Not All Electronic Health Record Warnings Are Accurate

MedicalResearch.com Interview with:

Katharine Phillips, M.D. Professor of Psychiatry DeWitt Wallace Senior Scholar Residency Research Director Department of Psychiatry Weill Cornell Medical College, Cornell University Attending Psychiatrist, New York-Presbyterian Hospital  Adjunct Professor of Psychiatry and Human Behavior Alpert Medical School of Brown University Weill Cornell Psychiatry Specialty Center Weill Cornell Medicine I NewYork-Presbyterian

Dr. Phillips

Katharine Phillips, M.D.
Professor of Psychiatry
DeWitt Wallace Senior Scholar
Residency Research Director
Department of Psychiatry
Weill Cornell Medical College, Cornell University
Attending Psychiatrist, New York-Presbyterian Hospital
Adjunct Professor of Psychiatry and Human Behavior
Alpert Medical School of Brown University
Weill Cornell Psychiatry Specialty Center
Weill Cornell Medicine I NewYork-Presbyterian

MedicalResearch.com: What is the background for this study? What are the main findings?

  • Electronic prescribing of medication by clinicians is widespread; it is required in many institutions and in some states. Electronic prescribing systems commonly use computerized decision support algorithms that give prescribers automated warnings or alerts at the time of prescribing if the system identifies a potential prescribing error.
  • Some prior studies suggest that electronic prescribing warnings/alerts may reduce prescribing errors and thus can be clinically useful. However, other prior studies caution that these alerts may have substantial limitations.
  • Despite the importance of this topic, relatively few studies have examined the accuracy of automated prescribing warnings in electronic prescribing systems; to our knowledge, no prior study has focused primarily on prescribing of medications for psychiatric conditions.
  • This report presents results from a survey of members of the American Society of Clinical Psychopharmacology (ASCP), a specialty society that advances the science and practice of clinical psychopharmacology, regarding automated warnings generated by electronic prescribing systems.

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Electronic Health Record Reminders Help Patients Adhere to Glaucoma Medications

MedicalResearch.com Interview with:

Michael Vincent Boland, M.D., Ph.D. Glaucoma Center of Excellence Director of Information Technology, Wilmer Eye Institute Associate Professor of Ophthalmology Johns Hopkins University School of Medicine Baltimore, Maryland

Dr. Boland

Michael Vincent Boland, M.D., Ph.D.
Glaucoma Center of Excellence
Director of Information Technology, Wilmer Eye Institute
Associate Professor of Ophthalmology
Johns Hopkins University School of Medicine
Baltimore, Maryland

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Effective medications are available to treat glaucoma and prevent or stop vision loss.

Unfortunately, patients frequently do not use the eye drops as prescribed, oftentimes simply
because they forget to. Since patient medications are now managed via electronic health
records (EHRs), we built a system to deliver automated reminders to patients using the patient
portal to our EHR.

We found that the majority (75%, 66 of 88) of participants that received these reminders found them to be useful, and about half (47%, 41 of 88) the participants wanted to

continue using the reminders after the study ended

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What Types of Health Care Records Are Breached?

MedicalResearch.com Interview with:

Thomas McCoy, M.D. Assistant Professor of Psychiatry Massachusetts General Hospital Psychiatry Massachusetts General Hospital

Dr. McCoy

Thomas McCoy, M.D.
Assistant Professor of Psychiatry
Massachusetts General Hospital
Psychiatry
Massachusetts General Hospital

MedicalResearch.com: What is the background for this study?

 Response: Big data has the potential to transform how we care for patients but comes with risks of big breaches. My co-author and I use health records in our research and we wanted to better understand the risks that these data might pose to our patients.

MedicalResearch.com:? What are the main findings? 

Response: The majority of breaches are of health care providers whereas the majority of breached records are from health plans. The three largest breaches account for the over half of records breached.

MedicalResearch.com: What should readers take away from your report?

Response: This study doesn’t speak to any particular solution; rather, it speaks to the aspects of the system that are most often breached: In 2017 it was hacking or IT incidents and networked servers. 

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: This study speaks to the aspects of the system that are most often breached: In 2017 it was hacking or IT incidents and networked servers; however, much is left to be learned about the specific mechanisms and consequences of these events.

MedicalResearch.com: Is there anything else you would like to add?

Response: Large healthcare datasets present a means of transformational discovery but also come with real risks of large scale disclosure. 

Disclosures: Dr. McCoy reports unrelated grants from The Stanley Center at The Broad Institute, Brain and Behavior Research Foundation, and Telefonica Alpha. Dr. Perlis reports unrelated grants from the National Human Genome Research Institute, National Institute of Mental Health, and Telefonica Alpha; serves on the scientific advisory board for Perfect Health, Genomind, and Psy Therapeutics; and consults to RID Ventures. Dr. Perlis is an editor of JAMA Network Open.

Citation:

McCoy TH, Perlis RH. Temporal Trends and Characteristics of Reportable Health Data Breaches, 2010-2017. JAMA. 2018;320(12):1282–1284. doi:10.1001/jama.2018.9222

 

Sep 28, 2018 @ 11:22 am

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Study Finds Patients Equally Likely To Fill Paper vs Electronic Prescriptions

MedicalResearch.com Interview with:

Shannon Toohey, MD, MAEd Associate Residency Director, Emergency Medicine Assistant Clinical Professor, Emergency Medicine University of California, Irvine Editor-in-Chief Journal of Education and Teaching in Emergency Medicine

Dr. Toohey

Shannon Toohey, MD, MAEd
Associate Residency Director, Emergency Medicine
Assistant Clinical Professor, Emergency Medicine
University of California, Irvine
Editor-in-Chief
Journal of Education and Teaching in Emergency Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Electronic prescriptions (e-prescriptions) are now the predominant form of prescription used in the US. Concern has been raised that this form of prescription may be more difficult for emergency department (ED) patients to utilize than traditional printed prescriptions, given the unplanned nature of most ED visits at all times of day.

While there are disincentives for physicians who choose not to use them, many emergency physicians are still concerned that it could decrease compliance in their patients.
This study evaluated prescription compliance in insured patients at a single center. In our studied population, we found that patients were as equally likely to fill paper and e-Prescriptions.

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Machine Learning and Free-Text Analysis of Notes Improves Patient Identification

MedicalResearch.com Interview with:

Saul Blecker, MD, MHS Department of Population Health New York University Langone School of Medicine, New York, NY 10016

Dr. Saul Blecker,

Saul Blecker, MD, MHS
Department of Population Health
New York University Langone School of Medicine,
New York, NY 10016

Saul.Blecker@nyumc.org

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The identification of conditions or diseases in the electronic health record (EHR) is critical in clinical practice, for quality improvement, and for clinical interventions. Today, a disease such as heart failure is typically identified in real-time using a “problem list”, i.e., a list of conditions for each patient that is maintained by his or her providers, or using simple rules drawn from structured data. In this study, we examined the comparative benefit of using more sophisticated approaches for identifying hospitalized patients with heart failure.

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Electronic Records Can Suppress Rapport Between Patients and Providers

Neda Ratanawongsa, MD, MPH CMIO for CareLinkSF Associate Professor, Division of General Internal Medicine UCSF Center for Vulnerable Populations Physician, Richard H. Fine People's Clinic (RHPC) San Francisco, CA 94110

Dr. Ratanawongsa

MedicalResearch.com Interview with:
Neda Ratanawongsa, MD, MPH

CMIO for CareLinkSF
Associate Professor, Division of General Internal Medicine
UCSF Center for Vulnerable Populations
Physician, Richard H. Fine People’s Clinic (RHPC)
San Francisco, CA 94110

Medical Research: What is the background for this study?

Dr. Ratanawongsa: Many people are concerned about the growing intrusion of computers into the patient-provider relationship. Touted as systems that will make care safer and more cost-effective, electronic health records (EHRs) have proliferated rapidly across the country, fueled by HITECH funding. However, some health care professionals feel like computers keep them from connecting with their patients. Also prior research has shown that computer use can change communication in the exam room and shift agenda from patients’ concerns toward medical talk.

Safety net patients already face communication barriers in routine care, particularly language and literacy barriers. Although EHRs could help improve care and communication with these vulnerable patients by helping clinicians fill in the gaps (e.g., what happened in the ED, what medication were you given by that specialist), EHRs could also worsen communication by drawing clinicians’ focus away from patients during visits.

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Electronic Health Records Linked To Only Slightly Better Medical Care

Jonathan R. Enriquez, MD Assistant Professor of Medicine Division of Cardiology University of Missouri- Kansas City Director, Coronary Care Unit Truman Medical Center

Dr. Enriquez

MedicalResearch.com Interview with:
Jonathan R. Enriquez, MD
Assistant Professor of Medicine
Division of Cardiology
University of Missouri- Kansas City
Director, Coronary Care Unit
Truman Medical Center 

Medical Research: What is the background for this study?

Dr. Enriquez:  

  • In 2009, U.S. legislation appropriated tens of billions of dollars to promote the use of electronic health records (EHRs).
  • Approximately 4 million hospitalizations for cardiovascular diagnoses occur annually in the U.S., which are more hospitalizations than for any other category of disease.  Therefore, evaluating the use of EHRs in these settings can help us understand how to best optimize the care and outcomes of a huge set of patients.

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Electronic Health Records Not Adaptive To Patient-Centered Primary Care

MedicalResearch.com Interview with:
Dr-Talley-Holman
Talley Holman, PhD, MBA 
Senior eHealth Systems Analyst, Practice Advancement
American Academy of Family Physicians
Leawood, KS 66211  and

John Beasley MD Professor of Family Medicine School of Medicine and Public Health and the Department of Industrial and Systems Engineering University of Wisconsin Madison, WIJohn Beasley MD
Professor of Family Medicine
School of Medicine and Public Health and the
Department of Industrial and Systems Engineering
University of Wisconsin Madison, WI

Medical Research: What is the background for this study?

Dr. Holman: From an engineering standpoint, tools such as EHRs are designed based on objectives, and the workflows that are created are developed to achieve those objectives. In health care, workflows have not been well understood, so designers have made assumptions when pressed to create tools to address specific situations, problems, or issues. However, the effectiveness of many of these tools is lacking, based on feedback. This led us to take a step back and ask if there is a standard workflow, and if so, what is it?

Dr. Beasley: Physicians (and staff) have noted that the EHR is not doing a good job of supporting their work – and changes are made that appear to disrupt the physician’s workflow. There appears to have been an assumption on the part of designers/implementers that workflow is linear.

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Integrating Outpatient and Hospital Electronic Health Records Is a Work In Progress

Professor Susan A. Sherer, Ph.D. Lehigh University College of Business and Economics Department of Management Bethlehem, PA 18015 MedicalResearch.com Interview with:
Professor Susan A. Sherer, Ph.D.
Lehigh University
College of Business and Economics
Department of Management
Bethlehem, PA 18015 

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Sherer: With the growth in electronic health record implementation, there has been increasing demand for integration of these records within and across practice settings that have different work cultures, e.g. ambulatory and hospital locations. We find that computer integration alone does not result in coordination; users must value the integrated information and incorporate this information within their workflows. Users must move beyond technology acceptance and adaptation to focus on and value coordination. The system itself cannot drive these process changes; specific work process changes must be instituted and the users must adapt these changes.

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Electronic Health Records Allow Agencies To Improve Surveillance and Patient Care

Dawn Heisey-Grove, MPHCDCMedicalResearch.com Interview with:
Dawn Heisey-Grove, MPH
Office of Planning, Evaluation, and Analysis Office of the National Coordinator for Health Information Technology U.S. Department of Health and Human Services Washington, DC

Medical Research: What is the background for this study?

Response:  Population health surveillance can be costly, time consuming, and limited, depending on the data source. Electronic Clinical Quality Measures (eCQMs) reported to the Medicare Electronic Health Record (EHR) Incentive Program reflect aggregate data on all patients seen by a participating health care provider during a given measure’s reporting period and therefore represent a substantial proportion of the U.S. population. These data are reported as a function of a federal program and are the result of automated extraction from an EHR, which might streamline the reporting process for the health care provider, resulting in data that are a useful resource in public health surveillance.

Medical Research:? What are the main findings?

Response: This first published use of Medicare EHR Incentive Program data for national population surveillance reported on an eCQM that is aligned with Million Hearts®, a national initiative launched by the U.S. Department of Health and Human Services to prevent 1 million heart attacks and strokes by 2017. The eCQM tracks the proportion of patients with hypertension who had controlled blood pressure during the reporting period. During the first three years of the EHR Incentive Program (2011-2013), approximately 3 in 10 participating health care professionals reported on this eCQM, making it the 5th most commonly selected measure overall. This represented 63,000 ambulatory care professionals and approximately 17 million patients. On average, 62 percent of patients with hypertension had controlled blood pressure. Read more here.

Medical Research: What should clinicians and patients take away from your report?

Response: Electronic health record systems provide an opportunity to improve patient care and more easily monitor population health. Using data stored in EHRs, clinicians may be better equipped to generate reports that track the health of high risk patients. In addition, public health could expand its surveillance capabilities, potentially at lower costs and in a more timely fashion, by taking advantage of existing systems such as eCQM reporting. Further alignment of eCQMs across federal and private sector programs will enable clinicians to collect data once and report to selected programs.

Medical Research: What recommendations do you have for future research as a result of this study?

Response: Future research endeavors should begin to maximize the potential data captured through eCQM reporting. State and local public health agencies can partner with state, regional, or local health information exchanges; the state primary care associations; the state Medicaid programs; and health systems to explore the use of existing EHR data for surveillance while still ensuring appropriate safeguards to maintain patient privacy. As EHR implementation becomes more widespread, the data collected by these systems will be invaluable for monitoring numerous clinical conditions.

Citation:

Using Electronic Clinical Quality Measure Reporting for Public Health Surveillance

Weekly

May 1, 2015 / 64(16);439-442

MedicalResearch.com Interview with: Dawn Heisey-Grove, MPH CDC (2015). Electronic Health Records Allow Agencies To Improve Surveillance and Patient Care MedicalResearch.com

Electronic Records Facilitating Hospital Reporting Of Public Health Measures

Dawn Heisey-Grove, MPH Office of Planning, Evaluation, and Analysis Office of the National Coordinator for Health Information Technology U.S. Department of Health and Human Services Washington, DC 20201MedicalResearch.com Interview with:
Dawn Heisey-Grove, MPH
Office of Planning, Evaluation, and Analysis
Office of the National Coordinator for Health Information Technology
U.S. Department of Health and Human Services
Washington, DC 20201

Medical Research: What is the background for this study?

Response: To complete outbreak investigations and perform tasks geared towards improving the public’s health, public health agencies need clinical information from hospitals and health care providers. Adoption of electronic health records (EHRs) and other health IT has made it possible to shift from time-intensive, paper-based public health reporting to electronic information exchange, which enables sending more complete information to public health agencies faster.

Such electronic information exchange with public health agencies is a component of the Medicare and Medicaid EHR Incentive Program meaningful use attestation process. Hospitals in the first stage of meaningful use must select at least one of three optional public health measures to report: immunization registry reporting, syndromic surveillance reporting, and electronic laboratory results reporting. Hospitals in the second stage of meaningful use are required to report on all three public health measures unless there is a valid exclusion.

Medical Research: What are the main findings?

Response: Using 2014 data from the Medicare EHR Incentive Program, we found that stage 2 hospitals were electronically reporting to local public health agencies more than stage 1 hospitals. Nationally, almost 75% of stage 2 hospitals were able to report all three measures to public health agencies, compared to only 5% of stage 1 hospitals. Stage 2 hospitals had very high rates for electronic exchange with public health agencies across all three measures. Specifically, immunization registry reporting among stage 2 hospitals was highest at 88%, 85% were electronically submitting lab results, and 75% successfully reported the syndromic surveillance measure.

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Electronic Health Record Alerts Reduced Urinary Tract Infections

Craig A Umscheid, MD, MSCE, FACP Assistant Professor of Medicine and Epidemiology Director, Center for Evidence-based Practice Medical Director, Clinical Decision Support Chair, Department of Medicine Quality Committee Senior Associate Director, ECRI-Penn AHRQ Evidence-based Practice Center University of Pennsylvania, Philadelphia, PA 19104MedicalResearch.com Interview with:
Craig A Umscheid, MD, MSCE, FACP
Assistant Professor of Medicine and Epidemiology
Director, Center for Evidence-based Practice
Medical Director, Clinical Decision Support
Chair, Department of Medicine Quality Committee

Senior Associate Director, ECRI-Penn AHRQ Evidence-based Practice Center
University of Pennsylvania, Philadelphia, PA 19104

Medical Research: What are the main findings of the study?

Dr. Umscheid: We found that targeted automated alerts in electronic health records significantly reduce urinary tract infections in hospital patients with urinary catheters. In addition, when the design of the alert was simplified, the rate of improvement dramatically increased.

Approximately 75 percent of urinary tract infections acquired in the hospital are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine.  According to the Centers for Disease Control and Prevention, 15 to 25 percent of hospitalized patients receive urinary catheters during their hospital stay. As many as 70 percent of urinary tract infections in these patients may be preventable using infection control measures such as removing no longer needed catheters resulting in up to 380,000 fewer infections and 9,000 fewer deaths each year.

Our study has two crucial, applicable findings.  First, electronic alerts do result in fewer catheter-associated urinary tract infections. Second, the design of the alerts is very important. By making the alert quicker and easier to use, we saw a dramatic increase in the number of catheters removed in patients who no longer needed them. Fewer catheters means fewer infections, fewer days in the hospital, and even, fewer deaths. Not to mention the dollars saved by the health system in general.

In the first phase of the study, two percent of urinary catheters were removed after an initial “off-the-shelf” electronic alert was triggered (the stock alert was part of the standard software package for the electronic health record). Hoping to improve on this result in a second phase of the study, we developed and used a simplified alert based on national guidelines for removing urinary catheters that we previously published with the CDC. Following introduction of the simplified alert, the proportion of catheter removals increased more than seven-fold to 15 percent.

The study also found that catheter associated urinary tract infections decreased from an initial rate of .84 per 1,000 patient days to .70 per 1,000 patient-days following implementation of the first alert and .50 per 1,000 patient days following implementation of the simplified alert. Among other improvements, the simplified alert required two mouse clicks to submit a remove-urinary-catheter order compared to seven mouse clicks required by the original alert.

The study was conducted among 222,475 inpatient admissions in the three hospitals of the University of Pennsylvania Health System between March 2009 and May 2012. In patients’ electronic health records, physicians were prompted to specify the reason (among ten options) for inserting a urinary catheter. On the basis of the reason selected, they were subsequently alerted to reassess the need for the catheter if it had not been removed within the recommended time period based on the reason chosen.
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Electronic Health Records Can Present Ongoing Patient Safety Concerns

Dr. Hardeep Singh MD, MPH Chief the Health Policy, Quality & Informatics Program Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety Michael E. DeBakey VA Medical Center in Houston, Texas Associate professor at Baylor College of MedicineMedicalResearch.com Interview with:
Dr. Hardeep Singh MD, MPH
Chief the Health Policy, Quality & Informatics Program
Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety
Michael E. DeBakey VA Medical Center in Houston, Texas
Associate professor at Baylor College of Medicine

MedicalResearch: What are the main findings of the study?

Dr. Singh: EHRs use can prompt new patient safety concerns, and many of these problems are complex and difficult to detect. We sought to better understand the nature of these patient safety concerns and reviewed 100 closed investigations involving 344 technology-related incidents arising between 2009 and 2013 at the Department of Veterans Affairs (VA).

We evaluated safety concerns related to technology itself as well as human and operational factors such as user behaviors, clinical workflow demands, and organizational policies and procedures involving technology. Three quarters of the investigations involved unsafe technology while the remainder involved unsafe use of technology. Most (70%) investigations identified a mix of 2 or more technical and/or non-technical underlying factors.

The most common types of safety concerns were related to the display of information in the EHR; software upgrades or modifications; and transmission of data between different components of the EHR system.

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Electronic Health Record Utilization as a Measure of Hospital Care Intensity

MedicalResearch.com Interview with:

Saul Blecker, MD, MHS Assistant Professor Department of Population Health NYU School of Medicine 227 East 30th St., #648 New York, NY 10016Saul Blecker, MD, MHS
Assistant Professor
Department of Population Health
NYU School of Medicine
227 East 30th St., #648
New York, NY 10016
MedicalResearch.com: What are the main findings of the study?

Dr. Blecker: We tracked utilization of the inpatient electronic health record (EHR) as a proxy for hospital intensity of care. EHR utilization was found to have variations over time, particularly when comparing days to nights and weekdays to weekends.
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