Daniel Z. Sands

Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption

Recently there has been a remarkable upsurge in activity surrounding the adoption of personal health record (PHR) systems for patients and consumers. The biomedical literature does not yet adequately describe the potential capabilities and utility of PHR systems. In addition, the lack of a proven business case for widespread deployment hinders PHR adoption. In a 2005 working symposium, the American Medical Informatics Associations College of Medical Informatics discussed the issues surrounding personal health record systems and developed recommendations for PHR-promoting activities. Personal health record systems are more than just static repositories for patient data; they combine data, knowledge, and software tools, which help patients to become active participants in their own care. When PHRs are integrated with electronic health record systems, they provide greater benefits than would stand-alone systems for consumers. This paper summarizes the College Symposium discussions on PHR systems and provides definitions, system characteristics, technical architectures, benefits, barriers to adoption, and strategies for increasing adoption.

Guidelines for the Clinical Use of Electronic Mail with Patients

Guidelines regarding patient - provider electronic mail are presented. The intent is to provide guidance concerning computer-based communications between clinicians and patients within a contractual relationship in which the health-care provider has taken on an explicit measure of responsibility for the clients care. The guidelines address two interrelated aspects: effective interaction between the clinician and patient, and observance of medicolegal prudence. Recommendations for site-specific policy formulation are included. n JAMIA. 1998;5:104 - 111.

Overrides of Medication Alerts in Ambulatory Care

BACKGROUND Electronic prescribing systems with decision support may improve patient safety in ambulatory care by offering drug allergy and drug interaction alerts. However, preliminary studies show that clinicians override most of these alerts. METHODS We performed a retrospective analysis of 233 537 medication safety alerts generated by 2872 clinicians in Massachusetts, New Jersey, and Pennsylvania who used a common electronic prescribing system from January 1, 2006, through September 30, 2006. We used multivariate techniques to examine factors associated with alert acceptance. RESULTS A total of 6.6% of electronic prescription attempts generated alerts. Clinicians accepted 9.2% of drug interaction alerts and 23.0% of allergy alerts. High-severity interactions accounted for most alerts (61.6%); clinicians accepted high-severity alerts slightly more often than moderate- or low-severity interaction alerts (10.4%, 7.3%, and 7.1%, respectively; P < .001). Clinicians accepted 2.2% to 43.1% of high-severity interaction alerts, depending on the classes of interacting medications. In multivariable analyses, we found no difference in alert acceptance among clinicians of different specialties (P = .16). Clinicians were less likely to accept a drug interaction alert if the patient had previously received the alerted medication (odds ratio, 0.03; 95% confidence interval, 0.03-0.03). CONCLUSION Clinicians override most medication alerts, suggesting that current medication safety alerts may be inadequate to protect patient safety.

What Can Hospitalized Patients Tell Us About Adverse Events? Learning from Patient-Reported Incidents

PURPOSE: Little is known about how well hospitalized patients can identify errors or injuries in their care. Accordingly, the purpose of this study was to elicit incident reports from hospital inpatients in order to identify and characterize adverse events and near-miss errors.SUBJECTS: We conducted a prospective cohort study of 228 adult inpatients on a medicine unit of a Boston teaching hospital.METHODS: Investigators reviewed medical records and interviewed patients during the hospitalization and by telephone 10 days after discharge about “problems,” “mistakes,” and “injuries” that occurred. Physician investigators classified patients’ reports. We calculated event rates and used multivariable Poisson regression models to examine the factors associated with patient-reported events.RESULTS: Of 264 eligible patients, 228 (86%) agreed to participate and completed 528 interviews. Seventeen patients (8%) experienced 20 adverse events; 1 was serious. Eight patients (4%) experienced 13 near misses; 5 were serious or life threatening. Eleven (55%) of 20 adverse events and 4 (31%) of 13 near misses were documented in the medical record, but none were found in the hospital incident reporting system. Patients with 3 or more drug allergies were more likely to report errors compared with patients without drug allergies (incidence rate ratio 4.7, 95% CI 1.7, 13.4).CONCLUSIONS: Inpatients can identify adverse events affecting their care. Many patient-identified events are not captured by the hospital incident reporting system or recorded in the medical record. Engaging hospitalized patients as partners in identifying medical errors and injuries is a potentially promising approach for enhancing patient safety.

Who Uses the Patient Internet Portal? The PatientSite Experience

OBJECTIVE Although the patient Internet portal is a potentially transformative technology, there is little scientific information about the demographic and clinical characteristics of portal enrollees and the features that they access. DESIGN We describe two pilot studies of a comprehensive Internet portal called PatientSite. These pilots include a prospective one-year cohort study of all patients who enrolled in April 2003 and a case-control study in 2004 of enrollees and nonenrollees at two hospital-based primary care practices. MEASUREMENTS The cohort study tracked patient enrollment and features in PatientSite that enrollees accessed, such as laboratory and radiology results, prescription renewals, appointment requests, managed care referrals, and clinical messaging. The case-control study used medical record review to compare the demographic and clinical characteristics of 100 randomly selected PatientSite enrollees and 100 nonenrollees. RESULTS PatientSite use grew steadily after its introduction. New enrollees logged in most frequently in the first month, but 26% to 77% of the cohort continued to access the portal at least monthly. They most often examined laboratory and radiology results and sent clinical messages to their providers. PatientSite enrollees were younger and more affluent and had fewer medical problems than nonenrollees. CONCLUSION Expanding the use of patient portals will require an understanding of obstacles that prevent access for those who might benefit most from this technology.

Guidelines for management of HIV infection with computer-based patient's record

Computers are steadily being incorporated in clinical practice. We conducted a nonrandomised, controlled, prospective trial of electronic messages designed to enhance adherence to clinical practice guidelines. We studied 126 physicians and nurse practitioners who used electronic medical records when caring for 349 patients with HIV infection in a primary care practice. We analysed the response times of clinicians to the situations that triggered alerts and reminders, the number of ambulatory visits, and hospitalisation. The median response times to 303 alerts in the intervention group and 388 alerts in the control group were 11 and 52 days (p < 0.0001), respectively. The median response time to 432 reminders in the intervention group was 114 days and that for 360 reminders in the control group was over 500 days (p < 0.0001). There was no effect on visits to the primary care practice. There was, however, a significant increase in the rate of visits outside the primary care practice (p = 0.02), which is explained by the increased frequency of visits to ophthalmologists. There were no differences in admission rates (p = 0.47), in admissions for pneumocystosis (p = 0.09), in visits to the emergency ward (p = 0.24), or in survival (p = 0.19). We conclude that the electronic medical record was effective in helping clinicians adhere to practice guidelines.

Quantifying the economic impact of communication inefficiencies in U.S. hospitals.

EXECUTIVE SUMMARY Care delivery is a complex enterprise that involves multiple interactions among multiple stakeholders. Effective communication between these dispersed parties is critical to ensuring quality and safety and improves operational efficiencies. Time and motion studies in hospital settings provide strong evidence that care providers—doctors and nurses—spend a significant proportion of their time obtaining or providing information (i.e., communicating). Yet, surprisingly, no studies attempt to quantify the economic waste associated with communication inefficiencies in hospital settings at a national level. Our research focuses on developing models for quantifying the economic burden on hospitals of poor communications. We developed a conceptual model of the effects of poor communications in hospitals that isolates four outcomes: (1) efficiency of resource utilization, (2) effectiveness of core operations, (3) quality of work life, and (4) service quality, identifying specific metrics for each outcome. We developed estimates of costs associated with wasted physician time, wasted nurse time, and increase in length of stay caused by communication inefficiencies across all U.S. hospitals, using primary data collected from interviews in seven hospitals and secondary data from a literature review, the Bureau of Labor Statistics (BLS), and the Agency for Healthcare Research and Quality (AHRQ). We find that U.S. hospitals waste over

PDA vs. laptop: a comparison of two versions of a nursing documentation application

12 billion annually as a result of communication inefficiency among care providers. Increase in length of stay accounts for 53 percent of the annual economic burden. A 500‐bed hospital loses over

PatientSite: Patient-Centered Communication, Services, and Access to Information

4 million annually as a result of communication inefficiencies. We note that our estimates are conservative as they do not include all dimensions of economic waste arising from poor communications. The economic burden of communication inefficiency in U.S. hospitals is substantial. Information technologies and process redesign may help alleviate some of this burden.

Help for Physicians Contemplating Use of E-mail with Patients

A great deal of nursing documentation involves data collection at the point of care. In most inpatient settings this activity is carried out by nurses using paper forms or simply by memorizing the information and documenting it later on the patients record. These methods for collecting data at point of care delay the update of the patient record and may result in loss of information. PDA (personal digital assistant) technology can help overcome these problems. Their small size and their wireless connection capability make them a viable alternative for collecting and entering patients data at the point of care. In this paper we describe a usability study in which we compared two versions (PDA and laptop) of a nursing documentation application in terms of the efficiency and satisfaction achieved by nurses while conducting typical tasks. The results of the study indicate that it take nurses significantly less time to look for vital signs measurements, acknowledge a pending medication order, enter I/O measurements and enter a daily assessment on a PDA than on a Laptop. However, it takes them significantly less time to read a paragraph, enter a set of vital sign measurements and write a note on a laptop than on a PDA. The results also indicate that with the exception of writing notes, the overall user satisfaction is very similar for the both systems.