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ABSTRACT: Background/Aims With the adoption of electronic medical records (EMR) by medical group practices, there are opportunities to improve the quality of care for patients who are discharged from hospitals and intermediate care facilities. While transitions within vertically-integrated healthcare systems are amenable to EMR-based transition interventions, there is little guidance for medical groups without integrated hospital-EMR access who wish to automate the flow of patient information during critical transitions in care. Our aim was to describe the technological resources, expertise and time needed to develop and implement an automated system providing critical information and alerts to primary care physicians when their patients transition from hospitals or skilled nursing facilities to home. Methods Within a large medical group practice with an EMR, we developed and implemented an automated alert system that provides notification of discharges, reminders of the need for follow-up visits, new drugs added during the in-patient stay, warnings about drug-drug interactions, and recommendations for dosing changes and laboratory monitoring of high risk drugs. We tracked components of the information system required to accomplish this as well as the time spent by team members. We used US national averages of relevant hourly wages to estimate personnel costs. Results Critical components of the information system are notifications of hospital discharges through an admission, discharge and transfer registration (ADT) interface, linkage to the group practice scheduling system, timely access to information on pharmacy dispensing and lab tests, and an interface engine to direct messages to specific physicians and staff. Total personnel cost was $76,314. Nearly half (47%) was for 614 hours by physicians who developed content, provided overall project management, and reviewed alerts during a test period to ensure that only "actionable" alerts would be sent. Discussion Implementing a system to provide a flow of critical information about patient transitions requires strong internal informatics expertise, cooperation between facilities and ambulatory providers, development of a number of electronic linkages, and extensive commitment of physician time.
Clinical Medicine & Research 08/2012; 10(3):166.
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ABSTRACT: Background/Aims Inadequate laboratory monitoring of high-risk medications is a medical error associated with preventable adverse drug events. Patient failure to complete ordered laboratory tests is not uncommon. We conducted in-depth interviews with patients who did not complete a recently ordered laboratory test to identify barriers to test completion. Methods The target population was patients in a large multispecialty group practice who failed to complete an ordered laboratory test. We conducted semi-structured interviews with 18 patients who did not complete a monitoring test order related to 1 of 7 high-risk medications (angiotensin converting enzyme inhibitors (ACE) inhibitors, angiotensin II receptor blockers (ARBs), digoxin, phenytoin, statins, thyroid replacement hormone, or valproic acid) between July 2008 and October 2010. For comparison, we also interviewed 5 patients who completed all ordered laboratory tests. The interviews occurred in person when possible (n=17) as well as by phone (n=6). All interviews were recorded and transcribed and analyzed using a grounded theory approach. Results The laboratory monitoring discussions included the following themes: physician communication about lab tests, patient comprehension of lab test purpose, patient attitude toward lab tests, and barriers to test completion. The most prominent barrier to test completion was forgetting. Patients often did not realize they had missed an ordered test. When patients did acknowledge missing an ordered test, they often noted that they did not encounter any barriers besides forgetting. Regarding potential interventions, patients reported that understanding the indication for the tests would not help reduce non-completion. Several patients understood the reason for the test, but still failed to complete it. While some thought it was important to understand the reason for the test, others trusted their physician and did not believe it was essential to understand. Some patients were using an online personal health portal system offered through the practice that included information about upcoming tests. Conclusions Forgetting was the most prominent theme for non-completion of ordered test. Patients felt that providing timely (near desired test completion date) patient reminders, either by phone or by e-mail, would likely improve completion rates of laboratory monitoring for high-risk medications, while providing more information about the test indication would not.
Clinical Medicine & Research 11/2011; 9(3-4):158-159.
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ABSTRACT: Background/Aims Initiative to improve the quality and safety of pharmaceutical care have lead to the development of quality of care measures including standards for the appropriate monitoring of high-risk medications (defined as medications commonly implicated in adverse drug events or with narrow therapeutic window). While low rates of laboratory monitoring of high-risk medications might indicate poor physician performance, it is unclear how much patient non-adherence to physician-ordered tests contribute to undermeasruement of physician quality. The study aim is to determine, for Health Employer Data Information Set (HEDIS) quality of care, high-risk medication laboratory monitoring measures: the prevalence of completion of recommended monitoring tests; and the proportion of incomplete testing attributable to lack of clinician test ordering relative to patient non-adherence to ordered tests. Methods and Results We measured the ordering and completion of laboratory tests for HEDIS-based high-risk medications (ACE inhibitors, ARBs, digoxin and diuretics, and anticonvulants) in a large multispecialty group practice between January 1, 2008 and July 31, 2008. Laboratory test completion for HEDIS cardiovascular drugs was higher than for anticonvulsants. Each cardiovascular drug had a completion rate of > 85%, while the completion rate for anticonvulsants ranged from 30-75%. The lowest test completion rate was for phenobarbital levels to monitor phenobarbital (30%). For all cardiovascular and anticonvulsant drugs, the proportion of recommended tests not ordered by the clinician ranged from 5% to 60%. The lowest test order prevalence was for phenobarbital level for phenobarbital use (35%), followed by valproic acid level for valproate use(48%), and carbamazepine level for carbamazepine use (60%). Rates of patient noncompletion of ordered tests for all drugs was generally <10%. Conclusion Completion of laboratory monitoring tests for high-risk cardiovascular medications was higher than for high-risk anticonvulsants according to HEDIS guidelines. Clinician ordering behavior exhibited more variation than patient adherence to test orders. Underestimation of HEDIS quality of care monitoring due to patient non-adherence is minimal for cardiovascular medications, but higher for anticonvulsants.
Clinical Medicine & Research 11/2011; 9(3-4):178-179.
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Jennifer Tjia,
Terry Field,
Lawrence Garber,
Marsha Raebel,
Jennifer Donovan,
Abir Kanaan,
Shira Fischer, Shawn Gagne,
Yanfang Zhao,
Jackie Fuller,
Jerry Gurwitz
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ABSTRACT: Background: Inadequate laboratory monitoring of high-risk medications contributes to preventable adverse drug events. One barrier to appropriate monitoring is lack of standardized monitoring guidelines. The study aims were to develop guidelines to monitor high-risk medications and to assess the prevalence of laboratory testing for these medications in a multispecialty group practice.
