William M. Tierney

Reminders to physicians from an introspective computer medical record: a two-year randomized trial

We developed a computer-stored medical record system containing a limited set of the total clinical data base--primarily diagnostic studies and treatments. This system responds to its own content according to physician-authored reminder rules. To determine the effect of the reminder messages generated by 1490 rules on physician behavior, we randomly assigned practitioners in a general medicine clinic to study or control groups. The computer found indications for six different actions per patient in 12 467 patients during a 2-year study: 61 study group residents who received computer reminders responded to 49% of these indications; 54 control group residents, to only 29% (p less than 0.0001). Preventive care (occult blood testing, mammographic screening, weight reduction diets, influenza and pneumococcal vaccines) was affected. The intentions of the study group to use a given action for an indication predicted their response to the indications (p less than 0.03, r2 = 0.33). The intentions of the control residents did not.

Linking clinical relevance and statistical significance in evaluating intra-individual changes in health-related quality of life.

OBJECTIVE To compare the standard error of measurement (SEM) with established standards for clinically relevant intra-individual change in an evaluation of health-related quality of life. DESIGN Secondary analysis of data from a randomized controlled trial. SUBJECTS Six hundred and five outpatients with a history of cardiac problems attending the general medicine clinics of a major academic medical center. MEASURES Baseline and follow-up interviews included a modified version of the Chronic Heart Failure Questionnaire (CHQ) and the SF-36. The SEM values corresponding to established standards for minimal clinically important differences (MCIDs) on the CHQ were determined. Individual change on the SF-36 was explored using the same SEM criterion. RESULTS One-SEM changes in this population corresponded well to the patient-driven MCID standards on all CHQ dimensions (weighted kappas (0.87; P < 0.001). The distributions of outpatients who improved, remained stable, or declined (defined by the one-SEM criterion) were generally consistent between CHQ dimensions and SF-36 subscales. CONCLUSIONS The use of the SEM to evaluate individual patient change should be explored among other health-related quality of life instruments with established standards for clinically relevant differences. Only then can it be determined whether the one-SEM criterion can be consistently applied as a proxy for clinically meaningful change.

The Regenstrief Medical Record System: a quarter century experience

Entrusted with the records for more than 1.5 million patients, the Regenstrief Medical Record System (RMRS) has evolved into a fast and comprehensive data repository used extensively at three hospitals on the Indiana University Medical Center campus and more than 30 Indianapolis clinics. The RMRS routinely captures laboratory results, narrative reports, orders, medications, radiology reports, registration information, nursing assessments, vital signs, EKGs and other clinical data. In this paper, we describe the RMRS data model, file structures and architecture, as well as recent necessary changes to these as we coordinate a collaborative effort among all major Indianapolis hospital systems, improving patient care by capturing city-wide laboratory and encounter data. We believe that our success represents persistent efforts to build interfaces directly to multiple independent instruments and other data collection systems, using medical standards such as HL7, LOINC, and DICOM. Inpatient and outpatient order entry systems, instruments for visit notes and on-line questionnaires that replace hardcopy forms, and intelligent use of coded data entry supplement the RMRS. Physicians happily enter orders, problems, allergies, visit notes, and discharge summaries into our locally developed Gopher order entry system, as we provide them with convenient output forms, choice lists, defaults, templates, reminders, drug interaction information, charge information, and on-line articles and textbooks. To prepare for the future, we have begun wrapping our system in Web browser technology, testing voice dictation and understanding, and employing wireless technology.

A Randomized Trial of “Corollary Orders” to Prevent Errors of Omission

OBJECTIVE Errors of omission are a common cause of systems failures. Physicians often fail to order tests or treatments needed to monitor/ameliorate the effects of other tests or treatments. The authors hypothesized that automated, guideline-based reminders to physicians, provided as they wrote orders, could reduce these omissions. DESIGN The study was performed on the inpatient general medicine ward of a public teaching hospital. Faculty and housestaff from the Indiana University School of Medicine, who used computer workstations to write orders, were randomized to intervention and control groups. As intervention physicians wrote orders for 1 of 87 selected tests or treatments, the computer suggested corollary orders needed to detect or ameliorate adverse reactions to the trigger orders. The physicians could accept or reject these suggestions. RESULTS During the 6-month trial, reminders about corollary orders were presented to 48 intervention physicians and withheld from 41 control physicians. Intervention physicians ordered the suggested corollary orders in 46.3% of instances when they received a reminder, compared with 21.9% compliance by control physicians (p < 0.0001). Physicians discriminated in their acceptance of suggested orders, readily accepting some while rejecting others. There were one third fewer interventions initiated by pharmacists with physicians in the intervention than control groups. CONCLUSION This study demonstrates that physician workstations, linked to a comprehensive electronic medical record, can be an efficient means for decreasing errors of omissions and improving adherence to practice guidelines.

Longitudinal Study of Depression and Health Services Use Among Elderly Primary Care Patients

OBJECTIVE: To describe the prevalence and 9‐month incidence of depressive symptoms among a cohort of elderly primary care patients and to determine whether different patterns of depression are associated with different patterns of health services use.

Delayed feedback of physician performance versus immediate reminders to perform preventive care effects on physician compliance

In an academic general medicine clinic, we performed a randomized, controlled trial to compare (1) the effects of supplying monthly feedback reports of compliance with preventive care protocols by 135 internal medicine house staff with (2) the effects of specific reminders given to them at the time of patient visits. The protocols were randomly divided into two groups, A and B, and half the house staff were given feedback for Group A and half for Group B. Thus, each group served as a control for the other. Each feedback group was also randomly assigned to receive reminders for either Group A or B protocols. House staff receiving feedback more often complied with fecal occult blood testing, mammography, pneumococcal vaccination, use of metronidazole, and combined Group A and B protocols than did controls (P < 0.01). There was also significantly more compliance with the same protocols by house staff receiving reminders, but the increase for fecal occult blood testing, pneumococcal vaccination, and combined Group A protocols was twice that seen in physicians given feedback alone. In addition, reminders alone increased compliance with oral calcium supplementation. Overall compliance with the preventive care protocols was low: 10-15% in physicians receiving neither feedback nor reminders, increasing to 15-30% in those receiving reminders. Physician compliance with suggested preventive care protocols can be increased by both delayed feedback and immediate reminders, but reminders have a greater effect.

Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols

Objective: To improve compliance with computer-generated reminders to perform fecal occult blood testing (FOBT), mammography, and cervical Papanicolaou (Pap) testing.Design: Six-month prospective, randomized, controlled trial.Setting: Academic primary care general internal medicine practice.Subjects: Thirty-one general internal medicine faculty, 145 residents, and 5,407 patients with scheduled visits who were eligible for any of the three cancer screening protocols.Intervention: Primary care teams of internal medicine residents and faculty received either routine computer reminders (control) or the same reminders to which they were required to circle one of four responses: 1) “done/order today,” 2) “not applicable to this patient,” 3) “patient refused,” or 4) “next visit.”Results: Intervention physicians complied more frequently than control physicians with all reminders combined (46% vs 38%, respectively, p=0.002) and separately with reminders for FOBT (61% vs 49%, p=0.0007) and mammography (54% vs 47%, p=0.036) but not cervical Pap testing (21% vs 18%, p=0.2). Intervention residents responded significantly more often than control residents to all reminders together and separately to reminders for FOBT and mammography but not Pap testing. There was no significant difference between intervention and control faculty, but the compliance rate for control faculty was significantly higher than the rate for control residents for all reminders together and separately for FOBT but not mammography or Pap testing. The intervention’s effect was greatest for patients ≥70 years old, with significant results for all tests, together and singly, for residents but not faculty. Intervention physicians felt that the reminders were not applicable 21% of the time (due to inadequate data in patients’ electronic medical records) and stated that their patients refused 10% of the time.Conclusions: Requiring physicians to respond to computer-generated reminders improved their compliance with preventive care protocols, especially for elderly patients for whom control physicians’ compliance was the lowest. However, 100% compliance with cancer screening reminders will be unattainable due to incomplete data and patient refusal.

Controlled Trial of Direct Physician Order Entry: Effects on Physicians' Time Utilization in Ambulatory Primary Care Internal Medicine Practices

OBJECTIVE Direct physician order entry (POE) offers many potential benefits, but evidence suggests that POE requires substantially more time than traditional paper-based ordering methods. The Medical Gopher is a well-accepted system for direct POE that has been in use for more than 15 years. The authors hypothesized that physicians using the Gopher would not spend any more time writing orders than physicians using paper-based methods. DESIGN A randomized controlled trial of POE using the Medical Gopher system in 11 primary care internal medicine practices. MEASUREMENTS The authors collected detailed time use data using time motion studies of the physicians and surveyed their opinions about the POE system. RESULTS The authors found that physicians using the Gopher spent 2.2 min more per patient overall, but when duplicative and administrative tasks were taken into account, physicians were found to have spent only 0.43 min more per patient. With experience, the order entry time fell by 3.73 min per patient. The survey revealed that the physicians believed that the system improved their patient care and wanted the Gopher to continue to be available in their practices. CONCLUSIONS Little extra time, if any, was required for physicians to use the POE system. With experience in its use, physicians may even save time while enjoying the many benefits of POE.

Effects of computerized guidelines for managing heart disease in primary care.

BACKGROUND: Electronic information systems have been proposed as one means to reduce medical errors of commission (doing the wrong thing) and omission (not providing indicated care).OBJECTIVE: To assess the effects of computer-based cardiac care suggestions.DESIGN: A randomized, controlled trial targeting primary care physicians and pharmacists.SUBJECTS: A total of 706 outpatients with heart failure and/or ischemic heart disease.INTERVENTIONS: Evidence-based cardiac care suggestions, approved by a panel of local cardiologists and general internists, were displayed to physicians and pharmacists as they cared for enrolled patients.MEASUREMENTS: Adherence with the care suggestions, generic and condition-specific quality of life, acute exacerbations of their cardiac disease, medication compliance, health care costs, satisfaction with care, and physicians’ attitudes toward guidelines.RESULTS: Subjects were followed for 1 year during which they made 3,419 primary care visits and were eligible for 2,609 separate cardiac care suggestions. The intervention had no effect on physicians’ adherence to the care suggestions (23% for intervention patients vs 22% for controls). There were no intervention-control differences in quality of life, medication compliance, health care utilization, costs, or satisfaction with care. Physicians viewed guidelines as providing helpful information but constraining their practice and not helpful in making decisions for individual patients.CONCLUSIONS: Care suggestions generated by a sophisticated electronic medical record system failed to improve adherence to accepted practice guidelines or outcomes for patients with heart disease. Future studies must weigh the benefits and costs of different (and perhaps more Draconian) methods of affecting clinician behavior.

Outcomes of Percutaneous Endoscopic Gastrostomy Among Older Adults in a Community Setting

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) has become the preferred method to provide enteral tube feeding to older adults who have difficulty eating, but the impact of PEG on patient outcomes is poorly understood. The objective of this study was to describe changes in nutrition, functional status, and health‐related quality of life among older adults receiving PEG.