EHR in Emergency Rooms: Exploring the Effect of Key Information Components on Main Complaints

This study characterizes the information components associated with improved medical decision-making in the emergency room (ER). We looked at doctors’ decisions to use or not to use information available to them on an electronic health record (EHR) and a Health Information Exchange (HIE) network, and tested for associations between their decision and parameters related to healthcare outcomes and processes. Using information components from the EHR and HIE was significantly related to improved quality of healthcare processes. Specifically, it was associated with both a reduction in potentially avoidable admissions as well as a reduction in rapid readmissions. Overall, the three information components; namely, previous encounters, imaging, and lab results emerged as having the strongest relationship with physicians’ decisions to admit or discharge. Certain information components, however, presented an association between the diagnosis and the admission decisions (blood pressure was the most strongly associated parameter in cases of chest pain complaints and a previous surgical record for abdominal pain). These findings show that the ability to access patients’ medical history and their long term health conditions (via the EHR), including information about medications, diagnoses, recent procedures and laboratory tests is critical to forming an appropriate plan of care and eventually making more accurate admission decisions.     

Haemodynamic management in ruptured abdominal aortic aneurysm.

Ruptured abdominal aortic aneurysm currently accounts for about 1 in 200 deaths and is a critical surgical emergency with an average hospital mortality of 50%. The combination of acute massive haemorrhage in an elderly patient with pre-existing medical disease is highly lethal and a major challenge for any health care system. This article outlines the general principles of management and discusses the problems of haemodynamic assessment and preclamping fluid resuscitation.     

Cost-effectiveness analysis of endoscopic tympanoplasty versus microscopic tympanoplasty for chronic otitis media in Taiwan

Background

Health care systems and physicians need to conform to budgets and streamline resources to provide cost-effective quality care. Although endoscopic tympanoplasty (ET) has been performed for decades, no studies on the cost-effectiveness of ET and microscopic tympanoplasty (MT) for treating chronic otitis media have been published. The present study aimed to compare the cost-effectiveness of ET and MT for treating chronic otitis media.

Use and Satisfaction with Electronic Health Record by Primary Care Physicians in a Health District in Brazil

It is believed that Electronic Health Records (EHR) improve not only quality of care but also patient safety and health care savings. This seems to be true for developed countries but not necessarily in emerging economies. This paper examined the primary care physicians' satisfaction with a specific EHR in a health district of a major city in Brazil and describes how they are using it as well as its specific functions. A cross-sectional questionnaire survey with all physicians from all Community Health Centers of the 6th health district of the City of Fortaleza that were using HER was conducted. From the 111 subjects (100%), a total of 99 physicians answered the survey (89% response rate). For overall satisfaction with the EHR, 2 (2%) were satisfied, 50 (50.5%) were satisfied in part and 47 (47.5%) were not satisfied. For the functionalities, a proportion of correct answers (PCA) and an index of functionality usage (IFU) were developed. PCA and IFU were significantly correlated (p?相似文献   

The cost-effectiveness of counseling smokers to quit

Cigarette smoking is the most important preventable cause of death in the United States. Surveys of patients, however, suggest that many physicians do not routinely counsel smokers to quit. Because physicians may not consider counseling against smoking to be as worthwhile as other medical practices, we examined its cost-effectiveness. We based our estimates of the effectiveness of physician counseling on published reports of randomized trials and our estimates of its cost on average charges for physician office visits. Our results indicate that the cost-effectiveness of brief advice during routine office visits ranges from $705 to $988 per year of life saved for men and from $1204 to $2058 for women. Follow-up visits about smoking appear to be similarly cost-effective. Physician counseling against smoking, therefore, is at least as cost-effective as several other preventive medical practices and should be a routine part of health care for patients who smoke.     

Electronic health records and clinician burnout: A story of three eras

ObjectiveThe study sought to provide physicians, informaticians, and institutional policymakers with an introductory tutorial about the history of medical documentation, sources of clinician burnout, and opportunities to improve electronic health records (EHRs). We now have unprecedented opportunities in health care, with the promise of new cures, improved equity, greater sensitivity to social and behavioral determinants of health, and data-driven precision medicine all on the horizon. EHRs have succeeded in making many aspects of care safer and more reliable. Unfortunately, current limitations in EHR usability and problems with clinician burnout distract from these successes. A complex interplay of technology, policy, and healthcare delivery has contributed to our current frustrations with EHRs. Fortunately, there are opportunities to improve the EHR and health system. A stronger emphasis on improving the clinician’s experience through close collaboration by informaticians, clinicians, and vendors can combine with specific policy changes to address the causes of burnout.Target audienceThis tutorial is intended for clinicians, informaticians, policymakers, and regulators, who are essential participants in discussions focused on improving clinician burnout. Learners in biomedicine, regardless of clinical discipline, also may benefit from this primer and review.ScopeWe include (1) an overview of medical documentation from a historical perspective; (2) a summary of the forces converging over the past 20 years to develop and disseminate the modern EHR; and (3) future opportunities to improve EHR structure, function, user base, and time required to collect and extract information.     

The Relationship between Electronic Health Record Use and Quality of Care over Time

Objective

Electronic health records (EHRs) have the potential to advance the quality of care, but studies have shown mixed results. The authors sought to examine the extent of EHR usage and how the quality of care delivered in ambulatory care practices varied according to duration of EHR availability.

Methods

The study linked two data sources: a statewide survey of physicians' adoption and use of EHR and claims data reflecting quality of care as indicated by physicians' performance on widely used quality measures. Using four years of measurement, we combined 18 quality measures into 6 clinical condition categories. While the survey of physicians was cross-sectional, respondents indicated the year in which they adopted EHR. In an analysis accounting for duration of EHR use, we examined the relationship between EHR adoption and quality of care.

Results

The percent of physicians reporting adoption of EHR and availability of EHR core functions more than doubled between 2000 and 2005. Among EHR users in 2005, the average duration of EHR use was 4.8 years. For all 6 clinical conditions, there was no difference in performance between EHR users and non-users. In addition, for these 6 clinical conditions, there was no consistent pattern between length of time using an EHR and physicians performance on quality measures in both bivariate and multivariate analyses.

Conclusions

In this cross-sectional study, we found no association between duration of using an EHR and performance with respect to quality of care, although power was limited. Intensifying the use of key EHR features, such as clinical decision support, may be needed to realize quality improvement from EHRs. Future studies should examine the relationship between the extent to which physicians use key EHR functions and their performance on quality measures over time.     

Characterizing physician EHR use with vendor derived data: a feasibility study and cross-sectional analysis

ObjectiveTo derive 7 proposed core electronic health record (EHR) use metrics across 2 healthcare systems with different EHR vendor product installations and examine factors associated with EHR time.Materials and MethodsA cross-sectional analysis of ambulatory physicians EHR use across the Yale-New Haven and MedStar Health systems was performed for August 2019 using 7 proposed core EHR use metrics normalized to 8 hours of patient scheduled time.ResultsFive out of 7 proposed metrics could be measured in a population of nonteaching, exclusively ambulatory physicians. Among 573 physicians (Yale-New Haven N = 290, MedStar N = 283) in the analysis, median EHR-Time₈ was 5.23 hours. Gender, additional clinical hours scheduled, and certain medical specialties were associated with EHR-Time₈ after adjusting for age and health system on multivariable analysis. For every 8 hours of scheduled patient time, the model predicted these differences in EHR time (P < .001, unless otherwise indicated): female physicians +0.58 hours; each additional clinical hour scheduled per month −0.01 hours; practicing cardiology −1.30 hours; medical subspecialties −0.89 hours (except gastroenterology, P = .002); neurology/psychiatry −2.60 hours; obstetrics/gynecology −1.88 hours; pediatrics −1.05 hours (P = .001); sports/physical medicine and rehabilitation −3.25 hours; and surgical specialties −3.65 hours.ConclusionsFor every 8 hours of scheduled patient time, ambulatory physicians spend more than 5 hours on the EHR. Physician gender, specialty, and number of clinical hours practicing are associated with differences in EHR time. While audit logs remain a powerful tool for understanding physician EHR use, additional transparency, granularity, and standardization of vendor-derived EHR use data definitions are still necessary to standardize EHR use measurement.     

Specific clinical competencies for managing care: views of residency directors and managed care medical directors

CONTEXT: Although medical educators recognize the need to prepare physicians to work effectively in managed care environments, managed care is often perceived negatively by academic physicians. Curricular reform has been hampered by a failure to seek agreement about specific clinical competencies that are important to both managed care directors and medical educators. OBJECTIVES: To identify specific clinical competencies in the managed care setting and to assess agreement between residency directors and managed care medical directors on the importance of these competencies. DESIGN, SETTING, AND PARTICIPANTS: Surveys (1998-1999) of a national sample of 59 residency directors involved in managed care training programs (response rate, 94%); a sample of 186 residents in these programs and 258 matched control residents (response rate, 77%); and national samples of 147 managed care organization (MCO) medical directors (response rate, 67%) and 140 primary care residency program directors in areas of high MCO penetration (response rate, 73%). MAIN OUTCOME MEASURES: Specific clinical managed care tasks as defined by residency directors; self-reported confidence in performing these tasks by sample residents vs control residents; and importance of these tasks as rated by MCO medical directors and residency program directors. RESULTS: Twenty-six specific clinical managed care tasks were identified by the residency directors. Residents who participated in managed care training were significantly more confident than their counterparts in performing 20 of the 26 tasks (P<.01 for all). Residency directors and MCO medical directors viewed 65% of these tasks as important to patient care during the next 5 years. Of the 10 tasks most highly rated by residency directors and MCO medical directors, 9 were the same, addressing time management, ethics, case management, practice guidelines, cost-effective clinical decision making, referral management, disease management, patient satisfaction, and clinical epidemiology. CONCLUSIONS: Our data indicate that residency directors and managed care medical directors value mastery of many of the same specific clinical competencies in managed care. Previously documented negative attitudes toward managed care among academic physicians may obscure an underlying concordance about the skills essential to managing the health of populations. JAMA. 2000;284:1093-1098     

An Innovative Approach to Improve Communication and Reduce Physician Stress and Burnout in a University Affiliated Residency Program

Ineffective communication between nursing staff and residents leads to numerous educational and patient-care interruptions, increasing resident stress and overall workload. We developed an innovative and simple, secure electronic health record (EHR) base text paging system to communicate with internal medicine residents. The goal is to avoid unnecessary interruption during patient care or educational activities and reduce stress. Traditional paging system can send a phone number to call back. We developed and implemented a HIPPA-compliant, EHR-integrated text paging at a busy 591-bed urban hospital. Access was granted to unit clerks, nursing staff, case managers, and physicians. Senders could either send a traditional telephone number page or a text page through our EHR. The recipient could then either acknowledge receipt of the page or take appropriate actions. Afterward, Internal medicine residents were polled on overall satisfaction difference between basic phone based numeric paging and the enhanced EHR text paging system. Educational interruptions (averaging over 7 pages) decreased from 64% to 16%. Patient care interruptions fell from 68% to 12%. 88% of residents felt that 50% or less of the pages were non-emergent and did not require an immediate action. 92% of 25 surveyed internal medicine residents preferred text paging over numeric paging and responded through the EHR 60% of the time by placing direct orders. Time savings using the new system over a 3-month span amounted to 72.5 h in transmission time alone. Text paging among medical caregivers and internal medicine residents through EHR-associated communication reduced patient care and educational interruptions. It saved time spent sending pages, answering unnecessary pages and it improved resident’s subjective stress and satisfaction levels.     

Electronic health records and support for primary care teamwork

Objective Consensus that enhanced teamwork is necessary for efficient and effective primary care delivery is growing. We sought to identify how electronic health records (EHRs) facilitate and pose challenges to primary care teams as well as how practices are overcoming these challenges.Methods Practices in this qualitative study were selected from those recognized as patient-centered medical homes via the National Committee for Quality Assurance 2011 tool, which included a section on practice teamwork. We interviewed 63 respondents, ranging from physicians to front-desk staff, from 27 primary care practices ranging in size, type, geography, and population size.Results EHRs were found to facilitate communication and task delegation in primary care teams through instant messaging, task management software, and the ability to create evidence-based templates for symptom-specific data collection from patients by medical assistants and nurses (which can offload work from physicians). Areas where respondents felt that electronic medical record EHR functionalities were weakest and posed challenges to teamwork included the lack of integrated care manager software and care plans in EHRs, poor practice registry functionality and interoperability, and inadequate ease of tracking patient data in the EHR over time.Discussion Practices developed solutions for some of the challenges they faced when attempting to use EHRs to support teamwork but wanted more permanent vendor and policy solutions for other challenges.Conclusions EHR vendors in the United States need to work alongside practicing primary care teams to create more clinically useful EHRs that support dynamic care plans, integrated care management software, more functional and interoperable practice registries, and greater ease of data tracking over time.     

A cost-effectiveness analysis of hormone replacement therapy in the menopause.

OBJECTIVE: To evaluate the cost-effectiveness of hormone replacement therapy in the menopause with particular reference to osteoporotic fracture and myocardial infarction. DESIGN: The multiple-decrement form of the life table was the mathematical model used to follow women of age 50 through their lifetime under the "no hormone replacement" and "hormone replacement" assumptions. Standard demographic and health economic techniques were used to calculate the corresponding lifetime differences in direct health care costs (net costs in dollars) and health effects ("net effectiveness" in terms of life expectancy and quality, in "quality-adjusted life-years"). This was then expressed as a cost-effectiveness ratio or the cost ($) per quality-adjusted life-year (QALY) for each of the chosen hormone replacement regimens. SETTING AND PATIENTS: All women of age 50 in New South Wales, Australia (n = 27,021). RESULTS: The analysis showed that the lifetime net increments in direct medical care costs were largely contributed by hormone drug and consultation costs. Hormone replacement was associated with increased quality-adjusted life expectancy, a large percentage of which was attributed to a relief of menopausal symptoms. Cost-effectiveness ratios ranged from under 10,000 to over a million dollars per QALY. Factors associated with improved cost-effectiveness were prolonged treatment duration, the presence of menopausal symptoms, minimum progestogen side effects (in the case of oestrogen with progestogen regimens), oestrogen use after hysterectomy and the inclusion of cardiac benefits in addition to fracture prevention. CONCLUSIONS: Hormone replacement therapy for symptomatic women is cost-effective when factors that enhance its efficiency are considered. Short-term treatment of asymptomatic women for prevention of osteoporotic fractures and myocardial infarction is an inefficient use of health resources. Cost-effectiveness of hormone replacement in asymptomatic women is dependent on the magnitude of cardiac benefits associated with hormone use and the treatment duration.     

Treating competent patients by force: the limits and lessons of Israel's Patient's Rights Act

Competent patients who refuse life saving medical treatment present a dilemma for healthcare professionals. On one hand, respect for autonomy and liberty demand that physicians respect a patient's decision to refuse treatment. However, it is often apparent that such patients are not fully competent. They may not adequately comprehend the benefits of medical care, be overly anxious about pain, or discount the value of their future state of health. Although most bioethicists are convinced that partial autonomy or marginal competence of this kind demands the same respect as full autonomy, Israeli legislators created a mechanism to allow ethics committees to override patients' informed refusal and treat them against their will. To do so, three conditions must be satisfied: physicians must make every effort to ensure the patient understands the risks of non-treatment, the treatment physicians propose must offer a realistic chance of significant improvement, and there are reasonable expectations that the patient will consent retroactively. Although not all of these conditions are equally cogent, they offer a way forward to assure care for certain classes of competent patients without abandoning the principle of autonomy altogether. These concerns reach past Israel and should engage healthcare professionals wary that respect for autonomy may sometimes cause avoidable harm.     

Resolving disagreements in the patient-physician relationship: tools for improving communication in managed care.

Managed care uses financial incentives and restrictions on tests and procedures to attempt to influence physician decision making and limit costs. Increasingly, the public is questioning whether physicians are truly making decisions based on the patient's best interest or are unduly influenced by economic incentives. These circumstances lead to the potential for disagreements and conflict in the patient-physician relationship. We convened a group of individuals in October 1998, including patient representatives, leaders from health care organizations, practicing physicians, communication experts, and medical ethicists, to articulate the types of disagreements emerging in the patient-physician relationship as a result of managed care. We addressed 3 specific scenarios physicians may encounter, including allocation, illustrated by a patient who is referred to a different ophthalmologist based on a new arrangement in the physician's group; access, illustrated by a patient who wishes to see his own physician for a same-day visit rather than a nurse specialist; and financial incentives, illustrated by a patient who expects to have a test performed and a physician who does not believe the test is necessary but is afraid the patient will think the physician is not ordering the test because of financial incentives. Using these scenarios, we suggest communication strategies that physicians can use to decrease the potential for disagreements. In addition, we propose strategies that health plans or physician groups can use to alleviate or resolve these disagreements.     

腹主动脉瘤腔内隔绝术围手术期护理

目的:探讨腹主动脉瘤腔内隔绝术围手术期护理方法,为完善腹主动脉瘤腔内隔绝术围手术期护理提供参考。方法:通过对我院2004年6月～2009年5月收治的10例腹主动脉瘤患者护理实践的回顾,总结腹主动脉瘤腔内隔绝术术前护理和术后护理的护理重点、护理难点。结果:10例患者成功植入移植物,术后发热3例,发生肺部感染1例,动脉栓塞1例,经及时诊治后康复出院。结论:对腹主动脉瘤患者的护理应特别注重血压的监测,有效控制血压,防止因血压过高而发生瘤体破裂;同时,要做好患者的心理护理,并预防感染。     

Principles of educational outreach ('academic detailing') to improve clinical decision making

With the efficacy and costs of medications rising rapidly, it is increasingly important to ensure that drugs be prescribed as rationally as possible. Yet, physicians' choices of drugs frequently fall short of the ideal of precise and cost-effective decision making. Evidence indicates that such decisions can be improved in a variety of ways. A number of theories and principles of communication and behavior changes can be found that underlie the success of pharmaceutical manufacturers in influencing prescribing practices. Based on this behavioral science and several field trials, it is possible to define the theory and practice of methods to improve physicians' clinical decision making to enhance the quality and cost-effectiveness of care. Some of the most important techniques of such "academic detailing" include (1) conducting interviews to investigate baseline knowledge and motivations for current prescribing patterns, (2) focusing programs on specific categories of physicians as well as on their opinion leaders, (3) defining clear educational and behavioral objectives, (4) establishing credibility through a respected organizational identity, referencing authoritative and unbiased sources of information, and presenting both sides of controversial issues, (5) stimulating active physician participation in educational interactions, (6) using concise graphic educational materials, (7) highlighting and repeating the essential messages, and (8) providing positive reinforcement of improved practices in follow-up visits. Used by the nonprofit sector, the above techniques have been shown to reduce inappropriate prescribing as well as unnecessary health care expenditures.     

Correlates of Electronic Health Record Adoption in Office Practices: A Statewide Survey

Objective

Despite emerging evidence that electronic health records (EHRs) can improve the efficiency and quality of medical care, most physicians in office practice in the United States do not currently use an EHR. We sought to measure the correlates of EHR adoption.

Design

Mailed survey to a stratified random sample of all medical practices in Massachusetts in 2005, with one physician per practice randomly selected for survey.

Measurements

EHR adoption rates.

Results

The response rate was 71% (1345/1884). Overall, while 45% of physicians were using an EHR, EHRs were present in only 23% of practices. In multivariate analysis, practice size was strongly correlated with EHR adoption; 52% of practices with 7 or more physicians had an EHR, as compared with 14% of solo practices (adjusted odds ratio, 3.66; 95% confidence interval, 2.28–5.87). Hospital-based practices (adjusted odds ratio, 2.44; 95% confidence interval, 1.53–3.91) and practices that teach medical students or residents (adjusted odds ratio, 2.30; 95% confidence interval, 1.60–3.31) were more likely to have an EHR. The most frequently cited barriers to adoption were start-up financial costs (84%), ongoing financial costs (82%), and loss of productivity (81%).

Conclusions

While almost half of physicians in Massachusetts are using an EHR, fewer than one in four practices in Massachusetts have adopted EHRs. Adoption rates are lower in smaller practices, those not affiliated with hospitals, and those that do not teach medical students or residents. Interventions to expand EHR use must address both financial and non-financial barriers, especially among smaller practices.     

中老年人腹主动脉瘤超声筛查的临床价值

目的:探讨超声在中老年人腹主动脉瘤筛查中的价值。方法:对我院5 268例55岁以上的中老年人的腹主动脉进行超声检测,观察腹主动脉形态、走行、测量腹主动脉上下段内径、中-内膜厚度,测量钙化斑块及血管血流情况。结果:在筛查的病例中,发现腹主动脉瘤120例,其中1例腹主动脉破裂死亡。腹主动脉不同程度粥样硬化(钙化点及钙化斑)2 940例。结论:运用超声进行腹主动脉瘤的普查具有重要的意义,可以早期发现、及时治疗,预防瘤体破裂,提高生存率。     

Understanding differences in electronic health record (EHR) use: linking individual physicians’ perceptions of uncertainty and EHR use patterns in ambulatory care

Objective

Electronic health records (EHR) hold great promise for managing patient information in ways that improve healthcare delivery. Physicians differ, however, in their use of this health information technology (IT), and these differences are not well understood. The authors study the differences in individual physicians'' EHR use patterns and identify perceptions of uncertainty as an important new variable in understanding EHR use.

Design

Qualitative study using semi-structured interviews and direct observation of physicians (n=28) working in a multispecialty outpatient care organization.

Measurements

We identified physicians'' perceptions of uncertainty as an important variable in understanding differences in EHR use patterns. Drawing on theories from the medical and organizational literatures, we identified three categories of perceptions of uncertainty: reduction, absorption, and hybrid. We used an existing model of EHR use to categorize physician EHR use patterns as high, medium, and low based on degree of feature use, level of EHR-enabled communication, and frequency that EHR use patterns change.

Results

Physicians'' perceptions of uncertainty were distinctly associated with their EHR use patterns. Uncertainty reductionists tended to exhibit high levels of EHR use, uncertainty absorbers tended to exhibit low levels of EHR use, and physicians demonstrating both perspectives of uncertainty (hybrids) tended to exhibit medium levels of EHR use.

Conclusions

We find evidence linking physicians'' perceptions of uncertainty with EHR use patterns. Study findings have implications for health IT research, practice, and policy, particularly in terms of impacting health IT design and implementation efforts in ways that consider differences in physicians'' perceptions of uncertainty.