Lisa P. Newmark

Impact of Barcode Medication Administration Technology on How Nurses Spend Their Time Providing Patient Care

Background: Many hospitals use barcode medication administration (BCMA) technology to improve inpatient medication safety. However, implementation of this technology requires significant changes in workflow for nurses, potentially interfering with the delivery of care to patients. Objective: The aim of this study was to evaluate the impact of BCMA on nursing workflow. Design: Time-motion study during direct observations before and after BCMA deployment was used. Setting: The study was conducted at medical, surgical, medical-surgical, and intensive care units in a 735-bed tertiary care hospital. Intervention: An internally developed BCMA solution that supports communication between the pharmacy and nursing, organizes workflow for nurses, verifies by barcode scanning every dose of medication and patient identification before medication administration, and documents medication administrations electronically was used. Outcome Measures: The primary outcome was the proportion of time that nurses spent on medication-administration-related activities. Secondary outcomes included the proportion of time spent providing direct patient care and engaging in inefficient activities. Results: We conducted a total of 232 two-hour observation sessions evenly split between pre-BCMA and post-BCMA units. The proportion of time nurses spent on medication administration activities remained unchanged (pre-BCMA: 26.9%, post-BCMA: 24.9%; P = .16). The proportion of time spent providing direct patient care increased (pre-BCMA: 26.1%, post-BCMA: 29.9%; P = .03). Time spent on inefficient activities fell from 10.8% to 7.3% (P < .0001). Conclusion: A well-designed BCMA system did not increase the amount of time that nurses spent on medication administration activities. Barcode medication administration technology likely streamlined activities for nurses, allowing them more time for other professional activities. Our results should help to allay concerns regarding the impact of BCMA on nursing workflow.

Usability of a novel clinician interface for genetic results

The complexity and rapid growth of genetic data demand investment in information technology to support effective use of this information. Creating infrastructure to communicate genetic information to healthcare providers and enable them to manage that data can positively affect a patients care in many ways. However, genetic data are complex and present many challenges. We report on the usability of a novel application designed to assist providers in receiving and managing a patients genetic profile, including ongoing updated interpretations of the genetic variants in those patients. Because these interpretations are constantly evolving, managing them represents a challenge. We conducted usability tests with potential users of this application and reported findings to the application development team, many of which were addressed in subsequent versions. Clinicians were excited about the value this tool provides in pushing out variant updates to providers and overall gave the application high usability ratings, but had some difficulty interpreting elements of the interface. Many issues identified required relatively little development effort to fix suggesting that consistently incorporating this type of analysis in the development process can be highly beneficial. For genetic decision support applications, our findings suggest the importance of designing a system that can deliver the most current knowledge and highlight the significance of new genetic information for clinical care. Our results demonstrate that using a development and design process that is user focused helped optimize the value of this application for personalized medicine.

A novel clinician interface to improve clinician access to up-to-date genetic results

OBJECTIVES To understand the impact of GeneInsight Clinic (GIC), a web-based tool designed to manage genetic information and facilitate communication of test results and variant updates from the laboratory to the clinics, we measured the use of GIC and the time it took for new genetic knowledge to be available to clinicians. METHODS Usage data were collected across four study sites for the GIC launch and post-GIC implementation time periods. The primary outcome measures were the time (average number of days) between variant change approval and notification of clinic staff, and the time between notification and viewing the patient record. RESULTS Post-GIC, time between a variant change approval and provider notification was shorter than at launch (average days at launch 503.8, compared to 4.1 days post-GIC). After e-mail alerts were sent at launch, providers clicked into the patient record associated with 91% of these alerts. In the post period, clinic providers clicked into the patient record associated with 95% of the alerts, on average 12 days after the e-mail was sent. DISCUSSION We found that GIC greatly increased the likelihood that a provider would receive updated variant information as well as reduced the time associated with distributing that variant information, thus providing a more efficient process for incorporating new genetic knowledge into clinical care. CONCLUSIONS Our study results demonstrate that health information technology systems have the potential effectively to assist providers in utilizing genetic information in patient care.

Actionable reminders did not improve performance over passive reminders for overdue tests in the primary care setting

Actionable reminders (electronic reminders linked to computerized order entry) might improve care by facilitating direct ordering of recommended tests. The authors implemented four enhanced actionable reminders targeting performance of annual mammography, one-time bone-density screening, and diabetic testing. There was no difference in rates of appropriate testing between the four intervention and four matched, control primary care clinics for screening mammography (OR 0.81, 95% CI 0.64 to 1.02), bone-density exams (OR 1.29, 95% CI 0.82 to 2.02), HbA1c monitoring (OR 0.91, 95% CI 0.58 to 1.42) and LDL cholesterol monitoring (OR 1.40, 95% CI 0.76 to 2.59). Of the survey respondents, 79% almost never used the system or were unaware of the functionality. In the 9/228 (3.9%) cases with indirect evidence of mammography reminder use, there was a significantly lower proportion with test performance. Our actionable reminders did not improve receipt of overdue testing, potentially due to limitations of workflow integration.

Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record

Failure to follow-up nonurgent, clinically significant test results (CSTRs) is an ambulatory patient safety concern. Tools within electronic health records (EHRs) may facilitate test result acknowledgment, but their utility with regard to nonurgent CSTRs is unclear. We measured use of an acknowledgment tool by 146 primary care physicians (PCPs) at 13 network-affiliated practices that use the same EHR. We then surveyed PCPs to assess use of, satisfaction with, and desired enhancements to the acknowledgment tool. The rate of acknowledgment of non-urgent CSTRs by PCPs was 78%. Of 73 survey respondents, 72 reported taking one or more actions after reviewing a CSTR; fewer (40-75%) reported that using the acknowledgment tool was helpful for a specific purpose. Forty-six (64%) were satisfied with the tool. Both satisfied and nonsatisfied PCPs reported that enhancements linking acknowledgment to routine actions would be useful. EHR vendors should consider enhancements to acknowledgment functionality to ensure follow-up of nonurgent CSTRs.

The Impact of Alternative Payment in Chronically Ill and Older Patients in the Patient-centered Medical Home

Background: Patient-centered medical home (PCMH) has gained prominence as a promising model to encourage improved primary care delivery. There is a paucity of studies that evaluate the impact of payment models in the PCMH. Objectives: We sought to examine whether coupling coordinated, team-based care transformation plan with a novel reimbursement model affects outcomes related to expenditures and utilization. Research Design: Interrupted time-series model with a difference-in-differences approach to assess differences between intervention and control groups, across time periods attributable to PCMH transformation and/or payment change. Results: Although results were modest and mixed overall, PCMH with payment reform is associated with a reduction of

Electronic Health Records in Specialty Care: A Time-Motion Study

1.04 (P=0.0347) per member per month (PMPM) in pharmacy expenditures. Patients with hypertension, hyperlipidemia, diabetes, and coronary atherosclerosis enrolled in PCMH without payment reform experienced reductions in emergency department visits of 2.16 (P<0.0001), 2.42 (P<0.0001), 3.98 (P<0.0001), and 3.61 (P<0.0001) per 1000 per month. Modest increases in inpatient admission were seen among these patients in PCMH either with or without payment reform. Patients 65 and older enrolled in PMCH without payment reform experienced reductions in pharmacy expenditures

Trends in Primary Care Clinician Perceptions of a New Electronic Health Record

2.35 (P=0.0077) PMPM with a parallel reduction in pharmacy standardized cost of

An effort to improve electronic health record medication list accuracy between visits: Patients’ and physicians’ response

2.81 (P=0.0174) PMPM indicative of a reduction in the intensity of drug utilization. Conclusions: We conclude that PCMH implementation coupled with an innovative payment arrangement generated mixed results with modest improvements with respect to pharmacy expenditures, but no overall financial improvement. However, we did see improvement within specific groups, especially older patients and those with chronic conditions.