Mitchell J. Feldman

A Content Analysis of E-mail Communication Between Primary Care Providers and Parents

Background. E-mail exchange between parents of patients and providers has been cited by the Institute of Medicine as an important aspect of contemporary medicine; however, we are unaware of any data describing actual exchanges. Objective. The purpose of this study was to evaluate the content of e-mails between providers and parents of patients in pediatric primary care, as well as parent attitudes about e-mail. Design/Methods. Over a 6-week period, all e-mail exchanges between 2 primary care pediatricians and their patients’ parents were evaluated and coded. An exchange was defined as the e-mails between parent and primary care provider about a single inquiry. Parents also completed a questionnaire regarding this service. Results. Of 55 parents, 54 (98%) agreed to have their e-mails with their pediatrician reviewed. The 54 parents generated 81 e-mail exchanges; 86% required only 1 e-mail response from the pediatrician, and the other 14% required an average of 1.9 responses. E-mail inquiries were all for nonacute issues (as judged by S.G.A.) and included inquiries about a medical question (n = 43), medical update (n = 20), subspecialty evaluation (n = 9), and administrative issue (n = 9). The 81 exchanges resulted in 9 appointments, 21 phone calls, 4 subspecialty referrals, 34 prescriptions or recommendations for over-the-counter medications, 11 administrative tasks, and 1 radiograph. Of 91 pediatrician-generated e-mails, 39% were sent during the workday (9 am to 5 pm, Monday to Friday), 44% were sent on weeknights, and 17% were sent on weekends. During the study period, the 2 physicians estimated an average of 30 minutes/day spent responding to e-mail. Of the 54 parents, 45 (83%) returned the survey; 93% were mothers and 86% had completed college. Ninety-eight percent were very satisfied with their e-mail experience with their pediatrician. Although 80% felt that all pediatricians should use e-mail to communicate with parents and 65% stated they would be more likely to choose a pediatrician based on access by e-mail, 63% were unwilling to pay for access. Conclusions. This is the first study to describe actual e-mail exchange between parents and their providers. Exchanges seem to be different from those generated by the telephone, with more e-mails related to medical versus administrative issues and more resulting in office visits. Approximately 1 in 4 exchanges result in multiple e-mails back and forth between parent and provider. Parents who have actually exchanged e-mails with their providers overwhelmingly endorse it, although they are reluctant to pay for it.

The introduction of a diagnostic decision support system (DXplain™) into the workflow of a teaching hospital service can decrease the cost of service for diagnostically challenging Diagnostic Related Groups (DRGs)

BACKGROUND In an era of short inpatient stays, residents may overlook relevant elements of the differential diagnosis as they try to evaluate and treat patients. However, if a residents first principal diagnosis is wrong, the patients appropriate evaluation and treatment may take longer, cost more, and lead to worse outcomes. A diagnostic decision support system may lead to the generation of a broader differential diagnosis that more often includes the correct diagnosis, permitting a shorter, more effective, and less costly hospital stay. METHODS We provided residents on General Medicine services access to DXplain, an established computer-based diagnostic decision support system, for 6 months. We compared charges and cost of service for diagnostically challenging cases seen during the fourth through sixth month of access to DXplain (intervention period) to control cases seen in the 6 months before the system was made available. RESULTS 564 cases were identified as diagnostically challenging by our criteria during the intervention period along with 1173 cases during the control period. Total charges were

Evaluation of the Clinical Assessment Project: A Computer-Based Multimedia Tool to Assess Problem-Solving Ability in Medical Students

1281 lower (p=.006), Medicare Part A charges

The automated metabolic profile

1032 lower (p=0.006) and cost of service

Presence of key findings in the medical record prior to a documented high-risk diagnosis

990 lower (p=0.001) per admission in the intervention cases than in control cases. CONCLUSIONS Using DXplain on all diagnostically challenging cases might save our medical center over

An approach to evaluating the accuracy of DXplain

2,000,000 a year on the General Medicine Services alone. Using clinical diagnostic decision support systems may improve quality and decrease cost substantially at teaching hospitals.

DXplain on the Internet.

OBJECTIVE. The purpose of this work was to describe Clinical Assessment, a computer-based multimedia patient simulation used to assess the problem-solving abilities of medical students and to evaluate its capacity to guide the assignment of course grade. METHODS. This was a multisite reviewer-blinded comparison of course grades, National Board of Medical Examiners pediatric examination score, and Clinical Assessment scores at 3 pediatric clerkship sites of the Harvard Medical School. Participants included 470 students completing their pediatric clerkships. Each students performance on ≤4 Clinical Assessment patient case simulations was compared with National Board of Medical Examiners pediatric examination scores and course grades assigned by clerkship directors based on overall ward performance. RESULTS. Data from both the National Board of Medical Examiners pediatric “shelf” examination and the course grade were available for 411 students who completed ≥1 Clinical Assessment case. There was a strong correlation between Clinical Assessment score and course grade when comparing students receiving honors versus satisfactory category course grades. Students who ordered more expensive or greater numbers of laboratory tests did not achieve greater diagnostic accuracy on Clinical Assessment. Clinical Assessment had a high positive predictive value for course grade: 95% of students scoring ≥90% on Clinical Assessment achieved an honors category course grade. CONCLUSIONS. Because nearly all of the students who scored very well on Clinical Assessment received honors category course grades, future high scorers on this examination merit consideration for assigning a high course grade. A computer-based multimedia patient simulation assessment tool provides objective information that can complement a students National Board of Medical Examiners score and course grade and may assist in evaluating clinical problem-solving ability.

Medical informatics and pediatrics. Decision-support systems.

The automated metabolic profile provides the physician with a comprehensive review and graphic display of the patients nutritional status, energy expenditure, substrate utilization, and nutritional requirements. A paramedical assistant performs all data acquisition, anthropometric and indirect calorimetric measurements. Data reduction is performed on a standard microcomputer system utilizing off-the-shelf peripherals. A standardized graphic sheet is used for the printout. The automated metabolic profile is utilized before initiation of nutritional therapy and subsequently to record the progress. Its use optimizes the clinical management of patients needing both ventilatory and nutritional support. By its use, total parenteral nutrition can be tailored to the requirements of the critically ill patient.

DXplain: Patterns of Use of a Mature Expert System.

BACKGROUND Failure or delay in diagnosis is a common preventable source of error. The authors sought to determine the frequency with which high-information clinical findings (HIFs) suggestive of a high-risk diagnosis (HRD) appear in the medical record before HRD documentation. METHODS A knowledge base from a diagnostic decision support system was used to identify HIFs for selected HRDs: lumbar disc disease, myocardial infarction, appendicitis, and colon, breast, lung, ovarian and bladder carcinomas. Two physicians reviewed at least 20 patient records retrieved from a research patient data registry for each of these eight HRDs and for age- and gender-compatible controls. Records were searched for HIFs in visit notes that were created before the HRD was established in the electronic record and in general medical visit notes for controls. RESULTS 25% of records reviewed (61/243) contained HIFs in notes before the HRD was established. The mean duration between HIFs first occurring in the record and time of diagnosis ranged from 19 days for breast cancer to 2 years for bladder cancer. In three of the eight HRDs, HIFs were much less likely in control patients without the HRD. CONCLUSIONS In many records of patients with an HRD, HIFs were present before the HRD was established. Reasons for delay include non-compliance with recommended follow-up, unusual presentation of a disease, and system errors (eg, lack of laboratory follow-up). The presence of HIFs in clinical records suggests a potential role for the integration of diagnostic decision support into the clinical workflow to provide reminder alerts to improve the diagnostic focus.