Shira H. Fischer

Opportunities and Challenges in Integrating Electronic Health Records Into Undergraduate Medical Education: A National Survey of Clerkship Directors

Background: Few studies have reported on the utilization and the effect of electronic health records on the education of medical students. Purpose: The purpose of this study was to describe the current use of electronic health records by medical students in the United States and explore the opportunities and challenges of integrating electronic health records into daily teaching of medical students. Methods: A survey with 24 questions regarding the use of electronic health records by medical students was developed by the Alliance for Clinical Educators and sent to clerkship directors across the United States. Both quantitative and qualitative responses were collected and analyzed to determine current access to and use of electronic health records by medical students. Results: This study found that an estimated 64% of programs currently allow student use of electronic health records, of which only two thirds allowed students to write notes within the electronic record. Overall, clerkship directors’ opinions on the effects of electronic health records on medical student education were neutral, and despite acknowledging many advantages to electronic health records, there were many concerns raised regarding their use in education. Conclusions: Medical students are using electronic health records at higher rates than physicians in practice. Although this is overall reassuring, educators have to be cautious about the limitations being placed on students documentation in electronic health records as this can potentially have consequences on their training, and they need to explore ways to maximize the benefits of electronic health records in medical education.

Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review

Medication errors are a major source of morbidity and mortality. Inadequate laboratory monitoring of high-risk medications after initial prescription is a medical error that contributes to preventable adverse drug events. Health information technology (HIT)-based clinical decision support may improve patient safety by improving the laboratory monitoring of high-risk medications, but the effectiveness of such interventions is unclear. Therefore, the authors conducted a systematic review to identify studies that evaluate the independent effect of HIT interventions on improving laboratory monitoring for high-risk medications in the ambulatory setting using a Medline search from January 1, 1980 through January 1, 2009 and a manual review of relevant bibliographies. All anticoagulation monitoring studies were excluded. Eight articles met the inclusion criteria, including six randomized controlled trials and two pre-post intervention studies. Six of the studies were conducted in two large, integrated healthcare delivery systems in the USA. Overall, five of the eight studies reported statistically significant, but small, improvements in laboratory monitoring; only half of the randomized controlled trials reported statistically significant improvements. Studies that found no improvement were more likely to have used analytic strategies that addressed clustering and confounding. Whether HIT improves laboratory monitoring of certain high-risk medications for ambulatory patients remains unclear, and further research is needed to clarify this important question.

Beyond Medication Reconciliation: The Correct Medication List

Medication reconciliation is a major focus of quality measurement activities, and according to The Joint Commission, primary care clinicians are expected to reconcile a patient’s medications at every visit.1 In principle, medication reconciliation is quite important; in practice, however, it has failed to have a demonstrable effect on patient outcomes. This may partly be because the lack of agreement about what constitutes medication reconciliation makes it difficult to decide when it has occurred and therefore difficult to study its effect.

Parent Partnerships in Communication and Decision Making About Subspecialty Referrals for Children With Special Needs

OBJECTIVE To describe factors that influence parent-clinician partnerships in information exchange and shared decision making (SDM) when children with special health care needs are referred to subspecialists. METHODS We conducted focus groups with parents of children with special health care needs and pediatric primary care and subspecialty clinicians about how to include parents as partners in information exchange and SDM. Five parent and 5 clinician groups were held to identify themes to inform the development of interventions to promote parent partnerships; evaluate a prototype referral care plan and related parent supports as one example of a partnership tool; and compare the views of parents and clinicians. We used investigator triangulation and member checking to improve validity. RESULTS Nineteen parents and 23 clinicians participated. Parents discussed partnerships more easily than clinicians did, though clinicians offered more ideas as sessions progressed. Parents and clinicians agreed on the importance of 3-way communication and valued primary care involvement in all stages of referral and consultation. SDM was seen by all as important; clinicians cited difficulties inherent in discussing unclear options, while parents cited insufficient information as a barrier to understanding. Use of a brief referral care plan, with parent coaching, was embraced by all parents and most clinicians. Clinicians cited time pressures and interference with work flow as potential barriers to its use. CONCLUSIONS Parents and clinicians endorse partnership in referrals, though relatively greater enthusiasm from parents may signal the need for work in implementing this partnership. Use of a care plan to support parent engagement appears promising as a partnership tool.

Baseline and Follow-up Laboratory Monitoring of Cardiovascular Medications

Background Laboratory monitoring of medications is typically used to establish safety prior to drug initiation and to detect drug-related injury following initiation. It is unclear whether black box warnings (BBWs) as well as evidence- and consensus-based clinical guidelines increase the likelihood of appropriate monitoring. Objective: To determine the proportion of patients newly initiated on selected cardiovascular medications with baseline assessment and follow-up laboratory monitoring and compare the prevalence of laboratory testing for drugs with and without BBWs and guidelines. Methods: This cross-sectional study Included patients aged 18 years or older from a large multispecialty group practice who were prescribed a cardiovascular medication (angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, amlodarone, digoxin, lipid-lowering agents, diuretics, and potassium supplements) between January 1 and July 31, 2008. The primary outcome measure was laboratory test ordering for baseline assessment and follow-up monitoring of newly initiated cardiovascular medications. Results: The number of new users of each study drug ranged from 49 to 1757 during the study period. Baseline laboratory test ordering across study drugs ranged from 37.4% to 94.8%, and follow-up laboratory test ordering ranged from 20.0% to 77.2%. Laboratory tests for drugs with baseline laboratory assessment recommendations in BBWs were more commonly ordered than for drugs without BBWs (66.4% vs 78.0%, p < 0.001), Drugs with follow-up monitoring recommendations in clinical guidelines had a lower prevalence of monitoring (33.1% va 50.7%. p< 0.001). Conclusions: Baseline assessment of cardiovascular medication monitoring is variable. Quality measurement of adherence to BBW recommendations may improve monitoring.

Home Medication Support for Childhood Cancer: Family-Centered Design and Testing

PURPOSE Errors in the use of medications at home by children with cancer are common, and interventions to support correct use are needed. We sought to (1) engage stakeholders in the design and development of an intervention to prevent errors in home medication use, and (2) evaluate the acceptability and usefulness of the intervention. METHODS We convened a multidisciplinary team of parents, clinicians, technology experts, and researchers to develop an intervention using a two-step user-centered design process. First, parents and oncologists provided input on the design. Second, a parent panel and two oncology nurses refined draft materials. In a feasibility study, we used questionnaires to assess usefulness and acceptability. Medication error rates were assessed via monthly telephone interviews with parents. RESULTS We successfully partnered with parents, clinicians, and IT experts to develop Home Medication Support (HoMeS), a family-centered Web-based intervention. HoMeS includes a medication calendar with decision support, a communication tool, adverse effect information, a metric conversion chart, and other information. The 15 families in the feasibility study gave HoMeS high ratings for acceptability and usefulness. Half recorded information on the calendar to indicate to other caregivers that doses were given; 34% brought it to the clinic to communicate with their clinician about home medication use. There was no change in the rate of medication errors in this feasibility study. CONCLUSION We created and tested a stakeholder-designed, Web-based intervention to support home chemotherapy use, which parents rated highly. This tool may prevent serious medication errors in a larger study.

Responsible e-Prescribing Needs e-Discontinuation

Adding e-discontinuation functionality has the potential to help reduce medication errors and take fuller advantage of e-prescribing technology. Prescribers need to be able to e-discontinue prescriptions, just as easily as they can e-prescribe them.

A mixed-methods evaluation of an Integrated Medication Management program and implications for implementation

Background: Improving medication adherence is a common and challenging issue. Taking medications as prescribed becomes particularly difficult for individuals with multiple chronic conditions. Poor adherence can lead to exacerbated health issues and prolonged disease severity. Medication Therapy Management is increasingly being used to help clinics improve medication adherence and reduce adverse events, but factors that enable implementation of such programs are not well identified. Objective: To describe the factors associated with implementation of an innovative pharmacy program and to measure the impact of the intervention. Methods: This mixed‐methods cohort study in a federal qualified health center with its own pharmacy examined the implementation and the impact of a broad program including MTM. The intervention included appointments with pharmacists, communication between pharmacists and physicians, and, for some, monthly pre‐packaged medications. Semi‐structured interviews with patients and staff were recorded, transcribed, and analyzed for themes relating to implementation, satisfaction, and challenges. Quantitative methods using data collected by the pharmacists at each visit were used to compare the first visit to those at later visits and provided measures of impact on diabetes control, statin use, and medication‐related problems (MRPs). Results: Qualitative interviews identified enabling factors that contributed to successful implementation of this program, including: program factors such as data access, communication with patients, and dedicated staff; organizational factors such as culture of integration, leadership support, and staffing; and lastly, environmental factors such as the availability of 340B funding. Quantitative analyses were limited by poor retention and lack of a similarly‐documented comparison group. Health outcomes were not found to be significantly better, though there was a significant decrease in some kinds of MRPs. This program was well received by patients and staff and demonstrated some clinical impact. Conclusion: The programs implementation was enabled by design as well as organizational and external factors. Financial and leadership support allowed for flexibility and creativity, which contributed to successful implementation. Alternative delivery models beyond fee‐for‐service payments may make this kind of program more feasible. HIGHLIGHTSMixed methods evaluation of innovative MTM program, exploring implementation and impact.Some clinical impacts but limited quantitative impact.High satisfaction from staff and patients in qualitative interviews.Many contextual factors that affected program.

The Promise of Direct-to-Consumer Telehealth for Disaster Response and Recovery

Telehealth has great promise to improve and even revolutionize emergency response and recovery. Yet telehealth in general, and direct-to-consumer (DTC) telehealth in particular, are underutilized in disasters. Direct-to-consumer telehealth services allow patients to request virtual visits with health care providers, in real-time, via phone or video conferencing (online video or mobile phone applications). Although DTC services for routine primary care are growing rapidly, there is no published literature on the potential application of DTC telehealth to disaster response and recovery because these services are so new. This report presents several potential uses of DTC telehealth across multiple disaster phases (acute response, subacute response, and recovery) while noting the logistical, legal, and policy challenges that must be addressed to allow for expanded use. Uscher-Pines L , Fischer S , Chari R . The promise of direct-to-consumer telehealth for disaster response and recovery. Prehosp Disaster Med. 2016;31(4):454-456.

PS1-40: Laboratory Monitoring of HEDIS Medications in the Ambulatory Setting: The Relative Contribution of Physician and Patient Behavior to Undermonitoring

Background/Aims Initiative to improve the quality and safety of pharmaceutical care have lead to the development of quality of care measures including standards for the appropriate monitoring of high-risk medications (defined as medications commonly implicated in adverse drug events or with narrow therapeutic window). While low rates of laboratory monitoring of high-risk medications might indicate poor physician performance, it is unclear how much patient non-adherence to physician-ordered tests contribute to undermeasruement of physician quality. The study aim is to determine, for Health Employer Data Information Set (HEDIS) quality of care, high-risk medication laboratory monitoring measures: the prevalence of completion of recommended monitoring tests; and the proportion of incomplete testing attributable to lack of clinician test ordering relative to patient non-adherence to ordered tests. Methods and Results We measured the ordering and completion of laboratory tests for HEDIS-based high-risk medications (ACE inhibitors, ARBs, digoxin and diuretics, and anticonvulants) in a large multispecialty group practice between January 1, 2008 and July 31, 2008. Laboratory test completion for HEDIS cardiovascular drugs was higher than for anticonvulsants. Each cardiovascular drug had a completion rate of > 85%, while the completion rate for anticonvulsants ranged from 30–75%. The lowest test completion rate was for phenobarbital levels to monitor phenobarbital (30%). For all cardiovascular and anticonvulsant drugs, the proportion of recommended tests not ordered by the clinician ranged from 5% to 60%. The lowest test order prevalence was for phenobarbital level for phenobarbital use (35%), followed by valproic acid level for valproate use(48%), and carbamazepine level for carbamazepine use (60%). Rates of patient noncompletion of ordered tests for all drugs was generally <10%. Conclusion Completion of laboratory monitoring tests for high-risk cardiovascular medications was higher than for high-risk anticonvulsants according to HEDIS guidelines. Clinician ordering behavior exhibited more variation than patient adherence to test orders. Underestimation of HEDIS quality of care monitoring due to patient non-adherence is minimal for cardiovascular medications, but higher for anticonvulsants.