Jonathan S. Einbinder

Using Regular Expressions to Abstract Blood Pressure and Treatment Intensification Information from the Text of Physician Notes

This case study examined the utility of regular expressions to identify clinical data relevant to the epidemiology of treatment of hypertension. We designed a software tool that employed regular expressions to identify and extract instances of documented blood pressure values and anti-hypertensive treatment intensification from the text of physician notes. We determined sensitivity, specificity and precision of identification of blood pressure values and anti-hypertensive treatment intensification using a gold standard of manual abstraction of 600 notes by two independent reviewers. The software processed 370 Mb of text per hour, and identified elevated blood pressure documented in free text physician notes with sensitivity and specificity of 98%, and precision of 93.2%. Anti-hypertensive treatment intensification was identified with sensitivity 83.8%, specificity of 95.0%, and precision of 85.9%. Regular expressions can be an effective method for focused information extraction tasks related to high-priority disease areas such as hypertension.

Effect of Board Certification on Antihypertensive Treatment Intensification in Patients With Diabetes Mellitus

Background— Regular recertification is mandatory to maintain board certification status in all specialties. However, the evidence that physicians’ performance decreases with time since initial certification is limited. We therefore carried out a study to determine whether the frequency of antihypertensive treatment intensification for diabetic patients changes with time since their physicians’ last board certification. Methods and Results— In this retrospective cohort study, we analyzed treatment of 8127 hypertensive patients with diabetes mellitus treated by 301 internists at primary care practices affiliated with 2 large academic hospitals. Patient visits with documented blood pressure ≥130/85 mm Hg between January 1, 2000, and August 31, 2005, were studied. The association between the number of years since the physician’s last board certification and the probability of pharmacological antihypertensive treatment intensification at a given visit was analyzed. Frequency of treatment intensification decreased from 26.7% for physicians who were board certified the previous year to 6.9% for physicians who were board certified 31 years before the visit. Treatment intensification rate was 22.5% for physicians certified ≤10 years ago versus 16.9% for physicians last certified >10 years ago (P<0.0001). Multivariable analysis adjusted for patient and visit characteristics and physician age showed that for every decade since the physician’s last board certification, the probability of treatment intensification decreased by 21.3% (P=0.0097). Conclusion— Physician intensification of pharmacological therapy for blood pressure levels above the recommended treatment goals decreases with time since the last board certification. This finding supports the current policy of mandatory recertification.

Evaluation of a data warehouse in an academic health sciences center.

OBJECTIVES The Clinical data repository (CDR) at the University of Virginia Health System is a data warehouse that provides direct access to data for clinical research and effective decision making. We undertook an evaluation of the CDR to understand factors affecting its adoption. DESIGN We used a theoretical framework that is based on diffusion of innovation theory. Building on validated survey instruments, we developed a questionnaire and conducted interviews of key executive leaders. Fifty-three individuals with logon ids to the CDR completed our questionnaire. Twelve executive leaders were interviewed. MEASUREMENTS The outcome variables were the initial and continued use of the CDR. Independent variables included attributes suggested by diffusion theory (i.e. relative advantage, complexity), knowledge and skills expected to correlate with computer usage, and the influence of communication channels. RESULTS Our overall response rate was 82%. We identified characteristics of users associated with the initial decision to use the CDR. Compatibility with an individuals skills and work style was associated strongly with satisfaction and continued use. Secondly, the importance of organizational culture and the need for data was illuminated by management interviews. CONCLUSIONS We have shown that diffusion of innovation theory can be used to help understand factors contributing to the success of a data warehouse in a healthcare setting. Our results suggest areas for future research and inquiry as the CDR evolves.

An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies

Many e-prescribing systems allow for both structured and free-text fields in prescriptions, making possible internal discrepancies. This study reviewed 2914 electronic prescriptions that contained free-text fields. Internal discrepancies were found in 16.1% of the prescriptions. Most (83.8%) of the discrepancies could potentially lead to adverse events and many (16.8%) to severe adverse events, involving a hospital admission or death. Discrepancies in doses, routes or complex regimens were most likely to have a potential for a severe event (p=0.0001). Discrepancies between structured and free-text fields in electronic prescriptions are common and can cause patient harm. Improvements in electronic medical record design are necessary to minimize the risk of discrepancies and resulting adverse events.

Encounter Frequency and Blood Pressure in Hypertensive Patients With Diabetes Mellitus

The relationship between encounter frequency (average number of provider-patient encounters over a period of time) and blood pressure for hypertensive patients is unknown. We tested the hypothesis that shorter encounter intervals are associated with faster blood pressure normalization. We performed a retrospective cohort study of 5042 hypertensive patients with diabetes mellitus treated at primary care practices affiliated with 2 academic hospitals between 2000 and 2005. Distinct periods of continuously elevated blood pressure (≥130/85 mm Hg) were studied. We evaluated the association of the average encounter interval with time to blood pressure normalization and rate of blood pressure decrease. Blood pressure of the patients with the average interval between encounters ≤1 month normalized after a median of 1.5 months at the rate of 28.7 mm Hg/month compared with 12.2 months at 2.6 mm Hg/month for the encounter interval >1 month (P<0.0001 for all). Median time to blood pressure normalization was 0.7 versus 1.9 months for the average encounter interval ≤2 weeks versus between 2 weeks and 1 month, respectively (P<0.0001). In proportional hazards analysis adjusted for patient demographics, initial blood pressure, and treatment intensification rate, a 1 month increase in the average encounter interval was associated with a hazard ratio of 0.764 for blood pressure normalization (P<0.0001). Shorter encounter intervals are associated with faster decrease in blood pressure and earlier blood pressure normalization. Greatest benefits were observed at encounter intervals (≤2 weeks) shorter than what is currently recommended.

Copy/Paste Documentation of Lifestyle Counseling and Glycemic Control in Patients With Diabetes: True to Form?

Electronic medical records (EMRs) can improve many aspects of patient care(1). Utilization of electronic medical records is increasing and is particularly encouraged by recent federal legislation(2). However EMRs are not always used optimally. Concerns have been raised about inappropriate copying and pasting of information between provider notes(3, 4). Up to 50% of the content of progress notes may be copied from older documents(5, 6) and copying frequently leads to errors in documentation(6). However, whether copied text generally reflects the care delivered is not known. Lifestyle counseling improves outcomes in patients with diabetes and is recommended by treatment guidelines(7). Narrative provider notes are the primary source of information on whether lifestyle counseling was provided. However, if copying and pasting of note fragments does not reflect treatment, the information contained in narrative electronic documents may not be reliable. We therefore performed a retrospective study of over 5,000 patients with diabetes to determine the relationship between copied lifestyle counseling and glucose control.

Prevalence and factors affecting home blood pressure documentation in routine clinical care: a retrospective study

BackgroundHome blood pressure (BP) is closely linked to patient outcomes. However, the prevalence of its documentation has not been examined. The objective of this study was to analyze the prevalence and factors affecting documentation of home BP in routine clinical care.MethodsA retrospective study of 142,973 encounters of 9,840 hypertensive patients with diabetes from 2000 to 2005 was performed. The prevalence of recorded home BP and the factors associated with its documentation were analyzed. We assessed validity of home BP information by comparing the difference between home and office BP to previously published prospective studies.ResultsHome BP was documented in narrative notes for 2.08% of encounters where any blood pressure was recorded and negligibly in structured data (EMR flowsheets). Systolic and diastolic home BP in narrative notes were lower than office BP readings by 9.6 and 2.5 mm Hg, respectively (p < 0.0001 for both), consistent with prospective data. Probability of home BP documentation increased by 23.0% for each 10 mm Hg of office systolic BP (p < 0.0001), by 6.2% for each

“Smart Forms” in an Electronic Medical Record: Documentation-based Clinical Decision Support to Improve Disease Management

10,000 in median income of zip code (p = 0.0055), and by 17.7% for each decade in the patients age (p < 0.0001).ConclusionsHome BP readings provide a valid representation of the patients condition, yet are seldom documented despite their potential utility in both patient care and research. Strong association between higher patient income and home BP documentation suggests that the cost of the monitors may be a limiting factor; reimbursement of home BP monitoring expenses should be pursued.