Ambulatory Electronic Medical Record Research Articles

“Meaningful Use” of ambulatory EMR: Does it improve the quality and efficiency of health care?

The US government has initiated incentive programs to encourage the adoption of Electronic Medical Records (EMR). To qualify for the incentive payment, healthcare providers need to demonstrate “meaningful use” of EMR systems, which requires the use of certified EMRs and the implementation of a set of standard functionalities. In this paper, we examine how the meaningful use of EMRs would affect health care outcomes in outpatient settings. Our results show that the use of core functionalities required by “meaningful use” criteria and the use of certified EMRs have a positive impact on the quality and efficiency of health care. In addition, we find the relationship between the meaningful use and quality of care is moderated by the length of use. The implications of this study are also discussed.

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.

Lessons learned from implementation of a computerized application for pending tests at hospital discharge

Patients are often discharged from the hospital before test results are finalized. Awareness of these results is poor and therefore an important patient safety concern. Few computerized systems have been deployed at care transitions to address this problem. We describe an attempt to implement a computerized application to help inpatient physicians manage these test results. We modified an ambulatory electronic medical record (EMR)-based results management application to track pending tests at hospital discharge (Hospitalist Results Manager, HRM). We trained inpatient physicians at 2 academic medical centers to track these tests using this application. We surveyed inpatient physicians regarding usage of and satisfaction with the application, barriers to use, and the characteristics of an ideal system to track pending tests at discharge. Of 29 survey respondents, 14 (48%) reported never using HRM, and 13 (45%) used it 1 to 2 times per week. A total of 23 (79%) reported barriers prohibiting use, including being inundated with clinically "irrelevant" results, not having sufficient time, and a lack of integration of post-discharge test result management into usual workflow. Twenty-one (72%) wanted to receive notification of abnormal and clinician-designated pending test results. Twenty-seven physicians (93%) agreed that an ideally designed computerized application would be valuable for managing pending tests at discharge. Although inpatient physicians would highly value a computerized application to manage pending tests at discharge, the characteristics of an ideal system are unclear and there are important barriers prohibiting adoption and optimal usage of such systems. We outline suggestions for future electronic systems to manage pending tests at discharge.

Electronic Record Systems Often Fail to Meet Lofty Goals

Back to table of contents Previous article Next article Government NewsFull AccessElectronic Record Systems Often Fail to Meet Lofty GoalsRich DalyRich DalySearch for more papers by this authorPublished Online:5 Feb 2010https://doi.org/10.1176/pn.45.3.psychnews_45_3_007AbstractPsychiatrists using available electronic medical records may not see much improvement in patient care coordination, according to a recent report.Improved patient care coordination has been highlighted as one of the likely benefits of widespread physician adoption of electronic medical records (EMR). An interview-based survey of physician experiences with ambulatory care EMRs found, however, that they do little to improve care coordination between clinicians who are not in the same practice or health system. Psychiatrists who have moved to EMRs often adapt ambulatory care systems, which are closest to a mental health–specific program.The research, based on interviews with 52 physicians and staff from 26 practices across the country that have used a commercial ambulatory EMR system for at least two years, found current EMRs offer electronic message functions to facilitate intraoffice communication. However, most clinicians still rely on faxes for inter-office communications with other clinicians treating the same patient.The research was led by Ann O'Malley, M.D., M.P.H., a senior researcher at the Center for Studying Health Change. The results appeared in the December 22, 2009, Journal of General Internal Medicine.“If [physicians] have an EMR system, they may take the fax and scan it into their EMR program,” O'Malley told Psychiatric News.Patient care coordination—vitally important to many psychiatrists whose patients often have co-occurring nonpsychiatric illnesses—should improve with the finalization of emerging federal performance and interoperability standards. Those standards stem from a $19 billion program to reimburse physicians for the cost of installing an EMR system in their practices (see EHR Reimbursement Proposal Troubles Psychiatrists).Those federal standards aim to help facilitate better physician sharing of basic patient information, such as medication lists. Federal regulators will take longer to develop standards on sharing more complex but critical information, such as summaries of patient problems that are very helpful in care coordination, O'Malley said.Psychiatrists should not interpret the lack of finalized federal standards or O'Malley's findings as reasons to drop plans to buy a commercial EMR system, she said. However, they should proceed cautiously.It is important that physicians ensure that the manufacturer of the commercial EMR system that the clinician intends to buy will commit in writing to provide all future upgrades needed to meet emerging federal guidelines.O'Malley also noted that despite problems with system interoperability, the clinicians interviewed for her research reported that their practice was improved after adopting an EMR system.Additionally, she noted that even after fully interoperable EMR systems are in widespread use, clinicians will still need to call other clinicians treating the same patient when there is a need for urgent “real-time communications.”Another barrier to the adoption of EMRs is the payment systems for most public and private insurance programs, which currently do not provide physician reimbursement for the time that such care coordination requires.“Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices” is posted at <www.commonwealthfund.org/Content/Publications/In-the-Literature/2009/Dec/Are-Electronic-Medical-Records-Helpful-for-Care-Coordination-Experiences-of-Physician-Practices.aspx>. ISSUES NewArchived

Use of information and communication technologies to support effective work practice innovation in the health sector: a multi-site study.

BackgroundWidespread adoption of information and communication technologies (ICT) is a key strategy to meet the challenges facing health systems internationally of increasing demands, rising costs, limited resources and workforce shortages. Despite the rapid increase in ICT investment, uptake and acceptance has been slow and the benefits fewer than expected. Absent from the research literature has been a multi-site investigation of how ICT can support and drive innovative work practice. This Australian-based project will assess the factors that allow health service organisations to harness ICT, and the extent to which such systems drive the creation of new sustainable models of service delivery which increase capacity and provide rapid, safe, effective, affordable and sustainable health care.DesignA multi-method approach will measure current ICT impact on workforce practices and develop and test new models of ICT use which support innovations in work practice. The research will focus on three large-scale commercial ICT systems being adopted in Australia and other countries: computerised ordering systems, ambulatory electronic medical record systems, and emergency medicine information systems. We will measure and analyse each system's role in supporting five key attributes of work practice innovation: changes in professionals' roles and responsibilities; integration of best practice into routine care; safe care practices; team-based care delivery; and active involvement of consumers in care.DiscussionA socio-technical approach to the use of ICT will be adopted to examine and interpret the workforce and organisational complexities of the health sector. The project will also focus on ICT as a potentially disruptive innovation that challenges the way in which health care is delivered and consequently leads some health professionals to view it as a threat to traditional roles and responsibilities and a risk to existing models of care delivery. Such views have stifled debate as well as wider explorations of ICT's potential benefits, yet firm evidence of the effects of role changes on health service outcomes is limited. This project will provide important evidence about the role of ICT in supporting new models of care delivery across multiple healthcare organizations and about the ways in which innovative work practice change is diffused.

Selecting an Electronic Medical Record: System for Small Physician Practices

While electronic medical record (EMR) systems have demonstrated the potential to improve quality of care and reduce medical errors, relatively few practitioners have implemented EMR systems. This article presents a case study that explores the process by which small physician practices may select an ambulatory EMR system. We assessed the appropriate criteria small practices should use in selecting an EMR system and then evaluated a range of commercially available EMR systems according to cost, functionality, and interoperability with existing systems. The process for selecting an EMR system starts by creating a budget for start-up costs and monthly maintenance expenses. Next, a practice should evaluate its strategic objectives and current computer infrastructure. The group should then define the appropriate functionality requirements specific for their practice. Finally, a certified ambulatory EMR system that interfaces with existing office systems can be selected. This case study explores the process of EMR selection for rural, solo physician practices. The ability to generalize the process described herein to broader types of physician practices, such as multi-specialty group practices or to those practices with larger budgets for EMR systems, may be limited. Multiple critical and often competing factors--including cost and interoperability with existing systems, as well as organizational goals and obstacles--influence the selection of an EMR system for small physician practices. However, by following a standardized process for selecting an EMR system, small physician practices will find EMR selection to be a relatively straightforward process.

Automated Identification of Acute Hepatitis B Using Electronic Medical Record Data to Facilitate Public Health Surveillance

BackgroundAutomatic identification of notifiable diseases from electronic medical records can potentially improve the timeliness and completeness of public health surveillance. We describe the development and implementation of an algorithm for prospective surveillance of patients with acute hepatitis B using electronic medical record data.MethodsInitial algorithms were created by adapting Centers for Disease Control and Prevention diagnostic criteria for acute hepatitis B into electronic terms. The algorithms were tested by applying them to ambulatory electronic medical record data spanning 1990 to May 2006. A physician reviewer classified each case identified as acute or chronic infection. Additional criteria were added to algorithms in serial fashion to improve accuracy. The best algorithm was validated by applying it to prospective electronic medical record data from June 2006 through April 2008. Completeness of case capture was assessed by comparison with state health department records.FindingsA final algorithm including a positive hepatitis B specific test, elevated transaminases and bilirubin, absence of prior positive hepatitis B tests, and absence of an ICD9 code for chronic hepatitis B identified 112/113 patients with acute hepatitis B (sensitivity 97.4%, 95% confidence interval 94–100%; specificity 93.8%, 95% confidence interval 87–100%). Application of this algorithm to prospective electronic medical record data identified 8 cases without false positives. These included 4 patients that had not been reported to the health department. There were no known cases of acute hepatitis B missed by the algorithm.ConclusionsAn algorithm using codified electronic medical record data can reliably detect acute hepatitis B. The completeness of public health surveillance may be improved by automatically identifying notifiable diseases from electronic medical record data.

Instantaneous preference was a stronger instrumental variable than 3- and 6-month prescribing preference for NSAIDs

ObjectivePrescriber preference has been used as an instrumental variable (IV) in a prior study of nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) vs. selective cyclooxygenase-2 (COX-2) inhibitors, with preference expressed as the drug constituting the immediately preceding prescription by the same prescriber (instantaneous preference). We sought to compare the correlations between different IV measures with exposure. Study Design and SettingIn an ambulatory electronic medical record database of university-based physicians, we compared correlations with exposure among three measures of prescriber preference: instantaneous preference, and the proportion of that prescriber's prescriptions in the past 3 and 6 months that were for an NSAID. ResultsWe identified 37,934 initial NSAID/COX-2 prescriptions. The correlation with exposure was 0.283 (95% confidence interval 0.274–0.292) for instantaneous preference, 0.197 (0.187–0.206) for 3-month preference, and 0.170 (0.160–0.180) for 6-month preference. ConclusionInstantaneous NSAID/COX-2 prescribing preference was most strongly correlated, and therefore the strongest IV. Future research should focus on the robustness of IV methods to violations of underlying assumptions, extension of IV methods to more than two groups, ratio measures of association, second and subsequent prescriptions per person, and time-varying exposures.

Using Electronic Medical Records to Enhance Detection and Reporting of Vaccine Adverse Events

We implemented an automated vaccine adverse event surveillance and reporting system based in an ambulatory electronic medical record to improve underreporting and incomplete reporting that prevails in spontaneous systems. This automated system flags potential vaccine adverse events for the clinician when a diagnosis is entered, prompts clinicians to consider the vaccine as a cause of the condition, and facilitates reporting of suspected adverse events to the Vaccine Adverse Event Reporting System (VAERS).During five months, a total of 33,420 vaccinations were administered during 14,466 encounters. There were 5,914 follow-up contacts by vaccinees within 14 days of the vaccination visits; 686 (11.6%) generated an alert. Clinicians submitted VAERS reports for 23 of these (0.69 per 1,000 vaccine doses), which is almost 6 times the dose-based reporting rate to VAERS.1 Clinician surveys indicated that it took a minimal amount of time to respond to the alerts. Of those who felt that an alert corresponded to an actual vaccine adverse event, the majority used the reporting feature to file a VAERS report.We believe that elicited surveillance via real time prompts to clinicians holds substantial promise. By coupling simplified reporting with the initial prompt, clinicians can consider and report a vaccine adverse event electronically in a few moments during the office visit.

Effectiveness of a Two‐Part Educational Intervention to Improve Hypertension Control: A Cluster‐Randomized Trial

To measure the effectiveness of a multifaceted educational intervention to improve ambulatory hypertension control. Cluster-randomized trial. Academic health system using an ambulatory electronic medical record. A total of 10,696 patients with a diagnosis of hypertension cared for by 93 primary care providers. Academic detailing, provision of provider-specific data about hypertension control, provision of educational materials to the provider, and provision of educational and motivational materials to patients. The primary outcome was blood pressure control, defined as a blood pressure measurement below 140/90 mm Hg, and was ascertained from electronic medical records over 6 months of follow-up. We determined the adjusted odds ratio for the association between the intervention and the achievement of controlled blood pressure. When we accounted for clustering by provider, this adjusted odds ratio was 1.13 (95% confidence interval 0.87-1.47). Adjusted odds ratios were 1.03 (95% confidence interval 0.78-1.36) in patients whose blood pressure was controlled at baseline and 1.25 (95% confidence interval 0.94-1.65) in those whose blood pressure was not. These odds ratios were not significantly different (p=0.11). These results were consistent with no effect or, at best, a relatively modest effect of the intervention among patients with hypertension. Had we not included a concurrent control group, the data would have provided an unduly optimistic view of the effectiveness of the program. The effectiveness of future interventions may be improved by focusing on patients whose blood pressure is uncontrolled at baseline.

Moving toward a United States strategic plan in primary care informatics: a White Paper of the Primary Care Informatics Working Group, American Medical Informatics Association.

The Primary Care Informatics Working Group (PCIWG) of the American Medical Informatics Association (AMIA) has identified the absence of a national strategy for primary care informatics. Under PCIWG leadership, major national and international societies have come together to create the National Alliance for Primary Care Informatics (NAPCI), to promote a connection between the informatics community and the organisations that support primary care. The PCIWG clinical practice subcommittee has recognised the necessity of a global needs assessment, and proposed work in point-of-care technology, clinical vocabularies, and ambulatory electronic medical record development. Educational needs include a consensus statement on informatics competencies, recommendations for curriculum and teaching methods, and methodologies to evaluate their effectiveness. The research subcommittee seeks to define a primary care informatics research agenda, and to support and disseminate informatics research throughout the primary care community. The AMIA board of directors has enthusiastically endorsed the conceptual basis for this White Paper.