Scribes Can Reduce Documentation Burden for Primary Care Physicians, But Cost is High

MedicalResearch.com Interview with:

Richard W. Grant MD MPH Research Scientist III, Kaiser Permanente Division of Resarch Adjunct Associate Professor, UCSF Dept Biostatistics & Epidemiology Director, Kaiser Permanente Delivery Science Fellowship Program Co-Director, NIDDK Diabetes Translational Research post-doctoral training program

Dr. Grant

Richard W. Grant MD MPH
Research Scientist III, Kaiser Permanente Division of Resarch
Adjunct Associate Professor, UCSF Dept Biostatistics & Epidemiology
Director, Kaiser Permanente Delivery Science Fellowship Program
Co-Director, NIDDK Diabetes Translational Research post-doctoral training program

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

Response: Primary care in the United States is in a state of crisis, with fewer trainees entering the field and more current primary care doctors leaving due to professional burnout. Changes in the practice of primary care, including the many burdens related to EHR documentation, has been identified as a major source of physician burnout. There are ongoing efforts to reduce physician burnout by improving the work environment. One innovation has been the use of medical scribes in the exam room who are trained to enter narrative notes based on the patient-provider interview. To date, there have only been a handful of small studies that have looked at the impact of medical scribes on the provider’s experience of providing care.

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Despite Promise, EMRs Have Not Reduced Administrative or Billing Expenses

Barak Richman JD, PhD Bartlett Professor of Law and Business Administration Duke University

Prof. Barak Richman

MedicalResearch.com Interview with:
Barak Richman JD, PhD
Bartlett Professor of Law and Business Administration
Duke University 

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

Response: The US not only has the highest health care costs in the world, we have the highest administrative costs in the world. If we can reduce non-value added costs like the ones we document, we can make substantial changes in the affordability of health care without having to resort to more draconian policy solutions.

Our paper finds that administrative costs remain high, even after the adoption of electronic health records.  Billing costs, for example, constituted 25.2% of professional revenue for ED departments and 14.5% of revenue for primary care visits.  The other numbers are captured below.

Administrative Costs Still High With EHRs

Administrative Costs Still High With EHRs

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Timicoin First Mobile Platform to Deploy Blockchain Technology to Store and Access Medical Records

MedicalResearch.com Interview with:
http://www.timicoin.io/Will Lowe, Timicoin CEO

Mr. Lower discusses the first cryptocurrency blockchain mobile platform for storing medical records that can be safely accessed from anywhere.

MedicalResearch.com: What is the background for this announcement? Would you briefly explain what is meant by blockchain technology?  How does  it allow for more efficient storage and transmittal of encrypted medical records?

Response: We do not store the data on any cloud storage to avoid any threat to data security and server overhead for data processing as well as to avoid temporary potential data unavailability.

When a certain kind of data is queried by the consumer, our cloud engine first passes on the query to each of the providers (our gateway applications that are running on their node) and see if there are enough query results, it shows a sample to the consumer and if consumer decides to pay, it creates a Blockchain channel between the providers and the consumer that queried the data and all the provider nodes propagate the queried data onto that channel.

So a common trust is built between the nodes and the consumer on that Blockchain channel and the shared query stays there as the trust builder. Then the consumer can anytime access the data needed from that blockchain channel.  Continue reading

Physicians Overwhelmed by Messaging From Electronic Medical Records

MedicalResearch.com Interview with:
“Computer” by FullCodePress is licensed under CC BY 2.0Matilda W. Nicholas,
 MD, PhD
Duke Dermatology
Durham, North Carolina

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

Response: I have found many physicians overwhelmed by the electronic messaging feature in Electronic Health Record systems (EHRs). I found there was very little published about this phenomenon, particularly for specialists. So, we set out to take a look at the volume and effect these systems have. 

MedicalResearch.com: What are the main findings?

 Response: We found that, on average, clinicians receive 3.24 messages per patient visit, for an average of about 50 messages per full day of clinic. The number of messages also correlated with poor reported work life balance for dermatologists. Continue reading

Patients Prefer Doctors Who Face Them Rather Than Computer Screen

MedicalResearch.com Interview with:
Dr. Ali Haider, MBBS MD

Assistant Professor, Department of Palliative Care and Rehabilitation Medicine
Division of Cancer Medicine
The University of Texas MD Anderson Cancer Center
Houston, TX 

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

Response: Patients with chronic and serious illnesses such as cancer often experience high physical and psychosocial symptoms. Recent studies have reported association of physicians’ examination room computer use with less face to face interactions and eye contact. It’s important for the clinicians to look for certain physical cues to better understand the well being of their patients. Therefore we conducted this randomized clinical trial to understand patients perception of physicians compassion, communication skills and professionalism with and without the use of examination room computer.

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What Do Patients Value About Reading Their Electronic Medical Record Notes?

MedicalResearch.com Interview with:
Macda Gerard
M.D. Candidate | Class of 2021
Wayne State University School of Medicine

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

Response: As electronic health records proliferate, patients are increasingly asking for their health information but little is known about how patients use that information or whether they encounter errors in their records. This comes at a time when we’re learning that understanding the patient and family experience, especially what is most valued in exchanges between doctors and patients is important and has many benefits. To learn more, we developed a formal mechanism for patients to provide feedback on what they like about accessing the information in their health records and to inform their clinical team about things like inaccuracies and perceived errors. So that’s the gap we tried to fill.

The patient feedback tool is linked to the visit note in the electronic health record (EHR), and it’s part of a quality improvement initiative aimed at improving safety and learning what motivates patients to engage with their health information on the patient portal. Over the 12-month pilot period, 260 patients and care partners provided feedback using the OpenNotes patient feedback tool. Nearly all respondents found the tool to be valuable and about 70 percent provided additional information regarding what they liked about their notes and the feedback process.

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Clinicians Multitask on Electronic Health Records 30% of Visit Time with Patients

MedicalResearch.com Interview with:

Neda Ratanawongsa, MD, MPH Associate Chief Health Informatics Officer for Ambulatory Services, San Francisco Health Network Associate Professor, Division of General Internal Medicine UCSF Center for Vulnerable Populations Physician, Richard H. Fine People's Clinic (RHPC) Zuckerberg San Francisco General Hospital San Francisco, CA 94110 

Dr. Ratanawongsa

Neda Ratanawongsa, MD, MPH
Associate Chief Health Informatics Officer for Ambulatory Services, San Francisco Health Network
Associate Professor, Division of General Internal Medicine
UCSF Center for Vulnerable Populations
Physician, Richard H. Fine People’s Clinic (RHPC)
Zuckerberg San Francisco General Hospital
San Francisco, CA 94110

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

Response: U.S. federal incentives allowed many safety net healthcare systems to afford fully functional electronic health record systems (EHRs). Although EHRs can help clinicians provide care to vulnerable populations, clinicians may struggle with managing the EHR workload, particularly in resource-limited settings. In addition, clinicians’ use of EHRs during clinic visits may affect how they communicate with patients.

There are two forms of EHR use during clinic visits.  Clinicians can multitask, for example, by ordering laboratory tests while chatting with a patient about baseball.  However, like distracted driving, using EHRs while talking with increases risks – in this case, the risk of errors in patient-provider communication or in the EHR task. Alternatively, clinicians can use EHRs in complete silence, which may be appropriate for high-risk tasks like prescribing insulin. However, silence during visits has been associated with lower patient satisfaction and less patient-centered communication.

So we studied how primary and specialty care clinicians used EHRs during visits with English- and Spanish-speaking patients in a safety net system with an EHR certified for Centers for Medicare & Medicaid Services meaningful use incentive programs. We found that multitasking EHR use was more common than silent EHR use (median of 30.5% vs. 4.6% of visit time). Focused patient-clinician talk comprised one-third of visit time.

We also examined the transitions into and out of silent EHR use. Sometimes clinicians explicitly stated a need to focus on the EHR, but at times, clinicians drifted into silence without warning. Patients played a role in breaking silent EHR use, either by introducing small talk or by bringing up their health concerns.

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Computerized Clinical Decision Support Systems Can Reduce Rate of Venous Thromboembolism

MedicalResearch.com Interview with:
Zachary Borabm, Research fellow

Hansjörg Wyss Department of Plastic Surgery
NYU Langone Medical Center

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

Response: Recent studies have shown that health care providers perform poorly in risk stratifying their patients for venous thromboembolism (VTE) which leads to inadequate VTE prophylaxis delivery, especially in surgical patients. Computerized Clinical Decision Support Systems (CCDSSs) are programs integrated into an electronic health record that have the power to aid health care providers. Using a meta-analysis study technique we were able to pool data from 11 studies, including 156,366 patients that either had CCDSSs intervention or routine care without CCDSSs.

Our main outcome measures were the rate of prophylaxis for VTE and the rate of actual VTE events. We found that CCDSSs increased the rate of VTE prophylaxis (odds ratio 2.35, p<0.001) and decreased the risk of VTE events (risk ratio 0.78, p<0.001).

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Drop in Adverse Drug Events Linked to Meaningful Use of Electronic Records

MedicalResearch.com Interview with:
Michael Furukawa, Ph.D.

Senior Economist
Agency for Healthcare Research and Quality 

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

Response: Despite some progress, patient safety remains a serious concern in U.S. health care delivery, particularly in acute care hospitals. In part to support safety improvement, the Health Information Technology for Economic and Clinical Health (HITECH) Act promoted widespread adoption and use of certified electronic health record technology. To meet Meaningful Use (MU) requirements in the law, hospitals are required to adopt specific capabilities, such as computerized physician order entry, which are expected to reduce errors and promote safer care.

We found that, after the HITECH Act was made law, the occurrence of in-hospital adverse drug events (ADEs) declined significantly from 2010 to 2013, a decline of 19%. Hospital adoption of medication-related MU capabilities was associated with 11% lower odds of ADEs occurring, but the effects did not vary by the number of years of experience with these capabilities. Interoperability capability was associated with 19% lower odds of adverse drug events occurring. Greater exposure to MU capabilities explained about one-fifth of the observed reduction in ADEs.

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Medical Residents Spend More Time Working on Electronic Medical Records than With Patients

MedicalResearch.com Interview with:
Dresse Nathalie Wenger

Cheffe de clinique
FMH médecine interne
Département de Médecine Interne
CHUV – Lausanne 

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

Response: The structure of a residents’ working day dramatically changed during the last decades (limitation of working hours per week, wide implementation of electronic medical records (EMR), and growing volume of clinical data and administrative tasks), especially in internal medicine with increasing complexity of patients. Electronic Medical Records (EMR) have some positive effects but negative effects have been also described ie more time writing notes, more administrative works, and less time for communication between physicians and patients.

Few time motion studies have been published about the resident’s working day in Internal Medicine: the impact of the computer, and what really do the residents do during their work, especially the time spent with the patient versus the computer, as now the EMRs are widely implemented. Previous studies have been mostly performed in the US, so we decided to conduct one observational and objective study in Europe.

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Electronic Records Can Provide Real World Evidence On Treatments of Type 2 Diabetes

MedicalResearch.com Interview with:

Lee Kallenbach, PhD, MPH Principal Investigator Practice Fusion

Dr. Lee Kallenbach

Lee Kallenbach, PhD, MPH
Principal Investigator
Practice Fusion

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

Response: Clinical inertia, or the tendency for patients and providers to continue using the same course of treatment even when clinical markers may suggest that treatment intensification is necessary, is an ongoing factor that can contribute to inadequate diabetes care. This is especially true when the treatment intensification may involve a switch from an oral medication to an injectable medication. It is less challenging for a patient to take a pill than it is to give themselves a shot.

Even with all the new diabetes treatments available, clinical inertia is still common among patients with uncontrolled type 2 diabetes (T2D). To further understand the extent of clinical inertia among patients with T2D, the study assessed treatment intensification patterns and associated demographic and clinical characteristics for patients with uncontrolled T2D who were already taking two or more oral anti-diabetes medications.

The study consisted of a retrospective observational analysis leveraging data from Practice Fusion’s de-identified clinical database, which includes more than 38 million records, representing 6.7 percent of all practices across the United States.1 Using a cohort of 25,365 de-identified records, we studied the care given by providers in independent practices to patients in need of intensifying their antidiabetic therapy for managing T2D. To our knowledge, this is one of the largest real world evidence (RWE) studies of T2D that has leveraged a de-identified clinical database from an electronic health record (EHR) platform.

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Targeted Case Finding Through EHR Starts More High Risk Patients On Treatment

MedicalResearch.com Interview with:

Tom Marshall, PhD, MRCGP, FFPH Professor of public health and primary care Institute of Applied Health Research University of Birmingham Edgbaston, Birmingham

Prof. Tom Marshall

Tom Marshall, PhD, MRCGP, FFPH
Professor of public health and primary care
Institute of Applied Health Research
University of Birmingham
Edgbaston, Birmingham

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

Response: Shortly before the Health Checks programme began, a programme of targeted case finding was set up in Sandwell in the West Midlands. In general practices in the area a programme nurse searched electronic medical records to identify untreated patients at high risk of cardiovascular disease. The nurse then invited high risk patients for assessment in the practice and those who needed treatment were referred to their GP for further action.

This was implemented in stages across 26 general practices, allowing it to be evaluated as a stepped wedge randomised controlled trial. The programme was successful, resulting in a 15.5% increase in the number of untreated high risk patients started on either antihypertensives or statins.

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Web-Based Handoff Tool Markedly Reduced Medical Errors

MedicalResearch.com Interview with:

Stephanie Mueller, MD MPH FHM Division of General Medicine Brigham and Women's Hospital Boston, MA 02120

Dr. Stephanie Mueller

Stephanie Mueller, MD MPH FHM
Division of General Medicine
Brigham and Women’s Hospital
Boston, MA 02120

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

Response: Failures in communication among healthcare personnel are known threats to patient safety, and occur all too commonly during times of care transition, such as when patient care responsibility is transferred from one provider to another (i.e., handoff). Such failures in communication put patients at risk for adverse outcomes.

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Medical Residents Work Almost 70 hours per week, 1/3 on Electronic Records

David Ouyang MD Department of Internal Medicine Stanford University School of Medicine Stanford, California

Dr. David Ouyang

MedicalResearch.com Interview with:
David Ouyang MD
Department of Internal Medicine
Stanford University School of Medicine
Stanford, California

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

Dr. Ouyang: In American teaching hospitals, trainee resident physicians are an integral part of the medical team in performing procedures, writing notes, and coordinating care. As more care is being facilitated by electronic medical record (EMR) systems, we are just now finally able to understand how much residents work and how residents spend their time. In our study, we examined the types and timing of electronic actions performed on the EMR system by residents and found that residents spend about a third (36%) of their day in front of the computer and frequently perform many simultaneous tasks across the charts of multiple patients. Additionally, residents often do work long hours, with a median of 69.2 hours per week when on the inpatient medicine service.

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Electronic Medical Records Make It Harder to Understand the Patient’s Story

MedicalResearch.com Interview with:
Lara Varpio, PhD
Associate Professor, Department of Medicine
Acting Associate Director, Graduate Programs in Health Professions Education
Uniformed Services University of the Health Sciences
Bethesda MD and
Dr. Judy Rashotte PhD
Director Nursing Research and Knowledge Translation Consultant  
Ottawa Canada

Medical Research: What is the background for this study?

Drs. Varpio and Rashotte: Electronic health records (EHRs) are being adopted in healthcare centers around the world. The patient record is intricately implicated in care processes, clinical reasoning activities, and in collaborative work. As part of a larger study aimed at understanding how EHRs impact health professionals’ interprofessional collaborative practice (ICP), we explored how changing from a paper chart to an EHR can impact clinical reasoning.

Medical Research: What are the main findings?

Drs. Varpio and Rashotte: Our research demonstrated how different parts of the patient record (i.e. communication genres / artefacts) are part of the contextual factors that influence clinical reasoning and ICP. A key finding of our study is that building the patient’s story is an essential part of clinical reasoning activities. Making and understanding data interconnections is facilitated when clinicians are actively engaged in assembling isolated data bits into contextually-derived, comprehensive, and comprehensible ensembles. Building the patient’s story is facilitated through the use of a chronologically-organized textual narrative (i.e. free-text notations) structure and structures that promote visual bundles of clinical data. The use of an EHR can problematize clinicians’ ability to build the patient’s story and to disseminate it with other members of the care team when data interconnections are fragmented. Fragmentation happens when narrative spaces are dispersed and/or character-limited, and when data displays are not chronologically organized in visual assemblies. The constraint of chronologically and contextually isolated data inhibits clinicians’ ability to read the why and how interpretations of clinical activities from other team members. When an EHR splinters narrative reports, there is a loss of shared interprofessional understanding of the patient’s story, and time efficient care delivery can be compromised.

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Pop-Up Screen On Electronic Medical Records May Reduce Some Unnecessary Testing

Elliot B Tapper, M.D. Clinical Fellow in Medicine (EXT) Beth Israel Deaconess Medical Center Boston MA 02215MedicalResearch.com Interview with:
Elliot B Tapper, M.D.
Clinical Fellow in Medicine (EXT)
Beth Israel Deaconess Medical Center
Boston MA 02215

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

Dr. Tapper: Elevation of liver enzymes is a common problem, affecting 7.9% of Americans. It is usually related to typical conditions such as fatty liver disease or viral hepatitis. Oftentimes, clinicians test patients with elevated liver enzymes for a multitude of possible causes including very rare genetic diseases, for example, a disease called Wilson Disease. This pattern of evaluation is called non-directed testing. It is a specific form of over-testing that is common in many fields and can be expensive or generate false positives. Wilson Disease, an inborn error of copper metabolism associated with liver injury, is rare (prevalence 0.003%) and there are guidelines available to suggest who should be tested, usually with a blood test called ceruloplasmin. These guidelines suggest excluding common liver diseases before testing for Wilson Disease and testing in younger patients (< 55 years old) because it is very rare to present after age 55.

We created a ‘pop-up’ screen in our provider ordering system to present clinicians who were choosing to order ceruloplasmin with the guidelines as well as its test characteristics, while still allowing them to order the test if they wanted. We studied the 7 months before and after the implementation of this intervention. We found a 51% reduction in ceruloplasmin orders. More importantly, we found that simultaneous testing for common liver diseases like viral hepatitis declined by 54% and the number of patients over the age of 55 who were tested declined by 61%. Incidentally, all positive tests were false positives.

First, we show that adherence to guidelines can be achieved when the ordering system interrupts clinician workflow to provide concrete data and advice. Second, we feel that there is considerable benefit to be obtained from similar interventions via reduced costs and fewer false positives given how common non-directed testing is in medical practice. Other areas that could benefit include, for example, antibody tests for rheumatogic or infectious diseases and daily blood tests for stable inpatients.

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

Dr. Tapper: Future research should pursue two questions. First, interventions to reduce over testing should include an assessment of patient outcomes both in terms of the burden of false positives or the possibility of missed diagnoses.

Second, studies should assess whether a directed strategy of testing is cost-effective compared to the seemingly more convenient all-at-once non-directed strategy.

Citation:

Tapper EB, Sengupta N, Lai M, Horowitz G. A Decision Support Tool to Reduce Overtesting for Ceruloplasmin and Improve Adherence With Clinical Guidelines. JAMA Intern Med. Published online June 01, 2015. doi:10.1001/jamainternmed.2015.2062.

 

Elliot B Tapper, M.D., Clinical Fellow in Medicine (EXT), Beth Israel Deaconess Medical Center, & Boston MA 02215 (2015). Pop-Up Screen On Electronic Medical Records May Reduce Some Unnecessary Testing 

Surgical Quality Enhanced By Electronics Records Data

MedicalResearch.com Interview with:
Jamie Anderson MD MPH
Department of Surgery
University of California, San Diego

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

Dr. Anderson: Risk adjustment is an important component of outcomes and quality analysis in surgical healthcare. To compare two hospitals fairly, you must take into account the “risk profile” of their patients. For example, a hospital operating on predominately very sick patients with multiple co-morbidities would be expected to have different outcomes to a hospital operating on relatively healthier patients with fewer co-morbidities. Somewhat counter-intuitively, it is possible that a hospital with a 10% mortality rate may be better than a hospital with 5% mortality rate when you adjust for the risk of the patient population.

Currently, the “gold standard” database to evaluate surgical outcomes is the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), which includes a number of variables on each patient to perform risk adjustment. However, collecting these variables is costly and time consuming. There is also concern that risk adjusted benchmarking systems can be “gamed” because they include data elements that require subjective interpretation by hospital personnel.

With the widespread adoption of electronic health records, the aim of this study was to determine whether a number of objective data elements already used for patient care could perform as well as a traditional, full risk adjustment model that includes other provider-assessed and provider-recorded data elements.

We tested this hypothesis with an analysis of the NSQIP database from 2005-2010, comparing models that adjusted for all 66 pre-operative risk variables captured by NSQIP to models that only included 25 objective variables. These results suggest that rigorous risk adjusted surgical quality assessment can be performed relying solely on objective variables already captured in electronic health records.

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Electronic Registries May Improve Diabetes Detection and Management

Dr. Tim A. Holt PhD MRCP FRCGP NIHR Academic Clinical Lecturer University of Oxford Department of Primary Care Health Sciences Radcliffe Observatory Quarter Woodstock Road OxfordMedicalResearch.com Interview with:
Dr. Tim A. Holt PhD MRCP FRCGP
NIHR Academic Clinical Lecturer
University of Oxford
Department of Primary Care Health Sciences
Radcliffe Observatory Quarter
Woodstock Road Oxford

Medical Research: What is the background for this study?

Dr. Holt: Undiagnosed diabetes is a serious and very costly problem. Early diagnosis is important to reduce risk of long term complications. A structured approach to management at the practice level involves electronic diabetes registers, enabling audit of care, automated recall, and screen reminders. Such registers depend on the presence of an electronic code for diabetes in the record.  Continue reading

Electronic Medical Records: Study Examines Patient-Initiated Amendment Requests

Dr David A Hanauer MD MS Department of Pediatrics University of Michigan Medical School Ann Arbor, MIMedicalResearch.com Interview with:
Dr David A Hanauer MD MS
Department of Pediatrics
University of Michigan Medical School
Ann Arbor, MI

 

MedicalResearch: What are the main findings of the study?

Dr. Hanauer: In this study we analyzed requests made by patients who wanted to make changes to their medical record. The goal was to develop an understanding of what the main reasons were for making a request to change the medical record, and what types of information they wanted changed.

One of the main findings was that about half of all requests were ultimately approved.  This suggests that patients reviewing their records can detect errors and have them corrected, which could ultimately lead to a more accurate record for a patient. In essence, giving patients the opportunity to further participate in their care by allowing them to review their record can lead to the identification and correction of errors or omissions.
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Patient-Centered Medical Homes: More Than Just Electronic Records Required to Improve Patient Care

Lisa M. Kern, MD, MPH, FACP Associate Professor of Healthcare Policy and Research and of Medicine Associate Director for Research, Center for Healthcare Informatics and Policy Deputy Director, Health Information Technology Evaluation Collaborative Weill Cornell Medical College New York, NY 10065MedicalResearch.com Interview with:
Lisa M. Kern, MD, MPH, FACP
Associate Professor of Healthcare Policy and Research and of Medicine
Associate Director for Research, Center for Healthcare Informatics and Policy Deputy Director, Health Information Technology Evaluation Collaborative Weill Cornell Medical College
New York, NY 10065

MedicalResearch: What are the main findings of the study?

Dr. Kern: We found that primary care physicians participating in Patient-Centered Medical Homes (PCMHs) improved their quality of care over time at a significantly higher rate than their non-PCMH peers.
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Electronic Medical Records: Decreased Face-to-Face Communication Between Physicians and Nurses

MedicalResearch.com Interview with:
Stephanie Parks Taylor MD MS
Associate Professor
Director of Clinical Research
Associate Division Director, Hospital Medicine
USF Department of Internal Medicine

MedicalResearch.com: What are the main findings of your study?

Dr. Parks Taylor: The integration of electronic medical records has been proposed to have many benefits for the healthcare system. We investigated the effect of EMR implementation on communication between physicians and nurses in a hospital setting. The primary finding was that overall agreement about a patient’s plan of care actually worsened after the implementation of EMR. This seemed to be related to a decrease in face-to-face communication between physicians and nurses.
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Using Electronic Medical Records to Follow Methotrexate Side Effects

Gabriela Schmajuk M.D. M.S. Department of Medicine (Rheumatology) University of California, San Francisco San Francisco VA Medical Center San Francisco, CA 94121MedicalResearch.com Interview with:
Gabriela Schmajuk M.D. M.S.
Department of Medicine (Rheumatology)
University of California, San Francisco
San Francisco VA Medical Center
San Francisco, CA 94121

MedicalResearch.com: What are the main findings of the study?

Dr. Schmajuk: Our main findings were that moderate LFT abnormalities were uncommon
in the first 7 months of methotrexate use among new users, and more
likely to occur in patients with obesity, untreated high cholesterol,
pre-methotrexate LFT elevations, biologic agent use, and lack of folic
acid supplementation.
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Using Clinical Databases to Monitor Drug Side Effects and Performance

MedicalResearch.com Interview with:
Leo Anthony Celi, MD, MS, MPH Massachusetts Institute of Technology Cambridge, MA 02139
Leo Anthony Celi, MD, MS, MPH

Massachusetts Institute of Technology
Cambridge, MA 02139


MedicalResearch.com: What are the main findings of the study?

Dr. Celi: The main take home point from the paper is that we know little about how drug perform in the real world. Which patients truly benefit? Which patients are harmed? How do drugs interact with different acute (such as critical illness) and chronic conditions? These questions are almost never answered during pre-marketing research due to cost. We need a better system of following the life cycle of drugs post-marketing. Clinical databases provide us with this opportunity.
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Electronic Medical Records: Tool to Identify Readmission Risk

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

MedicalResearch.com: What are the main findings of the study?

Dr. Umscheid: We developed and successfully deployed into the electronic health record of the University of Pennsylvania Health System an automated prediction tool which identifies newly admitted patients who are at risk for readmission within 30 days of discharge.  Using local data, we found that having been admitted to the hospital two or more times in the 12 months prior to admission was the best way to predict which patients are at risk for being readmitted in the 30 days after discharge. Using this finding, our automated tool identifies patients who are “high risk” for readmission and creates a “flag” in their electronic health record (EHR). The flag appears next to the patient’s name in a column titled “readmission risk.” The flag can be double-clicked to display detailed information relevant to discharge planning.  In a one year prospective validation of the tool, we found that patients who triggered the readmission alert were subsequently readmitted 31 percent of the time. When an alert was not triggered, patients were readmitted only 11 percent of the time.  There was no evidence for an effect of the intervention on 30-day all-cause readmission rates in the 12-month period after implementation.
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