Ronald W. Gimbel

The military health system's personal health record pilot with Microsoft HealthVault and Google Health

OBJECTIVE To design, build, implement, and evaluate a personal health record (PHR), tethered to the Military Health System, that leverages Microsoft® HealthVault and Google® Health infrastructure based on user preference. MATERIALS AND METHODS A pilot project was conducted in 2008-2009 at Madigan Army Medical Center in Tacoma, Washington. Our PHR was architected to a flexible platform that incorporated standards-based models of Continuity of Document and Continuity of Care Record to map Department of Defense-sourced health data, via a secure Veterans Administration data broker, to Microsoft® HealthVault and Google® Health based on user preference. The project design and implementation were guided by provider and patient advisory panels with formal user evaluation. RESULTS The pilot project included 250 beneficiary users. Approximately 73.2% of users were < 65 years of age, and 38.4% were female. Of the users, 169 (67.6%) selected Microsoft® HealthVault, and 81 (32.4%) selected Google® Health as their PHR of preference. Sample evaluation of users reflected 100% (n = 60) satisfied with convenience of record access and 91.7% (n = 55) satisfied with overall functionality of PHR. DISCUSSION Key lessons learned related to data-transfer decisions (push vs pull), purposeful delays in reporting sensitive information, understanding and mapping PHR use and clinical workflow, and decisions on information patients may choose to share with their provider. CONCLUSION Currently PHRs are being viewed as empowering tools for patient activation. Design and implementation issues (eg, technical, organizational, information security) are substantial and must be thoughtfully approached. Adopting standards into design can enhance the national goal of portability and interoperability.

America's "undiscovered" laboratory for health services research.

Debate over reforming the nations healthcare system has stimulated a need for health services research (HSR) models that are nationally applicable. Toward this end, the authors identify the Military Health System (MHS) as Americas “undiscovered” laboratory for HSR. Although many may confuse the MHS with the Department of Veterans Affairs (VA), the 2 systems vary dramatically with respect to their beneficiary populations, access to care, and other important attributes.In this article, the authors describe key characteristics of the MHS including its large beneficiary base, its direct care operating environment, its dedicated medical school and graduate education programs, and its fully operational integrated health information system. Although a few health systems (eg, Kaiser Permanente®, Partners™ Healthcare, and Department of Veterans Affairs) possess some characteristics, no other has all of these components in place.This article sets the stage for contemporary HSR studies with broad applicability to current issues in American healthcare that could be performed within the MHS. Inclusion of the MHS environment in HSR studies of health services delivery modalities, adoption of health information technology, access to care, relationship of medical education to effective safe care delivery, health disparities, child health, and behavioral health would provide strong underpinnings for proposed changes in American healthcare delivery.Finally, the article highlights current regulatory barriers to research within the MHS whereas suggesting steps to minimize their impact in conducting HSR.

Commentary: The RIME/EMR scheme: an educational approach to clinical documentation in electronic medical records.

Electronic medical records (EMRs) increasingly are used to document the delivery of patient care. Clinical practices that are involved in medical education are more likely to employ EMRs. Yet, the growing use of EMRs presents a new set of challenges for undergraduate and graduate medical education. EMRs can significantly impact how trainees learn and develop medical decision-making strategies and clinical documentation skills. EMRs also affect how clinical notes are evaluated and how feedback is provided to the learner. To use EMRs effectively, students must learn how narrative elements (how to take and record a medical history and physician examination), data elements (laboratory, radiology, medication, and information from ancillary and consultative services), and system elements (how EMRs function within the context of the health care or hospital system where the student trains) combine in the context of compassionate, competent, and safe patient care. This commentary specifically addresses educational issues surrounding student and resident use of EMR systems. The Reporter-Interpreter-Manager-Educator scheme is one approach to teach and evaluate clinical documentation skills using EMRs in the context of the Accreditation Council for Graduate Medical Education core educational competencies.

Electronic health records improve clinical note quality

Background and objective The clinical note documents the clinicians information collection, problem assessment, clinical management, and its used for administrative purposes. Electronic health records (EHRs) are being implemented in clinical practices throughout the USA yet it is not known whether they improve the quality of clinical notes. The goal in this study was to determine if EHRs improve the quality of outpatient clinical notes. Materials and methods A five and a half year longitudinal retrospective multicenter quantitative study comparing the quality of handwritten and electronic outpatient clinical visit notes for 100 patients with type 2 diabetes at three time points: 6 months prior to the introduction of the EHR (before-EHR), 6 months after the introduction of the EHR (after-EHR), and 5 years after the introduction of the EHR (5-year-EHR). QNOTE, a validated quantitative instrument, was used to assess the quality of outpatient clinical notes. Its scores can range from a low of 0 to a high of 100. Sixteen primary care physicians with active practices used QNOTE to determine the quality of the 300 patient notes. Results The before-EHR, after-EHR, and 5-year-EHR grand mean scores (SD) were 52.0 (18.4), 61.2 (16.3), and 80.4 (8.9), respectively, and the change in scores for before-EHR to after-EHR and before-EHR to 5-year-EHR were 18% (p<0.0001) and 55% (p<0.0001), respectively. All the element and grand mean quality scores significantly improved over the 5-year time interval. Conclusions The EHR significantly improved the overall quality of the outpatient clinical note and the quality of all its elements, including the core and non-core elements. To our knowledge, this is the first study to demonstrate that the EHR significantly improves the quality of clinical notes.

Radiation Exposure and Cost Influence Physician Medical Image Decision Making A Randomized Controlled Trial

Background: It is estimated that 20%–40% of advanced medical imaging in the United States is unnecessary, resulting in patient overexposure to radiation and increasing the cost of care. Previous imaging utilization studies have focused on clinical appropriateness. An important contributor to excessive use of advanced imaging may be a physician “knowledge gap” regarding the safety and cost of the tests. Objectives: To determine whether safety and cost information will change physician medical image decision making. Research Design: Double-blinded, randomized controlled trial. Following standardized case presentation, physicians made an initial imaging choice. This was followed by the presentation of guidelines, radiation exposure and health risk, and cost information. Results: Approximately half (57 of 112, 50.9%) of participants initially selected computed tomography (CT). When presented with guideline recommendations, participants did not modify their initial imaging choice (P=0.197). A significant reduction (56.3%, P<0.001) in CT ordering occurred after presentation of radiation exposure/health risk information; ordering changed to magnetic resonance imaging or ultrasound (US). A significant reduction (48.3%, P<0.001) in CT and magnetic resonance imaging ordering occurred after presentation of Medicare reimbursement information; ordering changed to US. The majority of physicians (31 of 40, 77.5%) selecting US never modified their ordering. No significant relationship between physician demographics and decision making was observed. Conclusions: This study suggests that physician decision making can be influenced by safety and cost information and the order in which information is provided to physicians can affect their decisions.

QNOTE: an instrument for measuring the quality of EHR clinical notes

Background and objective The outpatient clinical note documents the clinicians information collection, problem assessment, and patient management, yet there is currently no validated instrument to measure the quality of the electronic clinical note. This study evaluated the validity of the QNOTE instrument, which assesses 12 elements in the clinical note, for measuring the quality of clinical notes. It also compared its performance with a global instrument that assesses the clinical note as a whole. Materials and methods Retrospective multicenter blinded study of the clinical notes of 100 outpatients with type 2 diabetes mellitus who had been seen in clinic on at least three occasions. The 300 notes were rated by eight general internal medicine and eight family medicine practicing physicians. The QNOTE instrument scored the quality of the note as the sum of a set of 12 note element scores, and its inter-rater agreement was measured by the intraclass correlation coefficient. The Global instrument scored the note in its entirety, and its inter-rater agreement was measured by the Fleiss κ. Results The overall QNOTE inter-rater agreement was 0.82 (CI 0.80 to 0.84), and its note quality score was 65 (CI 64 to 66). The Global inter-rater agreement was 0.24 (CI 0.19 to 0.29), and its note quality score was 52 (CI 49 to 55). The QNOTE quality scores were consistent, and the overall QNOTE score was significantly higher than the overall Global score (p=0.04). Conclusions We found the QNOTE to be a valid instrument for evaluating the quality of electronic clinical notes, and its performance was superior to that of the Global instrument.

Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research

BackgroundThere are no empirically-grounded criteria or tools to define or benchmark the quality of outpatient clinical documentation. Outpatient clinical notes document care, communicate treatment plans and support patient safety, medical education, medico-legal investigations and reimbursement. Accurately describing and assessing quality of clinical documentation is a necessary improvement in an increasingly team-based healthcare delivery system. In this paper we describe the quality of outpatient clinical notes from the perspective of multiple stakeholders.MethodsUsing purposeful sampling for maximum diversity, we conducted focus groups and individual interviews with clinicians, nursing and ancillary staff, patients, and healthcare administrators at six federal health care facilities between 2009 and 2011. All sessions were audio-recorded, transcribed and qualitatively analyzed using open, axial and selective coding.ResultsThe 163 participants included 61 clinicians, 52 nurse/ancillary staff, 31 patients and 19 administrative staff. Three organizing themes emerged: 1) characteristics of quality in clinical notes, 2) desired elements within the clinical notes and 3) system supports to improve the quality of clinical notes. We identified 11 codes to describe characteristics of clinical notes, 20 codes to describe desired elements in quality clinical notes and 11 codes to describe clinical system elements that support quality when writing clinical notes. While there was substantial overlap between the aspects of quality described by the four stakeholder groups, only clinicians and administrators identified ease of translation into billing codes as an important characteristic of a quality note. Only patients rated prioritization of their medical problems as an aspect of quality. Nurses included care and education delivered to the patient, information added by the patient, interdisciplinary information, and infection alerts as important content.ConclusionsPerspectives of these four stakeholder groups provide a comprehensive description of quality in outpatient clinical documentation. The resulting description of characteristics and content necessary for quality notes provides a research-based foundation for assessing the quality of clinical documentation in outpatient health care settings.

Faculty Performance Evaluation in Accredited U.S. Public Health Graduate Schools and Programs: A National Study

Purpose To provide baseline data on evaluation of faculty performance in U.S. schools and programs of public health. Method The authors administered an anonymous Internet-based questionnaire using PHP Surveyor. The invited sample consisted of individuals listed in the Council on Education for Public Health (CEPH) Directory of Accredited Schools and Programs of Public Health. The authors explored performance measures in teaching, research, and service, and assessed how faculty performance measures are used. Results A total of 64 individuals (60.4%) responded to the survey, with 26 (40.6%) reporting accreditation/reaccreditation by CEPH within the preceding 24 months. Although all schools and programs employ faculty performance evaluations, a significant difference exists between schools and programs in the use of results for merit pay increases and mentoring purposes. Thirty-one (48.4%) of the organizations published minimum performance expectations. Fifty-nine (92.2%) of the respondents counted number of publications, but only 22 (34.4%) formally evaluated their quality. Sixty-two (96.9%) evaluated teaching through student course evaluations, and only 29 (45.3%) engaged in peer assessment. Although aggregate results of teaching evaluation are available to faculty and administrators, this information is often unavailable to students and the public. Most schools and programs documented faculty service activities qualitatively but neither assessed it quantitatively nor evaluated its impact. Conclusions This study provides insight into how schools and programs of public health evaluate faculty performance. Results suggest that although schools and programs do evaluate faculty performance on a basic level, many do not devote substantial attention to this process.

The adoption of an electronic health record did not improve A1c values in Type 2 diabetes

Background A major justification for the clinical adoption of electronic health records (EHRs) was the expectation that it would improve the quality of medical care. No longitudinal study has tested this assumption. Objective We used hemoglobin A1c, a recognized clinical quality measure directly related to diabetes outcomes, to assess the effect of EHR use on clinical quality. Methods We performed a five-and-one-half-year multicentre longitudinal retrospective study of the A1c values of 537 type 2 diabetic patients. The same patients had to have been seen on at least three occasions: once approximately six months prior to EHR adoption (before-EHR), once approximately six months after EHR adoption (after-EHR) and once approximately five years after EHR adoption (five-years), for a total of 1,611 notes. Results The overall mean confidence interval (CI) A1c values for the before-EHR, after-EHR and five-years were 7.07 (6.91 – 7.23), 7.33 (7.14 – 7.52) and 7.19 (7.06 – 7.32), respectively. There was a small but significant increase in A1c values between before-EHR and after-EHR, p = .04; there were no other significant differences. There was a significant decrease in notes missing at least one A1c value, from 42% before-EHR to 16% five-years (p < .001). Conclusion We found that based on patient’s A1c values, EHRs did not improve the clinical quality of diabetic care in six months and five years after EHR adoption. To our knowledge, this is the first longitudinal study to directly assess the relationship between the use of an EHR and clinical quality.

Toward a DoD/VA Longitudinal Health Record: Politics and the Policy Landscape

Policy implications of an interoperable Department of Defense (DoD) and Veterans Administration (VA) longitudinal health record (LHR) are substantial and far reaching. In this manuscript the authors explore the existing challenges and opportunities, the political landscape, and alternative solutions that have created a favorable environment for legislation and funding to support its development. The authors identify six policy themes emerging from the historic National Forum on the Future of the Defense Health Information System held recently at Georgetown University in Washington DC.