A Randomized Trial of Electronic Clinical Reminders to Improve Quality of Care for Diabetes and Coronary Artery Disease

Harvard University, Cambridge, Massachusetts, United States
Journal of the American Medical Informatics Association (Impact Factor: 3.5). 07/2005; 12(4):431-7. DOI: 10.1197/jamia.M1788
Source: DBLP


The aim of this study was to evaluate the impact of an integrated patient-specific electronic clinical reminder system on diabetes and coronary artery disease (CAD) care and to assess physician attitudes toward this reminder system.
We enrolled 194 primary care physicians caring for 4549 patients with diabetes and 2199 patients with CAD at 20 ambulatory clinics. Clinics were randomized so that physicians received either evidence-based electronic reminders within their patients' electronic medical record or usual care. There were five reminders for diabetes care and four reminders for CAD care.
The primary outcome was receipt of recommended care for diabetes and CAD. We created a summary outcome to assess the odds of increased compliance with overall diabetes care (based on five measures) and overall CAD care (based on four measures). We surveyed physicians to assess attitudes toward the reminder system.
Baseline adherence rates to all quality measures were low. While electronic reminders increased the odds of recommended diabetes care (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.01-1.67) and CAD (OR 1.25, 95% CI 1.01-1.55), the impact of individual reminders was variable. A total of three of nine reminders effectively increased rates of recommended care for diabetes or CAD. The majority of physicians (76%) thought that reminders improved quality of care.
An integrated electronic reminder system resulted in variable improvement in care for diabetes and CAD. These improvements were often limited and quality gaps persist.

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    • "The same EHR is used by all 12 clinics. The EHR is a homegrown system called the Longitudinal Medical Record which has been in use since July 2000 [20]. This electronic record allows physicians to maintain problem lists, medication lists, and allergy lists, view laboratory results, enter notes and write electronic prescriptions. "
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    ABSTRACT: Background Chronic kidney disease (CKD) is increasingly common and under-recognized in primary care clinics, leading to low rates of stage-appropriate monitoring and treatment. Our objective was to determine whether electronic problem list documentation of CKD is associated with monitoring and treatment. Methods This is a cross-sectional observational study of patients with stage 3 or 4 CKD, defined as two past estimated glomerular filtration rates (eGFR) 15-60 mL/min/1.73 m2 separated by 90 days and collected between 2007-2008. We examined the association of problem list documentation with: 1) serum eGFR monitoring test, 2) urine protein or albumin monitoring test, 3) an angiotensin converting enzyme inhibitor or angiotensin receptor blocker (ACE/ARB) prescription, 4) mean systolic blood pressure (BP), and 5) BP control. Results Out of 3,149 patients with stage 3 or 4 CKD, only 16% of patients had CKD documented on the problem list. After adjustment for eGFR, gender, and race/ethnicity and after clustering by physician, problem list documentation of CKD was associated with serum eGFR testing (97% with problem list documentation vs. 94% without problem list documentation, p = 0.02) and urine protein testing (47% with problem list documentation vs. 40% without problem list documentation, p = 0.04). After adjustment, problem list documentation was not associated with ACE/ARB prescription, mean systolic BP, or BP control. Conclusions Documentation of CKD on the electronic problem list is rare. Patients with CKD documentation have better stage-appropriate monitoring of the disease, but do not have higher rates of blood pressure treatment or better blood pressure control. Interventions aimed at increasing documentation of CKD on the problem list may improve stage-appropriate monitoring, but may not improve clinical outcomes.
    Full-text · Article · May 2014 · BMC Nephrology
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    • "Decision support can in many settings improve the quality of care and help to avoid mistakes in clinical work, thereby improving patient safety [18,19]. There is still, however, scant evidence on how such information technology solutions work across many diseases or conditions in primary healthcare where multi-professional teams [20,21] care for patients with multiple health problems, both acute and chronic [22,23]. "
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    ABSTRACT: Computer-based decision support systems are a promising method for incorporating research evidence into clinical practice. However, evidence is still scant on how such information technology solutions work in primary healthcare when support is provided across many health problems. In Finland, we designed a trial where a set of evidence-based, patient-specific reminders was introduced into the local Electronic Patient Record (EPR) system. The aim was to measure the effects of such reminders on patient care. The hypothesis was that the total number of triggered reminders would decrease in the intervention group compared with the control group, indicating an improvement in patient care. From July 2009 to October 2010 all the patients of one health center were randomized to an intervention or a control group. The intervention consisted of patient-specific reminders concerning 59 different health conditions triggered when the healthcare professional (HCP) opened and used the EPR. In the intervention group, the triggered reminders were shown to the HCP; in the control group, the triggered reminders were not shown. The primary outcome measure was the change in the number of reminders triggered over 12 months. We developed a unique data gathering method, the Repeated Study Virtual Health Check (RSVHC), and used Generalized Estimation Equations (GEE) for analysing the incidence rate ratio, which is a measure of the relative difference in percentage change in the numbers of reminders triggered in the intervention group and the control group. In total, 13,588 participants were randomized and included. Contrary to our expectation, the total number of reminders triggered increased in both the intervention and the control groups. The primary outcome measure did not show a significant difference between the groups. However, with the inclusion of patients followed up over only six months, the total number of reminders increased significantly less in the intervention group than in the control group when the confounding factors (age, gender, number of diagnoses and medications) were controlled for. Computerized, tailored reminders in primary care did not decrease during the 12 months of follow-up time after the introduction of a patient-specific decision support system.Trial registration: NCT00915304.
    Full-text · Article · Jan 2014 · Implementation Science
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    • "Several studies show positive effects of electronic reminders: a recall system can result in higher immunization rates against seasonal influenza of high-risk groups (8), computerized body mass index charts increase the likelihood that physicians would diagnose obesity and refer patients to treatment (9), and decision support in electronic prescribing leads to more responsible prescribing (10-13). However, the use of electronic reminders does not seem to improve the quality of care in diabetes and coronary artery disease (14). "
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    Full-text · Article · Feb 2012 · Croatian Medical Journal
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