Eugenia L. Siegler

Physicians' Attitudes Towards Copy and Pasting in Electronic Note Writing

BACKGROUNDThe ability to copy and paste text within computerized physician documentation facilitates electronic note writing, but may affect the quality of physician notes and patient care. Little is known about physicians’ collective experience with the copy and paste function (CPF).OBJECTIVESTo determine physicians’ CPF use, perceptions of its impact on notes and patient care, and opinions regarding its future use.DESIGNCross-sectional survey.PARTICIPANTSResident and faculty physicians within two affiliated academic medical centers currently using a computerized documentation system.MEASUREMENTSResponses on a self-administered survey.RESULTSA total of 315 (70%) of 451 eligible physicians responded to the survey. Of the 253 (80%) physicians who wrote inpatient notes electronically, 226 (90%) used CPF, and 177 (70%) used it almost always or most of the time when writing daily progress notes. While noting that inconsistencies (71%) and outdated information (71%) were more common in notes containing copy and pasted text, few physicians felt that CPF had a negative impact on patient documentation (19%) or led to mistakes in patient care (24%). The majority of physicians (80%) wanted to continue to use CPF.CONCLUSIONSAlthough recognizing deficits in notes written using CPF, the majority of physicians used CPF to write notes and did not perceive an overall negative impact on physician documentation or patient care. Further studies of the effects of electronic note writing on the quality and safety of patient care are required.

Treatment of urinary incontinence with anticholinergics in patients taking cholinesterase inhibitors for dementia

Clinicians often encounter patients with dementia and urge incontinence who might benefit from both an anticholinergic medication and a cholinesterase inhibitor. At first glance, this combination would seem to violate basic principles of geriatric pharmacology, as the drugs appear to be working at cross‐purposes and anticholinergic medications are notorious for worsening cognitive function in susceptible patients. A case is presented and discussed in which this combination was clinically effective and pharmacologically sound.

Provider-to-provider electronic communication in the era of meaningful use: a review of the evidence.

BACKGROUND Electronic communication between providers occurs daily in clinical practice but has not been well studied. PURPOSE To assess the impact of provider-to-provider electronic communication tools on communication and healthcare outcomes through literature review. DATA SOURCES Ovid MEDLINE, PubMed, Google Scholar, Cumulative Index to Nursing and Allied Health Literature, and Academic Search Premier. STUDY SELECTION Publication in English-language peer-reviewed journals. Studies provided quantitative provider-to-provider communication data, provider satisfaction statistics, or electronic health record (EHR) communication data. DATA EXTRACTION Literature review. DATA SYNTHESIS Two reviewers conducted the title review to determine eligible studies from initial search results. Three reviewers independently reviewed titles, abstracts, and full text (where appropriate) against inclusion and exclusion criteria. LIMITATIONS Small number of eligible studies; few described trial design (20%). Homogeneous provider type (physicians). English-only studies. CONCLUSIONS Of 25 included studies, all focused on physicians; most were observational (68%). Most (60%) described electronic specialist referral tools. Although overall use has been measured, there were no studies of the effectiveness of intra-EHR messaging. Literature describing the effectiveness of provider-to-provider electronic communications is sparse and narrow in scope. Complex care, such as that envisioned for the Patient Centered Medical Home, necessitates further research.

MODELS OF GERIATRICS PRACTICE

BACKGROUND AND OBJECTIVES: Frail older adults are especially vulnerable in a health system that is fragmented and fails to focus on preservation or restoration of function. The School of Nursing at the University of Pennsylvania, together with the School of Medicine and the Hospital of the University of Pennsylvania, established the Collaborative Assessment and Rehabilitation for Elders (CARE) Program to meet the needs of this population. We used the British Day Hospital as a model because it provides a comprehensive approach to care and a bridge between acute, home‐based, and institutional long‐term care. We have designed our program to provide innovative, interdisciplinary care as well as to be reimbursable under current and future payment structures. This nurse‐managed, collaborative practice seeks to maximize independent functioning, promote health, and enhance quality of life for chronically ill, frail older adults living in the community whose needs are left unmet by existing services. The program was certified as a Comprehensive Outpatient Rehabilitation Facility (CORF) in December 1993 to maximize reimbursement of services through Medicare and other third party payers. With a Gerontological Nurse Practitioner as care manager, clients receive an intensive, individualized, time‐limited program of nursing, rehabilitation, mental health, social, and medical services in one setting several days each week. Additional geriatric services, such as primary care, are available in the same location when needed.

The Medical Interview: Differences Between Adult and Geriatric Outpatients

BACKGROUND: There is a perception that primary care physicians spend less time with older patients and little is known about physician and older patient satisfaction during clinical encounters.

Acute Pain Management in Hospitalized Patients with Cognitive Impairment: A Study of Provider Practices and Treatment Outcomes

BACKGROUND Despite new guidelines and nationally mandated regular assessments, managing pain in cognitively impaired patients remains a complex and challenging task. Numerous studies have focused on assessing pain in this population; however, studies of treatment are limited. PURPOSE The purpose of this article was to characterize assessment and pain management strategies used by providers caring for hospitalized cognitively impaired patients with acute pain, and to assess for associations between amount of opioid received and specific adverse outcomes in this patient population. METHODS Medical records of patients admitted to the Geriatrics Service or Orthopedic Service or evaluated by the Geriatrics Consult Service at an urban tertiary care hospital between September 01, 2006 and September 30, 2007 with cognitive impairment and an acute pain problem on admission were reviewed. RESULTS Participants (N=100) had a mean age of 86 years (range=68-99), and were mostly female (83%) with fracture-related pain (62%). A numeric pain score was recorded in 67% of nursing assessments vs <5% of physician assessments. Opioids were prescribed for 100% of the surgical patients vs 43% of the medical patients. Only 15% of patients were placed on a standing analgesic regimen. Nonpharmacological management was employed for 75% of surgical patients vs 43% of medical patients. Delirium occurred in 27% of patients, and 33% experienced an interruption of physical therapy. Neither, however, was associated with level of opioid use. CONCLUSIONS Current assessment and treatment practices in acute pain management for cognitively impaired patients vary widely (to include service and provider type). Implementation of evidence-based guidelines is needed to improve patient care.

Improving Communication at the Transition to Home Health Care: Use of an Electronic Referral System

Appropriate and efficient provision of services at home requires more than skilled personnel; effective communication between the primary care provider and the agency is an often overlooked but essential tool for maintaining the patients health in the community. A method was developed to create home care orders (the “e-485”) that guides the physician through the order writing process, uploads data from the electronic medical record, and creates a legible, complete order set that can be faxed quickly to the agency. This paper describes this tool and the challenges and rewards of its implementation in an academic medical center.

From One Syndrome to Many: Incorporating Geriatric Consultation Into HIV Care

Antiretroviral therapy has enabled people to live long lives with human immunodeficiency virus (HIV). As a result, most HIV-infected adults in the United States are >50 years of age. In light of this changing epidemiology, HIV providers must recognize and manage multiple comorbidities and aging-related syndromes. Geriatric principles can help meet this new challenge, as preservation of function and optimization of social and psychological health are relevant to the care of aging HIV-infected adults, even those who are not yet old. Nonetheless, the field is still in its infancy. Although other subspecialties have started to explore the role of geriatricians, little is known about their role in HIV care, and few clinics have incorporated geriatricians. This article introduces basic geriatric nomenclature and principles, examines several geriatric consultation models from other subspecialties, and describes our HIV and Aging clinical program to encourage investigation of best practices for the care of this population.

Adapting Systems of Care for People Aging With HIV

People aging with HIV have medical and psychosocial needs that require more than the HIV services network can provide. HIV providers may lack experience managing multimorbidity or the functional consequences of aging. Social support services may be unable to provide necessary services for people living with HIV (PLWH) who are becoming increasingly frail or facing cognitive impairment. HIV providers will be caring for aging PLWH whose HIV management may seem simple compared with the significant burdens of stigma, mental health needs, social isolation, multimorbidity, and aging-related syndromes. Although practices can incorporate geriatric expertise and develop facility with the aging services network, a more comprehensive integration would adapt existing geriatric long-term care models for those aging with HIV. The diversity of aging PLWH and the tenuousness of the health safety net will necessitate innovative and flexible collaboration between content experts and social service agencies.

Improving the Transition to Home Healthcare by Rethinking the Purpose and Structure of the CMS 485: First Steps

ABSTRACT Transition points are the weak links in communication between providers. As an example, the discharge home often is a hurried “handoff” from inpatient physician to home care agency, whose visiting nurse admits the patient for a period of observation, medication management, rehabilitation, and teaching. The primary means of communication between physician and home health agency is the CMS 485, a form that contains the orders and that physicians frequently sign well after patients begin receiving services. This paper describes the first phase of a project that restructured and automated the CMS 485 using an existing electronic health record. The principles guiding the restructuring are described along with early reaction to and revision of the form to address operational issues. The paper also discusses evaluation plans and a web-based system of communication that will be developed in the second phase of the project.