scholarly journals Use of Electronic Health Record Access and Audit Logs to Identify Physician Actions Following Noninterruptive Alert Opening: Descriptive Study (Preprint)

2018 ◽  
Author(s):  
Azraa Amroze ◽  
Terry S Field ◽  
Hassan Fouayzi ◽  
Devi Sundaresan ◽  
Laura Burns ◽  
...  
Keyword(s):  
Electronic Health Record ◽  
Primary Care Physicians ◽  
Controlled Trial ◽  
Patient Characteristics ◽  
Clinical Decision ◽  
Descriptive Study ◽  
Health Record ◽  
Log Data ◽  
Electronic Health

BACKGROUND Electronic health record (EHR) access and audit logs record behaviors of providers as they navigate the EHR. These data can be used to better understand provider responses to EHR–based clinical decision support (CDS), shedding light on whether and why CDS is effective. OBJECTIVE This study aimed to determine the feasibility of using EHR access and audit logs to track primary care physicians’ (PCPs’) opening of and response to noninterruptive alerts delivered to EHR InBaskets. METHODS We conducted a descriptive study to assess the use of EHR log data to track provider behavior. We analyzed data recorded following opening of 799 noninterruptive alerts sent to 75 PCPs’ InBaskets through a prior randomized controlled trial. Three types of alerts highlighted new medication concerns for older patients’ posthospital discharge: information only (n=593), medication recommendations (n=37), and test recommendations (n=169). We sought log data to identify the person opening the alert and the timing and type of PCPs’ follow-up EHR actions (immediate vs by the end of the following day). We performed multivariate analyses examining associations between alert type, patient characteristics, provider characteristics, and contextual factors and likelihood of immediate or subsequent PCP action (general, medication-specific, or laboratory-specific actions). We describe challenges and strategies for log data use. RESULTS We successfully identified the required data in EHR access and audit logs. More than three-quarters of alerts (78.5%, 627/799) were opened by the PCP to whom they were directed, allowing us to assess immediate PCP action; of these, 208 alerts were followed by immediate action. Expanding on our analyses to include alerts opened by staff or covering physicians, we found that an additional 330 of the 799 alerts demonstrated PCP action by the end of the following day. The remaining 261 alerts showed no PCP action. Compared to information-only alerts, the odds ratio (OR) of immediate action was 4.03 (95% CI 1.67-9.72) for medication-recommendation and 2.14 (95% CI 1.38-3.32) for test-recommendation alerts. Compared to information-only alerts, ORs of medication-specific action by end of the following day were significantly greater for medication recommendations (5.59; 95% CI 2.42-12.94) and test recommendations (1.71; 95% CI 1.09-2.68). We found a similar pattern for OR of laboratory-specific action. We encountered 2 main challenges: (1) Capturing a historical snapshot of EHR status (number of InBasket messages at time of alert delivery) required incorporation of data generated many months prior with longitudinal follow-up. (2) Accurately interpreting data elements required iterative work by a physician/data manager team taking action within the EHR and then examining audit logs to identify corresponding documentation. CONCLUSIONS EHR log data could inform future efforts and provide valuable information during development and refinement of CDS interventions. To address challenges, use of these data should be planned before implementing an EHR–based study.

scholarly journals Electronic Health Record–Based Strategy to Promote Medication Adherence Among Patients With Diabetes: Longitudinal Observational Study

10.2196/13499 ◽  
2019 ◽  
Vol 21 (10) ◽  
pp. e13499 ◽  
Author(s):  
Stacy Cooper Bailey ◽  
Amisha Wallia ◽  
Sarah Wright ◽  
Guisselle A Wismer ◽  
Alexandra C Infanzon ◽  
...  
Keyword(s):  
Medication Adherence ◽  
Electronic Health Record ◽  
Low Cost ◽  
Clinical Decision ◽  
Health Record ◽  
Low Literacy ◽  
Minimal Impact ◽  
Patients With Diabetes ◽  
Electronic Health

Background Poor medication adherence is common; however, few mechanisms exist in clinical practice to monitor how patients take medications in outpatient settings. Objective This study aimed to pilot test the Electronic Medication Complete Communication (EMC2) strategy, a low-cost, sustainable approach that uses functionalities within the electronic health record to promote outpatient medication adherence and safety. Methods The EMC2 strategy was implemented in 2 academic practices for 14 higher-risk diabetes medications. The strategy included: (1) clinical decision support alerts to prompt provider counseling on medication risks, (2) low-literacy medication summaries for patients, (3) a portal-based questionnaire to monitor outpatient medication use, and (4) clinical outreach for identified concerns. We recruited adult patients with diabetes who were prescribed a higher-risk diabetes medication. Participants completed baseline and 2-week interviews to assess receipt of, and satisfaction with, intervention components. Results A total of 100 patients were enrolled; 90 completed the 2-week interview. Patients were racially diverse, 30.0% (30/100) had a high school education or less, and 40.0% (40/100) had limited literacy skills. About a quarter (28/100) did not have a portal account; socioeconomic disparities were noted in account ownership by income and education. Among patients with a portal account, 58% (42/72) completed the questionnaire; 21 of the 42 patients reported concerns warranting clinical follow-up. Of these, 17 were contacted by the clinic or had their issue resolved within 24 hours. Most patients (33/38, 89%) who completed the portal questionnaire and follow-up interview reported high levels of satisfaction (score of 8 or greater on a scale of 1-10). Conclusions Findings suggest that the EMC2 strategy can be reliably implemented and delivered to patients, with high levels of satisfaction. Disparities in portal use may restrict intervention reach. Although the EMC2 strategy can be implemented with minimal impact on clinic workflow, future trials are needed to evaluate its effectiveness to promote adherence and safety.

scholarly journals Electronic Health Record–Based Strategy to Promote Medication Adherence Among Patients With Diabetes: Longitudinal Observational Study (Preprint)

2019 ◽  
Author(s):  
Stacy Cooper Bailey ◽  
Amisha Wallia ◽  
Sarah Wright ◽  
Guisselle A Wismer ◽  
Alexandra C Infanzon ◽  
...  
Keyword(s):  
Medication Adherence ◽  
Electronic Health Record ◽  
Low Cost ◽  
Clinical Decision ◽  
Health Record ◽  
Low Literacy ◽  
Minimal Impact ◽  
Patients With Diabetes ◽  
Electronic Health

BACKGROUND Poor medication adherence is common; however, few mechanisms exist in clinical practice to monitor how patients take medications in outpatient settings. OBJECTIVE This study aimed to pilot test the Electronic Medication Complete Communication (EMC<sup>2</sup>) strategy, a low-cost, sustainable approach that uses functionalities within the electronic health record to promote outpatient medication adherence and safety. METHODS The EMC<sup>2</sup> strategy was implemented in 2 academic practices for 14 higher-risk diabetes medications. The strategy included: (1) clinical decision support alerts to prompt provider counseling on medication risks, (2) low-literacy medication summaries for patients, (3) a portal-based questionnaire to monitor outpatient medication use, and (4) clinical outreach for identified concerns. We recruited adult patients with diabetes who were prescribed a higher-risk diabetes medication. Participants completed baseline and 2-week interviews to assess receipt of, and satisfaction with, intervention components. RESULTS A total of 100 patients were enrolled; 90 completed the 2-week interview. Patients were racially diverse, 30.0% (30/100) had a high school education or less, and 40.0% (40/100) had limited literacy skills. About a quarter (28/100) did not have a portal account; socioeconomic disparities were noted in account ownership by income and education. Among patients with a portal account, 58% (42/72) completed the questionnaire; 21 of the 42 patients reported concerns warranting clinical follow-up. Of these, 17 were contacted by the clinic or had their issue resolved within 24 hours. Most patients (33/38, 89%) who completed the portal questionnaire and follow-up interview reported high levels of satisfaction (score of 8 or greater on a scale of 1-10). CONCLUSIONS Findings suggest that the EMC<sup>2</sup> strategy can be reliably implemented and delivered to patients, with high levels of satisfaction. Disparities in portal use may restrict intervention reach. Although the EMC<sup>2</sup> strategy can be implemented with minimal impact on clinic workflow, future trials are needed to evaluate its effectiveness to promote adherence and safety.

scholarly journals Dissemination of child abuse clinical decision support: Moving beyond a single electronic health record

2021 ◽  
Vol 147 ◽  
pp. 104349
Author(s):  
Thomas McGinn ◽  
David A. Feldstein ◽  
Isabel Barata ◽  
Emily Heineman ◽  
Joshua Ross ◽  
...  
Keyword(s):  
Child Abuse ◽  
Decision Support ◽  
Electronic Health Record ◽  
Clinical Decision Support ◽  
Clinical Decision ◽  
Health Record ◽  
Electronic Health

scholarly journals Optimizing the electronic health record: An inpatient sprint addresses provider burnout and improves electronic health record satisfaction

2020 ◽  
Author(s):  
Jennifer R Simpson ◽  
Chen-Tan Lin ◽  
Amber Sieja ◽  
Stefan H Sillau ◽  
Jonathan Pell
Keyword(s):  
Confidence Interval ◽  
Electronic Health Record ◽  
Health Record ◽  
Advanced Practice ◽  
Log Data ◽  
Net Promoter Score ◽  
Net Promoter ◽  
Electronic Health ◽  
Emotional Recovery ◽  
Very High

Abstract Objective We sought reduce electronic health record (EHR) burden on inpatient clinicians with a 2-week EHR optimization sprint. Materials and Methods A team led by physician informaticists worked with 19 advanced practice providers (APPs) in 1 specialty unit. Over 2 weeks, the team delivered 21 EHR changes, and provided 39 one-on-one training sessions to APPs, with an average of 2.8 hours per provider. We measured Net Promoter Score, thriving metrics, and time spent in the EHR based on user log data. Results Of the 19 APPs, 18 completed 2 or more sessions. The EHR Net Promoter Score increased from 6 to 60 postsprint (1.0; 95% confidence interval, 0.3-1.8; P = .01). The NPS for the Sprint itself was 93, a very high rating. The 3-axis emotional thriving, emotional recovery, and emotional exhaustion metrics did not show a significant change. By user log data, time spent in the EHR did not show a significant decrease; however, 40% of the APPs responded that they spent less time in the EHR. Conclusions This inpatient sprint improved satisfaction with the EHR.

scholarly journals Developing Clinical Decision Support within a Commercial Electronic Health Record System to Improve Antimicrobial Prescribing in the Neonatal ICU

2014 ◽  
Vol 05 (02) ◽  
pp. 368-387 ◽  
Author(s):  
K. Cato ◽  
B. Sheehan ◽  
S. Patel ◽  
J. Duchon ◽  
P. DeLaMora ◽  
...  
Keyword(s):  
Decision Support ◽  
Electronic Health Record ◽  
Clinical Decision Support ◽  
Clinical Decision ◽  
Electronic Health Record System ◽  
Health Record ◽  
Record System ◽  
Antimicrobial Prescribing ◽  
Neonatal Icu ◽  
Electronic Health

SummaryObjective: To develop and implement a clinical decision support (CDS) tool to improve antibiotic prescribing in neonatal intensive care units (NICUs) and to evaluate user acceptance of the CDS tool.Methods: Following sociotechnical analysis of NICU prescribing processes, a CDS tool for empiric and targeted antimicrobial therapy for healthcare-associated infections (HAIs) was developed and incorporated into a commercial electronic health record (EHR) in two NICUs. User logs were reviewed and NICU prescribers were surveyed for their perceptions of the CDS tool.Results: The CDS tool aggregated selected laboratory results, including culture results, to make treatment recommendations for common clinical scenarios. From July 2010 to May 2012, 1,303 CDS activations for 452 patients occurred representing 22% of patients prescribed antibiotics during this period. While NICU clinicians viewed two culture results per tool activation, prescribing recommendations were viewed during only 15% of activations. Most (63%) survey respondents were aware of the CDS tool, but fewer (37%) used it during their most recent NICU rotation. Respondents considered the most useful features to be summarized culture results (43%) and antibiotic recommendations (48%).Discussion: During the study period, the CDS tool functionality was hindered by EHR upgrades, implementation of a new laboratory information system, and changes to antimicrobial testing methodologies. Loss of functionality may have reduced viewing antibiotic recommendations. In contrast, viewing culture results was frequently performed, likely because this feature was perceived as useful and functionality was preserved.Conclusion: To improve CDS tool visibility and usefulness, we recommend early user and information technology team involvement which would facilitate use and mitigate implementation challenges.Citation: Hum RS, Cato K, Sheehan B, Patel S, Duchon J, DeLaMora P, Ferng YH, Graham P, Vawdrey DK, Perlman J, Larson E, Saiman L. Developing clinical decision support within a commercial electronic health record system to improve antimicrobial prescribing in the neonatal ICU. Appl Clin Inf 2014; 5: 368–387 http://dx.doi.org/10.4338/ACI-2013-09-RA-0069

scholarly journals Integrating pharmacogenetic information and clinical decision support into the electronic health record

2014 ◽  
Vol 21 (3) ◽  
pp. 522-528 ◽  
Author(s):  
Barry R Goldspiel ◽  
Willy A Flegel ◽  
Gary DiPatrizio ◽  
Tristan Sissung ◽  
Sharon D Adams ◽  
...  
Keyword(s):  
Decision Support ◽  
Electronic Health Record ◽  
Clinical Decision Support ◽  
Clinical Decision ◽  
Health Record ◽  
Electronic Health

scholarly journals Clinical decision support alert malfunctions: analysis and empirically derived taxonomy

2017 ◽  
Vol 25 (5) ◽  
pp. 496-506 ◽  
Author(s):  
Adam Wright ◽  
Angela Ai ◽  
Joan Ash ◽  
Jane F Wiesen ◽  
Thu-Trang T Hickman ◽  
...  
Keyword(s):  
Decision Support ◽  
Electronic Health Record ◽  
Medical Informatics ◽  
Clinical Decision Support ◽  
Quantitative Methods ◽  
Clinical Decision ◽  
The United States ◽  
Health Record ◽  
Qualitative And Quantitative Methods ◽  
Electronic Health

Abstract Objective To develop an empirically derived taxonomy of clinical decision support (CDS) alert malfunctions. Materials and Methods We identified CDS alert malfunctions using a mix of qualitative and quantitative methods: (1) site visits with interviews of chief medical informatics officers, CDS developers, clinical leaders, and CDS end users; (2) surveys of chief medical informatics officers; (3) analysis of CDS firing rates; and (4) analysis of CDS overrides. We used a multi-round, manual, iterative card sort to develop a multi-axial, empirically derived taxonomy of CDS malfunctions. Results We analyzed 68 CDS alert malfunction cases from 14 sites across the United States with diverse electronic health record systems. Four primary axes emerged: the cause of the malfunction, its mode of discovery, when it began, and how it affected rule firing. Build errors, conceptualization errors, and the introduction of new concepts or terms were the most frequent causes. User reports were the predominant mode of discovery. Many malfunctions within our database caused rules to fire for patients for whom they should not have (false positives), but the reverse (false negatives) was also common. Discussion Across organizations and electronic health record systems, similar malfunction patterns recurred. Challenges included updates to code sets and values, software issues at the time of system upgrades, difficulties with migration of CDS content between computing environments, and the challenge of correctly conceptualizing and building CDS. Conclusion CDS alert malfunctions are frequent. The empirically derived taxonomy formalizes the common recurring issues that cause these malfunctions, helping CDS developers anticipate and prevent CDS malfunctions before they occur or detect and resolve them expediently.

Implementation and evaluation of Stanford Health Care store-and-forward teledermatology consultation workflow built within an existing electronic health record system

2018 ◽  
Vol 26 (3) ◽  
pp. 125-131 ◽  
Author(s):  
Grace E Kim ◽  
Olga K Afanasiev ◽  
Chris O’Dell ◽  
Christopher Sharp ◽  
Justin M Ko
Keyword(s):  
Health Care ◽  
Electronic Health Record ◽  
Primary Care Physicians ◽  
Health Record ◽  
Record System ◽  
Privacy Concerns ◽  
Successful Model ◽  
Dermatology Clinic ◽  
Electronic Health ◽  
Store And Forward

Introduction Teledermatology services that function separately from patients’ primary electronic health record (EHR) can lead to fragmented care, poor provider communication, privacy concerns and billing challenges. This study addresses these challenges by developing PhotoCareMD, a store-and-forward (SAF) teledermatology consultation workflow built entirely within an existing Epic-based EHR. Methods Thirty-six primary care physicians (PCPs) from eight outpatient clinics submitted 215 electronic consults (eConsults) for 211 patients to a Stanford Health Care dermatologist via PhotoCareMD. Comparisons were made with in-person referrals for this same dermatologist prior to initiation of PhotoCareMD. Results Compared to traditional in-person dermatology clinic visits, eConsults decreased the time to diagnosis and treatment from 23 days to 16 hours. The majority (73%) of eConsults were resolved electronically. In-person referrals from PhotoCareMD (27%) had a 50% lower cancellation rate compared with traditional referrals (11% versus 22%). The average in-person visit and documentation was 25 minutes compared with 8 minutes for an eConsult. PhotoCareMD saved 13 additional clinic hours to be made available to the dermatologist over the course of the pilot. At four patients per hour, this opens 52 dermatology clinic slots. Over 96% of patients had a favourable experience and 95% felt this service saved them time. Among PCPs, 100% would recommend PhotoCareMD to their colleagues and 95% said PhotoCareMD was a helpful educational tool. Discussion An internal SAF teledermatology workflow can be effectively implemented to increase access to and quality of dermatologic care. Our workflow can serve as a successful model for other hospitals and specialties.

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