Heather L. Heiman

Electronically Screening Discharge Summaries for Adverse Medical Events

Objective: Detecting adverse events is pivotal for measuring and improving medical safety, yet current techniques discourage routine screening. The authors hypothesized that discharge summaries would include information on adverse events, and they developed and evaluated an electronic method for screening medical discharge summaries for adverse events. Design: A cohort study including 424 randomly selected admissions to the medical services of an academic medical center was conducted between January and July 2000. The authors developed a computerized screening tool that searched free-text discharge summaries for trigger words representing possible adverse events. Measurements: All discharge summaries with a trigger word present underwent chart review by two independent physician reviewers. The presence of adverse events was assessed using structured implicit judgment. A random sample of discharge summaries without trigger words also was reviewed. Results: Fifty-nine percent (251 of 424) of the discharge summaries contained trigger words. Based on discharge summary review, 44.8% (327 of 730) of the alerted trigger words indicated a possible adverse event. After medical record review, the tool detected 131 adverse events. The sensitivity and specificity of the screening tool were 69% and 48%, respectively. The positive predictive value of the tool was 52%. Conclusion: Medical discharge summaries contain information regarding adverse events. Electronic screening of discharge summaries for adverse events using keyword searches is feasible but thus far has poor specificity. Nonetheless, computerized clinical narrative screening methods could potentially offer researchers and quality managers a means to routinely detect adverse events.

Comparison of time spent writing orders on paper with computerized physician order entry.

Computerized physician order entry (CPOE) has been shown to improve quality, and to reduce resource utilization, but most available data suggest that it takes longer to enter orders using CPOE. We had previously implemented a CPOE system, and elected to evaluate its impact on physician time in the new setting. To do this, we performed a prospective study using random reminder methodology. Key findings were that interns spent 9.0% of their time ordering with CPOE, compared to 2.1% before, although CPOE saved them an additional 2% of time, so that the net difference was 5% of their total time. However, this is counterbalanced by decreased time for other personnel such as nursing and pharmacy, and by the quality and efficiency changes. We conclude that while CPOE has many benefits, it represents a major process change, and organizations must factor this in when they implement it.

E-learning and deliberate practice for oral case presentation skills: A randomized trial

Background: Oral case presentations are critical for patient care and student assessment. The best method to prepare early medical students for oral presentations is unknown. Aim: We aimed to develop and evaluate a curriculum of on-line learning and deliberate practice to improve pre-clinical students’ case presentation skills. Methods: We developed a web-based, interactive curriculum emphasizing conciseness and clinical reasoning. Using a waitlist control design, we randomly assigned groups of second-year students to receive the curriculum in December 2010 or in April 2011. We evaluated their presentations at three time points. We also examined the performance of an untrained class of students as a historical comparison. Results: We evaluated 132 second-year medical students at three time points. After the curriculum, mean scores of the intervention students improved from 60.2% to 70.1%, while scores of the waitlist control students improved less, from 61.8% to 64.5% (p < 0.01 for between-group difference in improvement). Once all students had received the curriculum, mean scores for the intervention and waitlist control students rose to 77.8% and 78.4%, respectively, compared to 68.1% for the untrained comparison students (p < 0.0001 compared to all curriculum students). Conclusion: An on-line curriculum followed by deliberate practice improved students’ oral presentation skills.

Medical students' observations, practices, and attitudes regarding electronic health record documentation.

Background: Medical students are increasingly documenting their patient notes in electronic health records (EHRs). Documentation short-cuts, such as copy–paste and templates, have raised concern among clinician-educators because they may perpetuate redundant, inaccurate, or even plagiarized notes. Little is known about medical students’ experiences with copy-paste, templates and other “efficiency tools” in EHRs. Purposes: We sought to understand medical students’ observations, practices, and attitudes regarding electronic documentation efficiency tools. Methods: We surveyed 3rd-year medical students at one medical school. We asked about efficiency tools including copy–paste, templates, auto-inserted data, and “scribing” (documentation under a supervisors name). Results: Overall, 123 of 163 students (75%) responded; almost all frequently use an EHR for documentation. Eighty-six percent (102/119) reported at least sometimes observing residents copying data from other providers’ notes and 60% (70/116) reported observing attending physicians doing so. Most students (95%, 113/119) reported copying from their own previous notes, and 22% (26/119) reported copying from residents. Only 10% (12/119) indicated that copying from other providers is acceptable, whereas 83% (98/118) believe copying from their own notes is acceptable. Most students use templates and auto-inserted data; 43% (51/120) reported documenting while signed in under an attendings name. Greater use of documentation efficiency tools is associated with plans to enter a procedural specialty and with lack of awareness of the medical school copy–paste policy. Conclusions: Students frequently use a range of efficiency tools to document in the electronic health record, most commonly copying their own notes. Although the vast majority of students believe it is unacceptable to copy–paste from other providers, most have observed clinical supervisors doing so.

Urine Drug Screens to Monitor Opioid Use for Managing Chronic Pain

A 53-year-old woman presented for a prescription refill of hydrocodone/acetaminophen 10 mg/325 mg. She had chronic low back pain and partial paralysis from a thoracic spinal cord infarction, secondary to aortic dissection from prior cocaine use. Taking 2 to 3 tablets of hydrocodone/acetaminophen daily improved her back pain from 5 to 2 on a 10-point scale. She reported no recent illicit substance or drug use and stated her last dose of hydrocodone was that day. The patient had not achieved pain control with prior nonopioid pharmacologic pain management, including duloxetine and gabapentin. Although past cocaine use was a risk factor for opioid misuse, a trial of hydrocodone was initiated, after discussion of risks and benefits, with a plan for careful monitoring. The state prescription drug monitoring program showed no other prescribers of controlled substances. A urine immunoassay drug screen was ordered to evaluate for medication misuse and illicit use (Table).

Interpretation of urine drug screens: Metabolites and impurities

A 50-year-old woman with chronic pain and recurrent infections from common variable immunodeficiency presented to a new primary care physician for management of her pain medications. Her pain was related to multiple vertebral fractures due to chronic steroid use for an inflammatory polyarthritis that was not responsive to hydroxychloriquine and methotrexate. Her pain medication regimen (methadone, 20 mg [3×/d]; immediaterelease morphine, 30 mg [5×/d]; gabapentin, 1200 mg [2×/d]; duloxetine, 60 mg/d; and celecoxib, 200 mg [2×/d]) helped her independently complete instrumental activities of daily living. She reported no adverse effects (eg, somnolence or constipation). A comprehensive urine drug screen using immunoassay and mass spectrometry was ordered (Table 1).

In reply to Gowda et al and to Yudkowsky.

Academic Medicine, Vol. 89, No. 6 / June 2014 835 While We Advocate for Integrated Electronic Medical Records, Continue to Empower Patients and Families To the Editor: Medical students everywhere sympathize with, and likely can unanimously relate to, Mr. Ehrmann’s account of his recent futile attempts to obtain a transfer patient’s medical records that were critical to ongoing treatment. Disjointed systems and unavailable archives regularly drive frustration and delay patient care. With each failed attempt to obtain records, the cycle of redundant diagnostic medicine repeats, as it is currently the only way to serve our patients in real time. I into an HTT exam. However, it is our impression that if the Core + Clusters curriculum is learned, there would be no need for students to perform the HTT in clinical settings. The Core + Clusters curriculum is designed to allow students to identify and perform maneuvers relevant to their particular patient, without the rote learning that the HTT perpetuates. We agree with Dr. Yudkowsky that determining which of these approaches to learning the PE is most effective is testable, and we look forward to further contributions to this area of research.