Electronic Reminders Research Articles

Adding a panel manager to EMR reminders improved some preventive care processes

Source Citation Loo TS, Davis RB, Lipsitz LA, et al. Electronic medical record reminders and panel management to improve primary care of elderly patients. Arch Intern Med. 2011;171:1552-8. 21949163

Impact of Electronic Health Records on Racial and Ethnic Disparities in Blood Pressure Control at US Primary Care Visits

Prior literature suggests that practice level characteristics mediate racial/ethnic disparities in clinical outcomes.1 One such practice level characteristic, use of electronic health records (EHRs) with clinical decision support (CDS), has been associated with improved blood pressure (BP) control in a national study.2 However, we do not know whether these effects differ across racial/ethnic groups.3 We sought to determine whether physician use of EHRs with and without CDS is associated with a reduction in racial/ethnic disparities in BP control in a nationally representative sample. Methods We examined data from primary care visits in the 2007-2008 National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of nonhospital-based ambulatory visits administered by the National Center for Health Statistics (NCHS).4 In a recent article, we examined visits to NAMCS physicians who answered questions about EHRs and electronic guideline-based reminders.2 Primary care . . .

Routine Screening for HIV Infection in a Low Risk Population

Context: Despite advances in therapy for HIV infection, treatment is often compromised by delayed diagnosis. Strate-gies are needed to improve broad based testing in all medical settings. Objective: To compare HIV screening rates in a primary care setting following implementation of an electronic reminder system to rates produced solely by provider educational efforts. Design: Prospective, observational study of HIV screening, comparing rates during implementation of strategies. Setting: Multiple clinic healthcare system affiliated with a tertiary care medical center. Patients: Veterans receiving care in the clinics affiliated with the Department of Veterans Affairs-Eastern Colorado Healthcare System. Intervention: Provider education and a provider clinical reminder system embedded in the electronic medical record. Main Outcome Measure: Proportion of primary care clinic appointments at which the veteran was screened for HIV infection. Results: The proportion of visits at which screening occurred increased from 2.7% during the provider edu-cation period to 16.7% during the provider clinical reminder period (p < 0.0001). All of the cases identified by the re-minder were antiretroviral therapy candidates, and there was a trend to earlier diagnosis in the screening group than in the diagnostic testing group (CD4 count 329 vs. 109, p = 0.13). Conclusions: An electronic clinical reminder system in a primary care setting is an effective strategy to increase testing for HIV infection, and may lead to fewer delayed diag-noses.

Using Clinical Vignettes to Evaluate VTE Protocol Adherence

BackgroundVenous thromboembolism (VTE) prophylaxis is underutilized in hospitalized medical patients. Underutilization might occur as a result of resident practice variation incurred by using a complex risk assessment tool.ObjectiveTo examine what impact repetitive exposure to an electronic point-based VTE risk assessment tool has on resident inter-rater reliability and protocol adherence.DesignPre and post intervention cross-sectional cohort study.SettingSingle academic center.PatientsConvenience samples of Internal Medicine residents.InterventionsResidents completed clinical vignettes before and after any exposure to an electronic risk assessment tool and reminder alert. They were asked to make three determinations using a point-based VTE risk assessment tool: risk stratification, identify contraindications, and VTE prevention strategy.MeasurementsInter-rater reliability for risk assessment, contraindications, and VTE prophylaxis strategy and protocol adherence.ResultsKappa scores for VTE risk assessment did not change, but improved for VTE plan increasing from 0.28 to 0.37. Protocol adherence improved from 71% in 2008 to 79% (P = 0.06). There was a significant decrease in under-prophylaxis (22% to 6%, P < 0.0001) but a significant increase in over-prophylaxis (7% to 16%, P = 0.001).ConclusionsUsing clinical vignettes, we determined that daily exposure to an electronic risk assessment tool did not improve the inter-rater reliability of a point-based risk assessment tool when used by medical residents. This might be due to inexperienced providers using a complex point-based tool. Overall, adherence improved, and under-prophylaxis decreased, but over-prophylaxis increased. Clinical vignettes are a generalizable method to monitor resident prophylaxis practices and way to identify educational and process improvement opportunities.KeywordsResident; Inter-rater reliability; Venous thromboembolism; Agreement; Risk assessment score

Decreasing Missed Opportunities for HIV Testing in Primary Care through Enhanced Utilization of the Electronic Medical Record.

We sought to decrease "missed opportunities" for HIV testing by implementing an electronic medical record based intervention designed to increase HIV testing among previously untested men and women ages 18-64 seeking primary medical care in an urban publicly-funded health care system. In July 2010, we implemented an electronic medical record based reminder to alert providers to the absence of an HIV test among all patients' ages 13-64 years old. We compared the rate of missed opportunities for HIV testing among primary care patients seen during the two and a half years before the intervention with that of patients seen during the two years after the intervention was begun. A "missed opportunity" was defined as the failure of a previously untested patient to obtain HIV testing despite having made one or more primary care office visits during a specified time period. After the implementation of HIV testing reminders, first-time HIV testing increased significantly for both men and women 18-64 years old, resulting in a significant reduction in "missed opportunities." The intervention was equally effective across different racial and ethnic groups. An increase in new HIV diagnoses after the intervention was observed, consistent with an increase in the number of individuals in the population who received testing. An electronic medical record-based reminder can significantly increase HIV testing among men and women ages 18-64 who are seeking primary care services.

Impact of remuneration and organizational factors on completing preventive manoeuvres in primary care practices

Several jurisdictions attempting to reform primary care have focused on changes in physician remuneration. The goals of this study were to compare the delivery of preventive services by practices in four primary care funding models and to identify organizational factors associated with superior preventive care. In a cross-sectional study, we included 137 primary care practices in the province of Ontario (35 fee-for-service practices, 35 with salaried physicians [community health centres], 35 practices in the new capitation model [family health networks] and 32 practices in the established capitation model [health services organizations]). We surveyed 288 family physicians. We reviewed 4108 randomly selected patient charts and assigned prevention scores based on the proportion of eligible preventive manoeuvres delivered for each patient. A total of 3284 patients were eligible for at least one of six preventive manoeuvres. After adjusting for patient profile and contextual factors, we found that, compared with prevention scores in practices in the new capitation model, scores were significantly lower in fee-for-service practices (β estimate for effect on prevention score = -6.3, 95% confidence interval [CI] -11.9 to -0.6) and practices in the established capitation model (β = -9.1, 95% CI -14.9 to -3.3) but not for those with salaried remuneration (β = -0.8, 95% CI -6.5 to 4.8). After accounting for physician characteristics and organizational structure, the type of funding model was no longer a statistically significant factor. Compared with reference practices, those with at least one female family physician (β = 8.0, 95% CI 4.2 to 11.8), a panel size of fewer than 1600 patients per full-time equivalent family physician (β = 6.8, 95% CI 3.1 to 10.6) and an electronic reminder system (β = 4.6, 95% CI 0.4 to 8.7) had superior prevention scores. The effect of these three factors was largely but not always consistent across the funding models; it was largely consistent across the preventive manoeuvres. No funding model was clearly associated with superior preventive care. Factors related to physician characteristics and practice structure were stronger predictors of performance. Practices with one or more female physicians, a smaller patient load and an electronic reminder system had superior prevention scores. Our findings raise questions about reform initiatives aimed at increasing patient numbers, but they support the adoption of information technology.

Improving diabetes management with electronic medical records

Most primary-care physicians have adopted electronic medical records (EMRs) for the management of patients in ambulatory care. Observational trials suggest that the use of EMRs improves the achievement of the recommended standards of diabetes care and intermediate outcomes. A French group of general practitioners has shown, in a randomized controlled trial of diabetes care, the beneficial effects of a follow-up module integrated into an EMR. Electronic reminders, eHealth technology and e-mail messaging to patients integrated into the EMR have also been reported to have a beneficial effect on diabetes care. Some recommendations have been devised for the meaningful use of EMRs to improve the process and, possibly, intermediate outcomes of diabetes care as well. Another potential benefit to consider is the extraction and aggregation of data to create diabetes registers. Large regional and national diabetes registers have been set up in the US and Europe for various purposes, including patient recall, description of care patterns and outcomes, improvement of practices, drug safety, observational research and retrospective trials. In France, the government initiative towards an Internet-based personal health record (PHR) provides an appropriate framework for implementing and sharing the information needed to improve diabetes care, such as electronic summaries of health information, personalized health plans (PHPs), and standardized and structured hospital-discharge forms. All of these materials can be generated from EMRs. The widespread and optimalized use of EMRs for diabetes care with links to the national diabetes register and the capacity to supply PHRs are major considerations. Achieving these goals requires a common initiative comprising primary care and diabetes scientific societies in cooperation with diabetes patients'associations.

Not 2 old 2 TXT: There is potential to use email and SMS text message healthcare reminders for rheumatology patients up to 65 years old

Short message service (SMS) and email reminders have the potential to improve adherence to appointments and medication taking. Within the UK, information and communication technology (ICT) is widely used with a very high proportion of people having access to the internet and mobile phones. Little is known about ICT use by older adults and those with chronic illness. A feasibility survey was carried out with 112 rheumatology patients in Hertfordshire, UK to determine their current use of the internet, email and SMS and their willingness to receive electronic reminders in the future. A high proportion of patients up to age 65 are successfully using ICT despite older age or functional disability caused by rheumatic disease. Forty-four percent would be willing to receive an electronic appointment reminder and 25% a medication reminder. The results suggest that reminders would be welcomed by some patients and extensive patient training would not be needed before implementation.

Technology-based self-care methods of improving antiretroviral adherence: a systematic review.

BackgroundAs HIV infection has shifted to a chronic condition, self-care practices have emerged as an important topic for HIV-positive individuals in maintaining an optimal level of health. Self-care refers to activities that patients undertake to maintain and improve health, such as strategies to achieve and maintain high levels of antiretroviral adherence.Methodology/Principal FindingsTechnology-based methods are increasingly used to enhance antiretroviral adherence; therefore, we systematically reviewed the literature to examine technology-based self-care methods that HIV-positive individuals utilize to improve adherence. Seven electronic databases were searched from 1/1/1980 through 12/31/2010. We included quantitative and qualitative studies. Among quantitative studies, the primary outcomes included ARV adherence, viral load, and CD4+ cell count and secondary outcomes consisted of quality of life, adverse effects, and feasibility/acceptability data. For qualitative/descriptive studies, interview themes, reports of use, and perceptions of use were summarized. Thirty-six publications were included (24 quantitative and 12 qualitative/descriptive). Studies with exclusive utilization of medication reminder devices demonstrated less evidence of enhancing adherence in comparison to multi-component methods.Conclusions/SignificanceThis systematic review offers support for self-care technology-based approaches that may result in improved antiretroviral adherence. There was a clear pattern of results that favored individually-tailored, multi-function technologies, which allowed for periodic communication with health care providers rather than sole reliance on electronic reminder devices.

The marginal value of pre-visit paper reminders when added to a multifaceted electronic health record based quality improvement system

We have reported that implementation of an electronic health record (EHR) based quality improvement system that included point-of-care electronic reminders accelerated improvement in performance for multiple measures of chronic disease care and preventive care during a 1-year period. This study examined whether providing pre-visit paper quality reminders could further improve performance, especially for physicians whose performance had not improved much during the first year. Time-series analysis at a large internal medicine practice using a commercial EHR. All patients eligible for each measure were included (range approximately 100-7500). The proportion of eligible patients in the practice who satisfied each of 15 quality measures after removing those with exceptions from the denominator. To analyze changes in performance for individual physicians, two composite measures were used: prescribing seven essential medications and completion of five preventive services. During the year after implementing pre-encounter reminders, performance continued to improve for eight measures, remained stable for four, and declined for three. Physicians with the worst performance at the start of the pre-encounter reminders showed little absolute improvement over the next year, and most remained below the median performance for physicians in the practice. Paper pre-encounter reminders did not appear to improve performance beyond electronic point-of-care reminders in the EHR alone. Lagging performance is likely not due to providers' EHR workflow alone, and trying to step backwards and use paper reminders in addition to point-of-care reminders in the EHR may not be an effective strategy for engaging slow adopters.

Electronic Reminders to Improve Timely Antibiotic Doses

Electronic Reminders to Improve Timely Antibiotic Doses

Helping Our Patients to Adhere to Chronic Medications: A New Arrow for the Quiver

Helping Our Patients to Adhere to Chronic Medications: A New Arrow for the Quiver

Effectiveness of an audible reminder on hand hygiene adherence

Multimodal interventions aim to improve health care workers' adherence to hand hygiene guidelines. Visitors are not primarily targeted, but may spread epidemic infections. Effective interventions that improve the adherence of visitors to hand hygiene guidelines are needed to prevent the transmission of epidemic infections to or from health care environments. An electronic motion sensor-triggered audible hand hygiene reminder was installed at hospital ward entrances. An 8-month preinterventional and postinterventional study was carried out to measure the adherence of hospital visitors and staff to hand hygiene guidelines. Overall hand hygiene adherence increased from 7.6% to 49.9% (P < .001). The adherence of visitors and nonclinical staff increased immediately from 10.6% to 63.7% and from 5.3% to 34.8%, respectively (P < .001). Adherence of doctors, nurses, and physiotherapists increased gradually from 4.5% to 38.3%, from 5.4% to 43.4%, and from 8.7% to 49.5%, respectively (P < .001). Improved adherence was sustained among visitors and clinical staff (P < .001), but not among nonclinical staff (P = .341). The electronic motion sensor-triggered audible reminder immediately and significantly improved and sustained greater adherence of hospital visitors and clinical staff to hand hygiene guidelines. This is an effective addition to multimodal hand hygiene interventions and may help control epidemic infections.

Improvement in Stroke Performance Measures

> Trust but verify. > > —Ronald Reagan Collecting and monitoring performance measure data are resource-intensive, requiring time and effort by a team that includes health care providers treating the patients and documenting their care, quality personnel monitoring and working to optimize performance rates, and quality abstractors, who extract information from the medical record. Recently, an additional group of people have become involved, informatics personnel, who strive to extract information electronically and improve performance measure adherence rates through improved electronic health record (EHR) functionality such as documentation templates and electronic reminders. Article see p 503 With the increased focus on measuring processes and outcomes of care, performance measurement will become increasingly widespread.1–3 The National Quality Forum (NQF), the nonprofit organization created to help improve the quality of health care,4 continues to endorse new measure sets. The Centers for Medicare and Medicaid Services (CMS) Voluntary Pay for Reporting Initiative, which began in 2005 with the voluntary hospital-based collection of 10 NQF-endorsed measures, continues to expand, with 76 measures planned by 2014.1 In addition to the increased burden of data collection, the stakes for performance are rising—the CMS “Pay for Reporting” program has become “Pay-for-Performance,” with reimbursement linked to adherence rates.5 Stroke, one of costliest conditions for Medicare and a leading cause of disability and mortality,6 has been a focus for performance measurement activities. Eight NQF-endorsed stroke performance measures are currently used as part of the voluntary Joint Commission Primary Stroke Center certification and will be part of the CMS Hospital Inpatient Prospective Payment System program beginning with 2013 stroke hospital discharges.1 In addition, collection of 7 stroke performance measures using certified EHR technology is required if hospitals wish to qualify for incentive payments through the CMS Electronic Health Record Meaningful Use Incentive program.7 Given the increased concentration …

Utility of an Electronic Monitoring and Reminder System for Enhancing Hand Hygiene Practices in a Pediatric Oncology Unit

Project: A gap analysis was performed as the initial step in the infection prevention program (IPP) redesign. This was performed by a team of stakeholders with strong leadership support. This analysis evaluated elements that were considered to be barriers to an effective and efficient IPP. The elements were placed into 4 main categories; resources; process; service; and regulatory compliance. Technology lag and limited IP resources were identified in addition to the limited IT support. The process analysis revealed that it is highly manual, retrospective, minimal analysis, with excessive data collection, with limited focus on prevention. The service analysis identified the limited visibility, collaboration, feedback, and that hospital staff was not aware of the IPP role and value. Finally, analysis of the regulatory compliance identified the increasing demands on the IPP. Results: ThegapanalysisresultedinrecommendationstoenhancetheIPPbyaddressingtheidentifiedbarriers.The cornerstone of these recommendations was to purchase a commercially available ESS to provide system risk-based surveillance. This was also accompanied by identifying the need to increase the staffing of the department. The realtime data availability and the ability to receive electronic alerts allowed IP staff to initiate daily patient care unit roundingwhichinturnincreasedtheirvisibility,butmoreimportantlycreatedadditionalHAIpreventionopportunities. Lessons Learned: A thorough gap analysis is essential in establishing infection prevention program priorities and gaining organizational support. The needs assessment and gap analysis should include as many stakeholders as possible, but leadership involvement is a must. Furthermore, role shift is paramount to the process and the shift from data collection into using data to initiate intervention which is the key to the success of our program.

Prescribing epinephrine injection (EPIPEN) for anaphylaxis in primary care – a survey

BackgroundEpinephrine injection (Epipen) is the definitive treatment for anaphylaxis. Life threatening airway, breathing or circulation manifestations or minor reactions that is skin or other systemic changes with a background of...

Effect of interventions to improve health care services for ethnic minority populations

Objectives: Since the early 1990s there has been an increasing awareness of social and ethnic inequity in health and for the last few years there has also been an increasing focus on disparities in the quality of health services to ethnic minority groups. The aim of this review was to collect and summarise in a systematic and transparent manner the effect of interventions to improve health care services for ethnic minorities.Methods: We searched several medical databases for systematic reviews and randomised controlled trials. Two researchers independently screened for and selected studies, assessed risk of bias, extracted data and graded the quality of the evidence for each outcome in the included studies. The analysis was done qualitatively by describing studies and presenting them in tables.Results: We included 19 primary studies. The interventions were targeted at reducing clinical, structural and organisational barriers against good quality health care services. Eight studies examined the effect of educational interventions in improving outcomes within cross-cultural communication, smoking cessation, asthma care, cancer screening and mental health care. In six comparisons the effect of reminders for improving health care services and patient outcomes within cancer screening and diabetes care was examined. Two studies compared professional remote interpretation services to traditional interpretation services, two studies compared ethnic matching of client and therapist and two studies examined the effect of providing additional support in the form of more personnel in the treatment of diabetes and kidney transplant patients. Most patients were African-Americans and Latin-Americans and all ages were represented.Conclusions: Educational interventions and electronic reminders to physicians may in some contexts improve health care and health outcomes for minority patients. The quality of the evidence varied from low to very low. The quality of available evidence for the other interventions was too low to draw reliable conclusions. We found no studies that only included young patients, but we suggest that interventions targeted at health personnel or health organisations may be applicable regardless of the age of the patient population. This review reveals that the evidence for interventions to improve health care for minorities is sparse and generally of low quality.

A Randomized Controlled Trial Comparing the Effects of Counseling and Alarm Device on HAART Adherence and Virologic Outcomes

Behavioral interventions that promote adherence to antiretroviral medications may decrease HIV treatment failure. Antiretroviral treatment programs in sub-Saharan Africa confront increasing financial constraints to provide comprehensive HIV care, which include adherence interventions. This study compared the impact of counseling and use of an alarm device on adherence and biological outcomes in a resource-limited setting. A randomized controlled, factorial designed trial was conducted in Nairobi, Kenya. Antiretroviral-naïve individuals initiating free highly active antiretroviral therapy (HAART) in the form of fixed-dose combination pills (d4T, 3TC, and nevirapine) were randomized to one of four arms: counseling (three counseling sessions around HAART initiation), alarm (pocket electronic pill reminder carried for 6 months), counseling plus alarm, and neither counseling nor alarm. Participants were followed for 18 months after HAART initiation. Primary study endpoints included plasma HIV-1 RNA and CD4 count every 6 months, mortality, and adherence measured by monthly pill count. Between May 2006 and September 2008, 400 individuals were enrolled, 362 initiated HAART, and 310 completed follow-up. Participants who received counseling were 29% less likely to have monthly adherence <80% (hazard ratio [HR] = 0.71; 95% confidence interval [CI] 0.49-1.01; p = 0.055) and 59% less likely to experience viral failure (HIV-1 RNA ≥5,000 copies/ml) (HR 0.41; 95% CI 0.21-0.81; p = 0.01) compared to those who received no counseling. There was no significant impact of using an alarm on poor adherence (HR 0.93; 95% CI 0.65-1.32; p = 0.7) or viral failure (HR 0.99; 95% CI 0.53-1.84; p = 1.0) compared to those who did not use an alarm. Neither counseling nor alarm was significantly associated with mortality or rate of immune reconstitution. Intensive early adherence counseling at HAART initiation resulted in sustained, significant impact on adherence and virologic treatment failure during 18-month follow-up, while use of an alarm device had no effect. As antiretroviral treatment clinics expand to meet an increasing demand for HIV care in sub-Saharan Africa, adherence counseling should be implemented to decrease the development of treatment failure and spread of resistant HIV.

Improving the Efficiency and Effectiveness of Performing the Diabetic Foot Exam

Microvascular complications of diabetes can result in peripheral neuropathy and impaired sensation in the feet. These issues can significantly affect morbidity and quality of life. Regular foot exams play a major role in early detection of foot problems and may help prevent amputations. An initial review found that a comprehensive diabetic foot exam (CDFE) was documented 13.5% of the time. A quality improvement effort combined provider and staff education, a standardized documentation form, an electronic reminder, and a well-defined process to improve the frequency and completeness of diabetic foot exams. After the intervention, 44.5% of CDFEs found in dictated notes lacked at least 1 component of the exam, whereas less than 4% of charts using a standardized form lacked documentation of any part of the foot exam. These efforts demonstrate the benefit of engaging providers and staff in a quality improvement initiative to increase consistency and frequency of documentation of annual CDFEs.

Work sampling observations of community pharmacists: a review

Abstract Activities undertaken by community pharmacists may be monitored in individual pharmacies to analyse the division of labour before and after changes in work practices, and for general insight into the current roles of pharmacists. Studies based in community pharmacies have used work sampling techniques, with activities recorded by observers at defined intervals. Sampling methods and the selection of observation periods have varied between studies, with activities recorded at one- to- five-minute intervals or at random. Differing classifications of activities also limit the comparison of findings. There exists a need for further research in this area to address sampling issues and limitations imposed by observers in pharmacies and to provide data relevant to present day practice. Self-reporting of activities using electronic bar code readers and reminders may be feasible for data collection from multiple-pharmacist pharmacies or larger samples of pharmacies.