17 target conditions and designed and validated a set of rules for identifying patient problems based on medications, laboratory results, billing codes, and vital signs. A panel of physicians provided input on a preliminary set of rules. Based on this input, we tested candidate rules on a sample of 100,000 patient records to assess their performance compared to gold standard manual chart review. The physician panel selected a final rule for each condition, which was validated on an independent sample of 100,000 records to assess its accuracy.
Seventeen rules were developed for inferring patient problems. Analysis using a validation set of 100,000 randomly selected patients showed high sensitivity (range: 62.8-100.0%) and positive predictive value (range: 79.8-99.6%) for most rules. Overall, the inference rules performed better than using either the problem list or billing data alone.
We developed and validated a set of rules for inferring patient problems. These rules have a variety of applications, including clinical decision support, care improvement, augmentation of the problem list, and identification of patients for research cohorts.
Journal of the American Medical Informatics Association 05/2011; 18(6):859-67. · 3.61 Impact Factor
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ABSTRACT: To improve the documentation and treatment of tobacco use in primary care, we developed and implemented a 3-part electronic health record enhancement: (1)smoking status icons, (2) tobacco treatment reminders, and (3) a Tobacco Smart Form that facilitated the ordering of medication and fax and e-mail counseling referrals.
We performed a cluster-randomized controlled trial of the enhancement in 26 primary care practices between December 19, 2006, and September 30, 2007. The primary outcome was the proportion of documented smokers who made contact with a smoking cessation counselor. Secondary outcomes included coded smoking status documentation and medication prescribing.
During the 9-month study period, 132 630 patients made 315 962 visits to study practices. Coded documentation of smoking status increased from 37% of patients to 54% (+17%) in intervention practices and from 35% of patients to 46% (+11%) in control practices (P < .001 for the difference in differences). Among the 9589 patients who were documented smokers at the start of the study, more patients in the intervention practices were recorded as nonsmokers by the end of the study (5.3% vs 1.9% in control practices; P < .001). Among 12 207 documented smokers, more patients in the intervention practices made contact with a cessation counselor (3.9% vs 0.3% in control practices; P < .001). Smokers in the intervention practices were no more likely to be prescribed smoking cessation medication (2% vs 2% in control practices; P = .40).
This electronic health record-based intervention improved smoking status documentation and increased counseling assistance to smokers but not the prescription of cessation medication.
Archives of internal medicine 04/2009; 169(8):781-7. · 11.46 Impact Factor
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ABSTRACT: An accurate method of measuring primary care providers' tobacco counseling actions is needed for monitoring adherence to clinical practice guidelines. We compared three methods of measuring providers' tobacco counseling practices: electronic medical record (EMR) review, patient survey, and provider survey. We mailed a survey to 1,613 smokers seen by 114 Boston-area primary care providers during a 2-month period to assess what tobacco counseling actions had occurred at the visit (N = 766; 47% response rate). Smokers' reports were compared with the EMR and with their providers' self-reported usual tobacco counseling practices, derived from a provider survey (N = 110; 96% response rate). Patients reported receiving each counseling action more frequently than providers documented it in the EMR. Agreement between the patient survey and the EMR was poor for all 5A steps (kappa statistic = 0.01-0.22). Providers reported that they often or always performed each 5A action at a higher rate than indicated by EMR or patient report. However, providers who said they often or always performed individual 5A steps did not have consistently higher mean rates of EMR documentation or patient report than those who said they performed the 5A's less frequently. Little agreement was found among the three methods of measuring primary care providers' tobacco counseling actions. Implementing an EMR does not necessarily improve providers' documentation of tobacco interventions, but EMR adaptations that would standardize provider documentation of tobacco counseling might make the EMR a more reliable tool for monitoring providers' delivery of tobacco treatment services.
Nicotine & Tobacco Research 05/2005; 7 Suppl 1:S35-43. · 2.58 Impact Factor
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ABSTRACT: U.S. Public Health Service (USPHS) clinical guidelines for tobacco treatment recommend that providers routinely counsel smokers using a five-step algorithm (5A's): ask about tobacco use, advise smokers to quit, assess interest in quitting, assist with treatment, and arrange follow-up. A potential barrier to compliance is providers' concern that addressing smoking might alienate smokers, especially those not ready to quit. A survey was mailed to 1,985 patients seen at one of eight Boston-area primary care practices from January 1 to March 31, 2003, and identified as smokers by chart review. The survey assessed respondents' receipt of the 5A's at their visit and their satisfaction with the provider's tobacco treatment and with their overall health care. We used multivariable logistic regression models to assess the association between satisfaction with care and patient-reported receipt of each 5A step, adjusted for age, sex, education, race, health status, smoking intensity, readiness to quit, and length of relationship with provider. Of 1,160 respondents (58% response rate), 765 reported that they smoked at the time of the visit. They reported high levels of satisfaction with their tobacco-related care and overall care. Patient-reported receipt of each 5A step was significantly associated with greater patient satisfaction with tobacco-related care and with overall health care, even after adjusting for a smoker's readiness to quit smoking. Satisfaction with overall health care increased as counseling intensity increased. Patient reports of smoking cessation interventions delivered during primary care practice are associated with greater patient satisfaction with their health care, even among smokers not ready to quit. Providers can follow USPHS guidelines with smokers without fear of alienating those not yet considering quitting.
Nicotine & Tobacco Research 05/2005; 7 Suppl 1:S29-34. · 2.58 Impact Factor
