Lisa M. Schilling

Systematic Review of Health Information Exchange in Primary Care Practices

Background: Unprecedented federal interest and funding are focused on secure, standardized, electronic transfer of health information among health care organizations, termed health information exchange (HIE). The stated goals are improvements in health care quality, efficiency, and cost. Ambulatory primary care practices are essential to this process; however, the factors that motivate them to participate in HIE are not well studied, particularly among small practices. Methods: We conducted a systematic review of the literature about HIE participation from January 1990 through mid-September 2008 to identify peer-reviewed and non–peer-reviewed publications in bibliographic databases and websites. Reviewers abstracted each publication for predetermined key issues, including stakeholder participation in HIE, and the benefits, barriers, and overall value to primary care practices. We identified themes within each key issue, then grouped themes and identified supporting examples for analysis. Results: One hundred and sixteen peer-reviewed, non–peer-reviewed, and web publications were retrieved, and 61 met inclusion criteria. Of 39 peer-reviewed publications, one-half reported original research. Among themes of cost savings, workflow efficiency, and quality, the only benefits to be reliably documented were those regarding efficiency, including improved access to test results and other data from outside the practice and decreased staff time for handling referrals and claims processing. Barriers included cost, privacy and liability concerns, organizational characteristics, and technical barriers. A positive return on investment has not been documented. Conclusions: The potential for HIE to reduce costs and improve the quality of health care in ambulatory primary care practices is well recognized but needs further empiric substantiation.

Residents' patient-specific clinical questions: opportunities for evidence-based learning.

Purpose Resident physicians generate many patient-related questions in the outpatient setting, but rarely answer them. This study examined how answering a patient-specific clinical question affected residents’ patient care decisions. Method From October 2001 to June 2002, 43 internal medicine residents at the University of Colorado Health Sciences Center outpatient clinic formulated and attempted to answer specific clinical questions based on patients seen in the outpatient setting. Residents completed a questionnaire after finishing their clinical question exercise. Results Residents completed 158 exercises (68%) out of 234 opportunities and found answers to 89% of questions (141/158). Questions most commonly addressed therapy (43%), diagnosis (15%), disease management (13%), and prevention (9%). The most frequently used methods to retrieve clinical information were Medline® 73% (115/158) and UpToDate® 70% (110/158). UpToDate (45%, 71/158) and journal articles (42%, 66/158) were the most helpful final information sources. Residents rated the impact of the information on a five-point scale (1 = strongly disagree; 5 = strongly agree) for the following: can be used to assist patients care (mean 4.1), improved care (mean 4.0), improved communication (mean 4.3), improved confidence in care (mean 4.3), improved knowledge (mean 4.6), and will improve care for future patients (mean 4.4). The information affected clinical decision making in 78% (110/141) of cases. Conclusion Internal medicine residents practicing self-directed learning by answering patient-specific clinical questions reported improvement in knowledge and changes in patient care decisions.

Health information exchange in small-to-medium sized family medicine practices: Motivators, barriers, and potential facilitators of adoption

PURPOSEnFor small-to-medium sized primary care practices (those with 20 or fewer clinicians), determine desired functions of health information exchange (HIE) and potential motivators, barriers, and facilitators of adoption.nnnMETHODSnCase study approach with mixed quantitative and qualitative methods. Nine practices in Colorado were purposively selected. Five used paper records and four were already participating in health information exchange.nnnRESULTSnPractices particularly desired HIE functions to allow anywhere/anytime lookup of test results and to consolidate delivery of test results. HIE-generated quality reporting was the least desired function. Practices were motivated to adopt HIE to improve the quality and efficiency of care, although they did not anticipate financial gains from adoption. The greatest facilitator of HIE adoption would be technical assistance and support during and after implementation. Financial incentives were also valued. Trust in HIE partners was a major issue, and practices with rich professional and social networks appeared to be especially favorable settings for HIE adoption.nnnCONCLUSIONSnThese findings may assist policymakers in promoting adoption of HIE among small-to-medium sized primary care practices, a major component of the US healthcare system.

Alternative/Complementary Medicine: Wider Usage Than Generally Appreciated

OBJECTIVEnTo test the hypothesis that there is substantial use of a practitioner of alternative/complementary medicine by patients traditionally considered to be underserved.nnnDESIGNnCross-sectional, self-administered survey study.nnnSETTINGSnThree university hospital-affiliated general ambulatory clinics serving patients of different socioeconomic status and racial origin.nnnSUBJECTSnFive hundred and thirty-six (93% of those attending) consecutive clinic attendees.nnnOUTCOME MEASURESnPast use and desired future use of one or more practitioners of five modalities of alternative/complementary medicine and willingness to pay for these modalities out-of-pocket.nnnRESULTSnPast usage and desired future usage of one or more practitioners of alternative/complementary medicine was comparable at the three clinic sites despite wide differences in socioeconomic status and willingness/ability to pay out-of-pocket for these services. Multivariable analyses revealed lower self-rated health status and female gender (both p < 0.006) but not income, race, age or education as independent, significant predictors of use of a practitioner of alternative/complementary medicine.nnnCONCLUSIONnUsage of alternative/complementary medicine is not confined to any well-circumscribed socioeconomic group and is common in patients often considered to be underserved. Self-assessed lower health status is significantly and independently associated with use of a practitioner of alternative/complementary care.

Cochrane Skin Group systematic reviews are more methodologically rigorous than other systematic reviews in dermatology.

Summary Backgroundu2002 The Cochrane collaboration aims to produce high‐quality systematic reviews. It is not known whether the methods used in producing Cochrane Skin Group (CSG) reviews result in higher quality reviews than other systematic reviews in dermatology.

Characterizing treatment pathways at scale using the OHDSI network

Observational research promises to complement experimental research by providing large, diverse populations that would be infeasible for an experiment. Observational research can test its own clinical hypotheses, and observational studies also can contribute to the design of experiments and inform the generalizability of experimental research. Understanding the diversity of populations and the variance in care is one component. In this study, the Observational Health Data Sciences and Informatics (OHDSI) collaboration created an international data network with 11 data sources from four countries, including electronic health records and administrative claims data on 250 million patients. All data were mapped to common data standards, patient privacy was maintained by using a distributed model, and results were aggregated centrally. Treatment pathways were elucidated for type 2 diabetes mellitus, hypertension, and depression. The pathways revealed that the world is moving toward more consistent therapy over time across diseases and across locations, but significant heterogeneity remains among sources, pointing to challenges in generalizing clinical trial results. Diabetes favored a single first-line medication, metformin, to a much greater extent than hypertension or depression. About 10% of diabetes and depression patients and almost 25% of hypertension patients followed a treatment pathway that was unique within the cohort. Aside from factors such as sample size and underlying population (academic medical center versus general population), electronic health records data and administrative claims data revealed similar results. Large-scale international observational research is feasible.

Melanoma chemoprevention: a role for statins or fibrates?

Although numerous second-generation isoprenylation inhibitors are proposed or under investigation for the treatment and/or prevention of cancer (eg, R115777, SCH 66336, L-778,123, BMS-214662), the chemotherapeutic and chemopreventive potential of commonly prescribed first-generation isoprenylation inhibitors, the statins, and other classes of lipid-lowering medications, the fibrates, has yet to be seriously explored. Two lipid-lowering medications, lovastatin and gemfibrozil, have been associated with a decreased incidence of melanoma in large, prospective, randomized, double-blind, placebo-controlled clinical cardiology trials. This article reviews melanoma biology and the clinical evidence for the use of lipid-lowering medications for melanoma chemoprevention and/or adjuvant chemotherapy.

Data Model Considerations for Clinical Effectiveness Researchers

INTRODUCTIONnGrowing adoption of electronic health records and increased emphasis on the reuse and integration of clinical care and administration data require a robust informatics infrastructure to inform health care effectiveness in real-world settings. The Scalable Architecture for Federated Translational Inquiries Network (SAFTINet) was one of 3 projects receiving Agency for Healthcare Quality and Research funds to create a scalable, distributed network to support Comparative Effectiveness Research. SAFTINets method of extracting and compiling data from disparate entities requires the use of a shared common data model. DATA MODELS: Focusing on the needs of CER investigators, in addition to other project considerations, we examined the suitability of several data models. Data modeling is the process of determining which data elements will be stored and how they will be stored, including their relationships and constraints. Addressing compromises between complexity and usability is critical to modeling decisions.nnnCASE STUDYnThe SAFTINet project provides the case study for describing data model evaluation. A sample use case defines a cohort of asthma subjects that illustrates the need to identify patients by age, diagnoses, and medication use while excluding those with diagnoses that may often be misdiagnosed as asthma.nnnDISCUSSIONnThe SAFTINet team explored several data models against a set of technical and investigator requirements to select a data model that best fit its needs and was conducive to expansion with new research requirements. Although SAFTINet ultimately chose the Observation Medical Outcomes Partnership common data model, other valid options exist and prioritization of requirements is dependent upon many factors.

Transparent Reporting of Data Quality in Distributed Data Networks

Introduction: Poor data quality can be a serious threat to the validity and generalizability of clinical research findings. The growing availability of electronic administrative and clinical data is accompanied by a growing concern about the quality of these data for observational research and other analytic purposes. Currently, there are no widely accepted guidelines for reporting quality results that would enable investigators and consumers to independently determine if a data source is fit for use to support analytic inferences and reliable evidence generation. Model and Methods: We developed a conceptual model that captures the flow of data from data originator across successive data stewards and finally to the data consumer. This “data lifecycle” model illustrates how data quality issues can result in data being returned back to previous data custodians. We highlight the potential risks of poor data quality on clinical practice and research results. Because of the need to ensure transparent reporting of a data quality issues, we created a unifying data-quality reporting framework and a complementary set of 20 data-quality reporting recommendations for studies that use observational clinical and administrative data for secondary data analysis. We obtained stakeholder input on the perceived value of each recommendation by soliciting public comments via two face-to-face meetings of informatics and comparative-effectiveness investigators, through multiple public webinars targeted to the health services research community, and with an open access online wiki. Recommendations: Our recommendations propose reporting on both general and analysis-specific data quality features. The goals of these recommendations are to improve the reporting of data quality measures for studies that use observational clinical and administrative data, to ensure transparency and consistency in computing data quality measures, and to facilitate best practices and trust in the new clinical discoveries based on secondary use of observational data.

Outpatient case presentations in the conference room versus examination room: results from two randomized controlled trials

PURPOSEnAmbulatory case presentations occur typically in conference rooms, and attending physicians often have little contact with patients. The purpose of this study was to examine the effects of two different ambulatory case presentation formats that involve attending physicians more directly.nnnSUBJECTS AND METHODSnWe conducted two randomized controlled trials in a community-based ambulatory internal medicine clinic. Participants comprised 393 adult patients, 40 house officers, and 14 attending physicians. In the first trial, patient encounters were assigned randomly to either exclusive house officer-attending physician conference room discussion or to house officer-attending physician conference room discussion plus attending physician-patient interaction. In the second trial, patient encounters were assigned randomly to either exclusive house officer-attending physician conference room discussion or to exclusive house officer-attending physician discussion in the examining room with the patient present. Patient satisfaction; attending physician contributions to teaching, diagnosis, and therapy; and house officer comfort and autonomy were assessed.nnnRESULTSnPatient visit satisfaction and house officer assessment of attending physician teaching, diagnosis, and therapy were similar in the control and intervention groups of both trials. Patients involved in examination room discussions thought they were more comfortable with the discussion (mean +/- SD, 4.3 +/- 0.9 vs. 3.4 +/- 0.9 on a one- to five-point Likert scale, P <0.001) and more often indicated a preference to listen to the discussion in the future than did the control group (86% [71/83] vs. 63% [52/83], P <0.001). Some house officers (11% [9/83]) but no attending physicians (0/83, P <0.001) were made uncomfortable by examination room presentations, and some house officers (11% [9/83]) thought that examination room presentations diminished their autonomy.nnnCONCLUSIONSnPatients perceive that ambulatory examination room presentations are beneficial, whereas some house officers perceive that examination room presentations are associated with discomfort and diminished autonomy.