Myrna M Khan

Publications of Myrna M Khan

• Electronic health record-based messages to primary care providers: valuable information or just noise?

  Authors: Daniel R Murphy, Brian Reis, Himabindu Kadiyala, Kamal Hirani, Dean F Sittig, Myrna M Khan, Hardeep Singh

  Archives of internal medicine. 02/2012; 172(3):283-5.

• Electronic health record-based surveillance of diagnostic errors in primary care.

  Authors: Hardeep Singh, Traber Davis Giardina, Samuel N Forjuoh, Michael D Reis, Steven Kosmach, Myrna M Khan, Eric J Thomas

  BMJ quality & safety. 02/2012; 21(2):93-100.

  Diagnostic errors in primary care are harmful but difficult to detect. The authors tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary careDiagnostic errors in primary care are harmful but difficult to detect. The authors tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary care practice. The authors conducted a retrospective study of primary care visit records 'triggered' through electronic queries for possible evidence of diagnostic errors: Trigger 1: A primary care index visit followed by unplanned hospitalisation within 14 days and Trigger 2: A primary care index visit followed by ≥1 unscheduled visit(s) within 14 days. Control visits met neither criterion. Electronic trigger queries were applied to EHR repositories at two large healthcare systems between 1 October 2006 and 30 September 2007. Blinded physician-reviewers independently determined presence or absence of diagnostic errors in selected triggered and control visits. An error was defined as a missed opportunity to make or pursue the correct diagnosis when adequate data were available at the index visit. Disagreements were resolved by an independent third reviewer. Queries were applied to 212 165 visits. On record review, the authors found diagnostic errors in 141 of 674 Trigger 1-positive records (positive predictive value (PPV)=20.9%, 95% CI 17.9% to 24.0%) and 36 of 669 Trigger 2-positive records (PPV=5.4%, 95% CI 3.7% to 7.1%). The control PPV of 2.1% (95% CI 0.1% to 3.3%) was significantly lower than that of both triggers (p≤0.002). Inter-reviewer reliability was modest, though higher than in comparable previous studies (к=0.37 (95% CI 0.31 to 0.44)). While physician agreement on diagnostic error remains low, an EHR-facilitated surveillance methodology could be useful for gaining insight into the origin of these errors.

• Passive monitoring versus active assessment of clinical performance: impact on measured quality of care.

  Authors: Sylvia J Hysong, Myrna M Khan, Laura A Petersen

  Medical care. 10/2011; 49(10):883-90.

  Measurement of hospitals' clinical performance is becoming more ubiquitous in an effort to inform patient choices, payer reimbursement decisions, and quality improvement initiatives such asMeasurement of hospitals' clinical performance is becoming more ubiquitous in an effort to inform patient choices, payer reimbursement decisions, and quality improvement initiatives such as pay-for-performance. As more measures are developed, the intensity with which measures are monitored changes. Performance measures are often retired after a period of sustained performance and not monitored as actively as other measures where performance is more variable. The effect of actively versus passively monitoring performance on measured quality of care is not known. We compared the nature and rate of change in hospital outpatient clinical performance as a function of a measure's status (active vs. passive), and examined the mean time to stability of performance after changing status. We hypothesize that performance will be higher when measures are actively monitored than when they are passively monitored. Longitudinal, hierarchical retrospective analyses of outpatient clinical performance measure data from Veterans Health Administration's External Peer Review Program from 2000 to 2008. One hundred thirty-three Veterans Health Administration Medical Centers throughout the United States and its associated territories. Clinical performance on 17 measures covering 5 clinical areas common to ambulatory care: screening, immunization, chronic care after acute myocardial infarction, diabetes mellitus, and hypertension. Contrary to expectations, we found that measure status (whether active or passive) did not significantly impact performance over time; time to stability of performance varied considerably by measure, and did not seem to covary with performance at the stability point (ie, performance scores for measures with short stability times were no higher or lower than scores for measures with longer stability times). We found no significant "extinction" of performance after measures were retired, suggesting that other features of the health care system, such as organizational policies and procedures or other structural features, may be creating a "strong situation" and sustaining performance. Future research should aim to better understand the effects of monitoring performance using process-of-care measures and creating sustained high performance.

• Disease-free survival at 2 or 3 years correlates with 5-year overall survival of patients undergoing radical cystectomy for muscle invasive bladder cancer.

  Authors: Guru Sonpavde, Myrna M Khan, Seth P Lerner, Robert S Svatek, Giacomo Novara, Pierre I Karakiewicz, Eila Skinner, Derya Tilki, Wassim Kassouf, Yves Fradet, Colin P Dinney, Hans-Martin Fritsche, Jonathan I Izawa, Patrick J Bastian, Vincenzo Ficarra, Mark Schoenberg, Arthur I Sagalowsky, Yair Lotan, Shahrokh F Shariat

  The Journal of urology. 02/2011; 185(2):456-61.

  The conventional primary end point in trials of perioperative systemic therapy for muscle invasive bladder cancer is 5-year overall survival. We identified an association between disease-freeThe conventional primary end point in trials of perioperative systemic therapy for muscle invasive bladder cancer is 5-year overall survival. We identified an association between disease-free survival at 2 to 3 years and 5-year overall survival. We retrospectively analyzed a multicenter database containing records of 2,724 patients treated with radical cystectomy for muscle invasive bladder cancer with negative margins. Of these patients 844 had received adjuvant chemotherapy. We evaluated the association of disease-free survival at 2 and 3 years with overall survival at 5 years using Cox proportional hazards modeling and the kappa statistic. Overall 2-year/3-year disease-free survival was 0.63/0.57 and 5-year overall survival was 0.47. The overall agreement between 2-year disease-free survival and 5-year overall survival was 79%, and between 3-year disease-free survival and 5-year overall survival was 81%. Agreements were similar when analyzed within pathological substages, radical cystectomy decades and adjuvant chemotherapy subgroups. The kappa statistic was 0.57 (95% CI 0.53-0.60) for 2-year disease-free survival/5-year overall survival and 0.61 (95% CI 0.58-0.64) for 3-year disease-free survival/5-year overall survival, indicating moderate agreement. The hazard ratio for disease-free survival as a time dependent variable was 12.7 (95% CI 11.60-13.90), indicating a strong relationship between disease-free and overall survival. Disease-free survival rates at 2 and 3 years correlate with and are potential intermediate surrogates for 5-year overall survival in patients treated with radical cystectomy for muscle invasive bladder cancer regardless of adjuvant chemotherapy. These data warrant external validation and may expedite the development of adjuvant systemic therapy. In addition, they may be applicable to the neoadjuvant setting.

• Prognostic risk stratification of pathological stage T3N0 bladder cancer after radical cystectomy.

  Authors: Guru Sonpavde, Myrna M Khan, Robert S Svatek, Richard Lee, Giacomo Novara, Derya Tilki, Seth P Lerner, Gilad E Amiel, Eila Skinner, Pierre I Karakiewicz, Patrick J Bastian, Wassim Kassouf, Hans-Martin Fritsche, Jonathan I Izawa, Douglas S Scherr, Vincenzo Ficarra, Colin P Dinney, Yair Lotan, Yves Fradet, Shahrokh F Shariat

  The Journal of urology. 02/2011; 185(4):1216-21.

  Patients with pathological T3N0 stage urothelial carcinoma of the bladder show a range of outcomes after radical cystectomy. Given that nomograms have included heterogeneous groups of patients, wePatients with pathological T3N0 stage urothelial carcinoma of the bladder show a range of outcomes after radical cystectomy. Given that nomograms have included heterogeneous groups of patients, we focused on and stratified patients with pT3N0 urothelial carcinoma of the bladder after radical cystectomy into prognostically different risk groups to facilitate the development of adjuvant therapy trials for those at high risk. The study comprised a total of 578 patients from 9 centers worldwide with pT3N0 urothelial carcinoma of the bladder who underwent radical cystectomy without perioperative chemotherapy. We evaluated the effect of pT3 substage at radical cystectomy, age, grade, lymphovascular invasion, margin status and number of lymph nodes removed on recurrence-free survival using Cox regression analysis. A weighted prognostic model was devised. Median followup was 39.4 months (IQR 64). On multivariate analysis pT3 substage at radical cystectomy (pT3b vs pT3a HR 2.056, p <0.0001), lymphovascular invasion (positive vs negative HR 2.004, p <0.0001) and margin status (positive vs negative HR 2.503, p = 0.002) were associated with recurrence-free survival (concordance index 0.66) in the context of generally adequate lymph node dissection, that is with a median of 17 removed. Three risk groups were devised based on weighted variables with a 5-year recurrence-free survival rate of 79% (95% CI 70-84), 57% (95% CI 50-64) and 37% (95% CI 26-48) in the low, intermediate and high risk groups, respectively. We constructed a user friendly prognostic risk model for patients with pT3N0 urothelial carcinoma of the bladder treated with radical cystectomy based on pT3 substage at radical cystectomy, lymphovascular invasion and margin status. These data warrant validation and may enable tailored monitoring and selection of appropriate patients for adjuvant therapy trials.

• Imagery rescripting and exposure group treatment of posttraumatic nightmares in Veterans with PTSD.

  Authors: Mary E Long, Mary E Hammons, Joanne L Davis, B Christopher Frueh, Myrna M Khan, Jon D Elhai, Ellen J Teng

  Journal of anxiety disorders. 01/2011; 25(4):531-5.

  This study details results of an open trial of a group psychological treatment for Veterans with posttraumatic stress disorder (PTSD) and chronic posttraumatic nightmares called "Imagery RescriptingThis study details results of an open trial of a group psychological treatment for Veterans with posttraumatic stress disorder (PTSD) and chronic posttraumatic nightmares called "Imagery Rescripting and Exposure Therapy" (IRET). IRET is a variant of a successful imagery rescripting treatment for civilian trauma-related nightmares that was modified to address the needs of the Veteran population. Thirty-seven male U.S. Veterans with PTSD and nightmares attended 6 multicomponent group sessions. Findings indicated that the intervention significantly reduced frequency of nightmares and PTSD severity, as well as increased hours of sleep. Unlike the few open trials examining treatment of nightmares in Veterans, effect sizes in this study were similar to those that have been found in the civilian randomized controlled trial. These preliminary findings suggest that a nightmares treatment can be adapted to successfully reduce distress associated with combat Veterans' chronic nightmares. Clinical and research implications are discussed.

• Prognostic risk stratification of pathological stage T2N0 bladder cancer after radical cystectomy.

  Authors: Guru Sonpavde, Myrna M Khan, Robert S Svatek, Richard Lee, Giacomo Novara, Derya Tilki, Seth P Lerner, Gilad E Amiel, Eila Skinner, Pierre I Karakiewicz, Patrick J Bastian, Wassim Kassouf, Hans-Martin Fritsche, Jonathan I Izawa, Vincenzo Ficarra, Colin P Dinney, Yair Lotan, Yves Fradet, Shahrokh F Shariat

  BJU international. 11/2010; 108(5):687-92.

  • To stratify risk of pathological (p) T2N0 urothelial carcinoma of the bladder after radical cystectomy (RC) based on pathological factors to facilitate the development of adjuvant therapy trials• To stratify risk of pathological (p) T2N0 urothelial carcinoma of the bladder after radical cystectomy (RC) based on pathological factors to facilitate the development of adjuvant therapy trials for high-risk patients. • The study comprised 707 patients from a database of patients with pT2N0 urothelial carcinoma of the bladder who had undergone RC and not received perioperative chemotherapy. • The effect of residual pT-stage at RC, age, grade, lymphovascular invasion and number of lymph nodes removed on recurrence-free survival was evaluated using Cox regression analyses. A weighted prognostic model was devised with significant variables. • The median follow up was 60.9 months. In multivariable analyses, residual disease at RC (pT2a: hazard ratio (HR) 1.740, P = 0.03; for pT2b: HR 3.075, P < 0.001; both compared with <pT2), high-grade (HR 2.127, P = 0.09) and lymphovascular invasion (HR 2.234, P < 0.001) were associated with recurrence-free survival (c = 0.70). • Three risk groups were devised based on weighted variables with 5-year recurrence-free survival of 95% (95% CI 87-98), 86% (95% CI 81-90) and 62% (95% CI 54-69) in the good-risk, intermediate-risk and poor-risk groups, respectively (c = 0.68). The primary limitation is the retrospective and multicenter feature. • A prognostic risk model for patients with pT2N0 bladder cancer undergoing RC with generally adequate lymph node dissection was constructed based on residual pathological stage at RC, grade and lymphovascular invasion. • These data warrant validation and may enable the selection of patients with high-risk pT2N0 urothelial carcinoma of the bladder for adjuvant therapy trials.

• Characteristics and predictors of missed opportunities in lung cancer diagnosis: an electronic health record-based study.

  Authors: Hardeep Singh, Kamal Hirani, Himabindu Kadiyala, Olga Rudomiotov, Traber Davis, Myrna M Khan, Terry L Wahls

  Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 07/2010; 28(20):3307-15.

  Understanding delays in cancer diagnosis requires detailed information about timely recognition and follow-up of signs and symptoms. This information has been difficult to ascertain from paper-basedUnderstanding delays in cancer diagnosis requires detailed information about timely recognition and follow-up of signs and symptoms. This information has been difficult to ascertain from paper-based records. We used an integrated electronic health record (EHR) to identify characteristics and predictors of missed opportunities for earlier diagnosis of lung cancer. Using a retrospective cohort design, we evaluated 587 patients of primary lung cancer at two tertiary care facilities. Two physicians independently reviewed each case, and disagreements were resolved by consensus. Type I missed opportunities were defined as failure to recognize predefined clinical clues (ie, no documented follow-up) within 7 days. Type II missed opportunities were defined as failure to complete a requested follow-up action within 30 days. Reviewers identified missed opportunities in 222 (37.8%) of 587 patients. Median time to diagnosis in cases with and without missed opportunities was 132 days and 19 days, respectively (P < .001). Abnormal chest x-ray was the clue most frequently associated with type I missed opportunities (62%). Follow-up on abnormal chest x-ray (odds ratio [OR], 2.07; 95% CI, 1.04 to 4.13) and completion of first needle biopsy (OR, 3.02; 95% CI, 1.76 to 5.18) were associated with type II missed opportunities. Patient adherence contributed to 44% of patients with missed opportunities. Preventable delays in lung cancer diagnosis arose mostly from failure to recognize documented abnormal imaging results and failure to complete key diagnostic procedures in a timely manner. Potential solutions include EHR-based strategies to improve recognition of abnormal imaging and track patients with suspected cancers.

• Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?

  Authors: Hardeep Singh, Eric J Thomas, Dean F Sittig, Lindsey Wilson, Donna Espadas, Myrna M Khan, Laura A Petersen

  The American journal of medicine. 03/2010; 123(3):238-44.

  Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examinedFollow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions. We studied 4 alerts: hemoglobin A1c > or =15%, positive hepatitis C antibody, prostate-specific antigen > or =15 ng/mL, and thyroid-stimulating hormone > or =15 mIU/L. An alert tracking system determined whether the alert was acknowledged (ie, provider clicked on and opened the message) within 2 weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (eg, patient contact, treatment). Multivariable logistic regression models analyzed predictors for lack of timely follow-up. Between May and December 2008, 78,158 tests (hemoglobin A1c, hepatitis C antibody, thyroid-stimulating hormone, and prostate-specific antigen) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%), and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs 10.1%; P =.13). Of 1163 alerts, 202 (17.4%) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (odds ratio 7.35; 95% confidence interval, 4.16-12.97), whereas alerts related to redundant tests were less likely to lack timely follow-up (odds ratio 0.24; 95% confidence interval, 0.07-0.84). Safety concerns related to timely patient follow-up remain despite automated notification of non-life-threatening abnormal laboratory results in the outpatient setting.

• Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?

  Authors: Hardeep Singh, Eric J Thomas, Shrinidi Mani, Dean Sittig, Harvinder Arora, Donna Espadas, Myrna M Khan, Laura A Petersen

  Archives of internal medicine. 09/2009; 169(17):1578-86.

  BACKGROUND: Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic imaging results remains a challenge. We hypothesized that an electronic medical record (EMR) thatBACKGROUND: Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic imaging results remains a challenge. We hypothesized that an electronic medical record (EMR) that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem. METHODS: We studied critical imaging alert notifications in the outpatient setting of a tertiary care Department of Veterans Affairs facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (ie, health care practitioner/provider [HCP] opened the message for viewing) within 2 weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted HCPs to determine timely follow-up actions (eg, ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by HCPs analyzed predictors for 2 outcomes: lack of acknowledgment and lack of timely follow-up. RESULTS: Of 123 638 studies (including radiographs, computed tomographic scans, ultrasonograms, magnetic resonance images, and mammograms), 1196 images (0.97%) generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when the ordering HCPs were trainees (odds ratio [OR], 5.58; 95% confidence interval [CI], 2.86-10.89) and when dual-alert (>1 HCP alerted) as opposed to single-alert communication was used (OR, 2.02; 95% CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs 9.7%; P = .22). Risk for lack of timely follow-up was higher with dual-alert communication (OR, 1.99; 95% CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12; 95% CI, 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment. CONCLUSIONS: Critical imaging results may not receive timely follow-up actions even when HCPs receive and read results in an advanced, integrated electronic medical record system. A multidisciplinary approach is needed to improve patient safety in this area.

• Quality of depression care and its impact on health service use and mortality among veterans.

  Authors: Jeffrey A Cully, Meghan Zimmer, Myrna M Khan, Laura A Petersen

  Psychiatric services (Washington, D.C.). 01/2009; 59(12):1399-405.

  OBJECTIVE: Little is known about the effects of quality of depression care on patient outcomes other than depression status. This study examined Veterans Health Administration (VHA) data over aOBJECTIVE: Little is known about the effects of quality of depression care on patient outcomes other than depression status. This study examined Veterans Health Administration (VHA) data over a six-year period to determine whether quality of depression care was related to patients' health service use and mortality. METHODS: Using a national VHA database, the authors identified 205,165 veterans with a new-onset depressive disorder and at least one filled prescription for an antidepressant medication between October 1, 1999, and September 30, 2005. Quality of depression care was assessed with antidepressant medication possession ratios and adequacy of follow-up care (three or more depression-related visits during the 84 days after a depression diagnosis). Logistic regression modeling was used to predict inpatient service use and all-cause mortality. RESULTS: Of the cohort 48% received an adequate supply of antidepressant medication and 31% had three or more follow-up visits during the 84-day profiling period. Rates of adequate medication supply did not change over the six-year period, but there were improvements in adequate follow-up care over the study period (p=.03). Adequate follow-up depression care was associated with increased health service use and decreased likelihood of 12-month all-cause mortality. CONCLUSIONS: According to the quality indicators, less than half of patients with newly diagnosed depression received high-quality care. Notably, adequate follow-up care for depression was significantly related to reduction in odds of patient mortality at the 12-month follow-up. These findings suggest that quality of depression care may significantly affect patient outcomes, including mortality, and that further efforts to improve quality appear warranted.

• Identifying diagnostic errors in primary care using an electronic screening algorithm.

  Authors: Hardeep Singh, Eric J Thomas, Myrna M Khan, Laura A Petersen

  Archives of internal medicine. 03/2007; 167(3):302-8.

  BACKGROUND: Diagnostic errors are the leading basis for malpractice claims in primary care, yet these errors are underidentified and understudied. Computerized methods used to screen for other typesBACKGROUND: Diagnostic errors are the leading basis for malpractice claims in primary care, yet these errors are underidentified and understudied. Computerized methods used to screen for other types of errors (eg, medication related) have not been applied to diagnostic errors. Our objectives were to assess the feasibility of computerized screening to identify diagnostic errors in primary care and to categorize diagnostic breakdowns using a recently published taxonomy. METHODS: We used an algorithm to screen the electronic medical records of patients at a single hospital that is part of a closed health care system. A Structured Query Language-based program detected the presence of 1 of 2 mutually exclusive electronic screening criteria: screen 1, a primary care visit (index visit) followed by a hospitalization in the next 10 days; or screen 2, an index visit followed by 1 or more primary care, urgent care, or emergency department visits within 10 days. Two independent, blinded reviewers determined the presence or absence of diagnostic error through medical record review of visits with positive and negative screening results. RESULTS: Among screen 1 and 2 positive visits, 16.1% and 9.4%, respectively, were associated with a diagnostic error. The error rate was 4% in control cases that met neither screening criterion. The most common primary errors in the diagnostic process were failure or delay in eliciting information and misinterpretation or suboptimal weighing of critical pieces of data from the history and physical examination. The most common secondary errors were suboptimal weighing or prioritizing of diagnostic probabilities and failure to recognize urgency of illness or its complications. CONCLUSIONS: Electronic screening has potential to identify records that may contain diagnostic errors in primary care, and its performance is comparable to screening tools for other types of errors. Future studies that validate these findings in other settings could provide improvement initiatives in this area.

• A quasi-experimental test of an intervention to increase the use of thiazide-based treatment regimens for people with hypertension.

  Authors: Carol M Ashton, Myrna M Khan, Michael L Johnson, Annette Walder, Elizabeth Stanberry, Rebecca J Beyth, Tracie C Collins, Howard S Gordon, Paul Haidet, Barbara Kimmel, Anna Kolpakchi, Lee B Lu, Aanand D Naik, Laura A Petersen, Hardeep Singh, Nelda P Wray

  Implementation science : IS. 02/2007; 2:5.

  BACKGROUND: Despite recent high-quality evidence for their cost-effectiveness, thiazides are underused for controlling hypertension. The goal of this study was to design and test a practice-basedBACKGROUND: Despite recent high-quality evidence for their cost-effectiveness, thiazides are underused for controlling hypertension. The goal of this study was to design and test a practice-based intervention aimed at increasing the use of thiazide-based antihypertensive regimens. METHODS: This quasi-experimental study was carried out in general medicine ambulatory practices of a large, academically-affiliated Veterans Affairs hospital. The intervention group consisted of the practitioners (13 staff and 215 trainees), nurses, and patients (3,502) of the teaching practice; non-randomized concurrent controls were the practitioners (31 providers) and patients (18,292) of the non-teaching practices. Design of the implementation intervention was based on Rogers' Diffusion of Innovations model. Over 10.5 months, intervention teams met weekly or biweekly and developed and disseminated informational materials among themselves and to trainees, patients, and administrators. These teams also reviewed summary electronic-medical-record data on thiazide use and blood pressure (BP) goal attainment. Outcome measures were the proportion of hypertensive patients prescribed a thiazide-based regimen, and the proportion of hypertensive patients attaining BP goals regardless of regimen. Thirty-three months of time-series data were available; statistical process control charts, change point analyses, and before-after analyses were used to estimate the intervention's effects. RESULTS: Baseline use of thiazides and rates of BP control were higher in the intervention group than controls. During the intervention, thiazide use and BP control increased in both groups, but changes occurred earlier in the intervention group, and primary change points were observed only in the intervention group. Overall, the pre-post intervention difference in proportion of patients prescribed thiazides was greater in intervention patients (0.091 vs. 0.058; p = 0.0092), as was the proportion achieving BP goals (0.092 vs. 0.044; p = 0.0005). At the end of the implementation period, 41.4% of intervention patients were prescribed thiazides vs. 30.6% of controls (p < 0.001); 51.6% of intervention patients had achieved BP goals vs. 44.3% of controls (p < 0.001). CONCLUSION: This multi-faceted intervention appears to have resulted in modest improvements in thiazide prescribing and BP control. The study also demonstrates the value of electronic medical records for implementation research, how Rogers' model can be used to design and launch an implementation strategy, and how all members of a clinical microsystem can be involved in an implementation effort.

• Research Paper: Communication Outcomes of Critical Imaging Results in a Computerized Notification System.

  Authors: Hardeep Singh, Harvinder S. Arora, Meena S. Vij, Raghuram Rao, Myrna M. Khan, Laura A. Petersen

  JAMIA. 01/2007; 14:459-466.

• Communication Outcomes of Critical Imaging Results in a Computerized Notification System

  Authors: Hardeep Singh, Harvinder S. Arora, Meena S. Vij, Raghuram Rao, Myrna M. Khan, Laura A. Petersen

  Journal of the American Medical Informatics Association.

  ObjectiveCommunication of abnormal test results in the outpatient setting is prone to error. Using information technology can improve communication and improve patient safety. We standardizedObjectiveCommunication of abnormal test results in the outpatient setting is prone to error. Using information technology can improve communication and improve patient safety. We standardized processes and procedures in a computerized test result notification system and examined their effectiveness to reduce errors in communication of abnormal imaging results.DesignWe prospectively analyzed outcomes of computerized notification of abnormal test results (alerts) that providers did not explicitly acknowledge receiving in the electronic medical record of an ambulatory multispecialty clinic.MeasurementsIn the study period, 190,799 outpatient visits occurred and 20,680 outpatient imaging tests were performed. We tracked 1,017 transmitted alerts electronically. Using a taxonomy of communication errors, we focused on alerts in which errors in acknowledgment and reception occurred. Unacknowledged alerts were identified through electronic tracking. Among these, we performed chart reviews to determine any evidence of documented response, such as ordering a follow-up test or consultation. If no response was documented, we contacted providers by telephone to determine their awareness of the test results and any follow-up action they had taken. These processes confirmed the presence or absence of alert reception.ResultsProviders failed to acknowledge receipt of over one-third (368 of 1,017) of transmitted alerts. In 45 of these cases (4% of abnormal results), the imaging study was completely lost to follow-up 4 weeks after the date of study. Overall, 0.2% of outpatient imaging was lost to follow-up. The rate of lost to follow-up imaging was 0.02% per outpatient visit.ConclusionImaging results continue to be lost to follow-up in a computerized test result notification system that alerted physicians through the electronic medical record. Although comparison data from previous studies are limited, the rate of results lost to follow-up appears to be lower than that reported in systems that do not use information technology comparable to what we evaluated.

• Notification of Abnormal Lab Test Results in an Electronic Medical Record: Do Any Safety Concerns Remain?

  Authors: Hardeep Singh, Eric J. Thomas, Dean F. Sittig, Lindsey Wilson, Donna Espadas, Myrna M. Khan, Laura A. Petersen

  The American Journal of Medicine.

  BackgroundFollow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification.BackgroundFollow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions.MethodsWe studied 4 alerts: hemoglobin A1c ≥15%, positive hepatitis C antibody, prostate-specific antigen ≥15 ng/mL, and thyroid-stimulating hormone ≥15 mIU/L. An alert tracking system determined whether the alert was acknowledged (ie, provider clicked on and opened the message) within 2 weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (eg, patient contact, treatment). Multivariable logistic regression models analyzed predictors for lack of timely follow-up.ResultsBetween May and December 2008, 78,158 tests (hemoglobin A1c, hepatitis C antibody, thyroid-stimulating hormone, and prostate-specific antigen) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%), and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs 10.1%; P =.13). Of 1163 alerts, 202 (17.4%) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (odds ratio 7.35; 95% confidence interval, 4.16-12.97), whereas alerts related to redundant tests were less likely to lack timely follow-up (odds ratio 0.24; 95% confidence interval, 0.07-0.84).ConclusionsSafety concerns related to timely patient follow-up remain despite automated notification of non-life-threatening abnormal laboratory results in the outpatient setting.

• Communication outcomes of critical imaging results in a computerized notification system.

  Authors: Hardeep Singh, Harvinder S Arora, Meena S Vij, Raghuram Rao, Myrna M Khan, Laura A Petersen

  Journal of the American Medical Informatics Association : JAMIA. 14(4):459-66.

  OBJECTIVE: Communication of abnormal test results in the outpatient setting is prone to error. Using information technology can improve communication and improve patient safety. We standardizedOBJECTIVE: Communication of abnormal test results in the outpatient setting is prone to error. Using information technology can improve communication and improve patient safety. We standardized processes and procedures in a computerized test result notification system and examined their effectiveness to reduce errors in communication of abnormal imaging results. DESIGN: We prospectively analyzed outcomes of computerized notification of abnormal test results (alerts) that providers did not explicitly acknowledge receiving in the electronic medical record of an ambulatory multispecialty clinic. MEASUREMENTS: In the study period, 190,799 outpatient visits occurred and 20,680 outpatient imaging tests were performed. We tracked 1,017 transmitted alerts electronically. Using a taxonomy of communication errors, we focused on alerts in which errors in acknowledgment and reception occurred. Unacknowledged alerts were identified through electronic tracking. Among these, we performed chart reviews to determine any evidence of documented response, such as ordering a follow-up test or consultation. If no response was documented, we contacted providers by telephone to determine their awareness of the test results and any follow-up action they had taken. These processes confirmed the presence or absence of alert reception. RESULTS: Providers failed to acknowledge receipt of over one-third (368 of 1,017) of transmitted alerts. In 45 of these cases (4% of abnormal results), the imaging study was completely lost to follow-up 4 weeks after the date of study. Overall, 0.2% of outpatient imaging was lost to follow-up. The rate of lost to follow-up imaging was 0.02% per outpatient visit. CONCLUSION: Imaging results continue to be lost to follow-up in a computerized test result notification system that alerted physicians through the electronic medical record. Although comparison data from previous studies are limited, the rate of results lost to follow-up appears to be lower than that reported in systems that do not use information technology comparable to what we evaluated.