http://www.clinfowiki.org/wiki/api.php?action=feedcontributions&user=Arshad+Ghauri&feedformat=atomClinfowiki - User contributions [en]2024-03-29T15:15:24ZUser contributionsMediaWiki 1.22.4http://www.clinfowiki.org/wiki/index.php/Why_doctors_quitWhy doctors quit2015-11-30T00:22:46Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>This is an article review of the article entitled Why Doctors Quit by Charles Krauthammer <ref name = "Krauthammer 2015"> https://www.washingtonpost.com/opinions/why-doctors-quit/2015/05/28/1e9d8e6e-056f-11e5-a428-c984eb077d4e_story.html </ref><br />
<br />
== Introduction ==<br />
<br />
This article is an important opinion piece by a noted physician turned political pundit. It is significant in that it perfectly captures the frustration physicians feel at the mandate to adopt Electronic Health Records [[EHR|(EHR)]]s in their practice, the impact that the feel it is having on their quality of care and the overall effect on the health care system as a result. <br />
<br />
=== Summary ===<br />
Dr. Charles Krauthammer left the practice of medicine years ago to follow his passion for writing and politics. At a recent medical school reunion he had the opportunity to speak to his fellow physicians still in practice and was struck by the overwhelmingly negative attitude they had toward regulatory changes in health care. Specifically, the mandated adoption of electronic medical records due to [[Meaningful Use]]. <br />
In the article, DR. Krauthammer reports many physicians felt that the Electronic Medical Record [[EMR|(EMR)]] was intrusive, created additional documentation that was of no value, and reduced the number of patients they were able to see by about ¾. Some were seriously considering leaving the practice of medicine for the first time in their careers, feeling that they were no longer doing patient care but data entry. <br />
=== Comments ===<br />
<br />
While this is not a peer reviewed article published in a scientific journal, it is an important paper. A Health Informatics professional working in a hospital is likely to have at least one physician refer to this article. It can be found pinned to the wall of physician lounges, or circulating among them in Medical Staff committee meetings. It is important also in that it gives insight into how EHR design must be driven by end-user experience.<br />
<br />
==Additional Comments==<br />
I agree with the above comment that EHR design must be driven by the end user experience, however one should also remember that what we want may not be what we need. Unfortunately at the time of this rush to implement EHR and even now the distinction between what the user wants and needs is not very clear.<br />
<br />
=== References ===<br />
<br />
<references/><br />
<br />
[[Category: Reviews]]<br />
[[Category: EHR]]<br />
[[Category: HI5313-2015-FALL]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Mobile_phone_diabetes_project_led_to_improved_glycemic_control_and_net_savings_for_Chicago_plan_participantsMobile phone diabetes project led to improved glycemic control and net savings for Chicago plan participants2015-11-30T00:14:24Z<p>Arshad Ghauri: /* Remarks about the article */</p>
<hr />
<div>This is a review of the research article authored by Nundy, S., Dick, J. J., Chou, C. H., Nocon, R. S., Chin, M. H., & Peek, M. E. (2014)<br />
<br />
<br />
<br />
<br />
<br />
== Introduction ==<br />
<br />
Patients with chronic diseases spend additional time in healthcare settings, where resources are directed, instead of around the patients and the community. Chronic diseases just like diabetes remain a leading cause of preventable morbidity, mortality, and excess costs. Quality outcomes for these patients are largely determined by the activities they engage in outside of their follow up clinical encounters with their providers. The activities include taking medications, eating healthy meals, signs and symptoms monitoring, and engaging in regular physical activities. Because a greater number of patients now have smart phones, mobile phones have been shown to be a promising platform for engaging chronic disease patients in these activities <ref name = "2014, Nundy et al.">Nundy, 2014. Mobile phone diabetes project led to improved glycemic control and net savings for Chicago plan participants http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4034376/</ref>.<br />
<br />
== Method ==<br />
<br />
The authors presented the results of a quasi-experimental (two-group pre-post) study of a behavioral intervention program (called CareSmart) among Chicago health plan participant and non-participant adults with diabetes. Study was conducted between May 2012 and February 2013. CareSmart is mobile Health ([[mHealth | mHealth]]) diabetes program that provide self-management support and team-based care management through automated text messages. The study population included all adult health plan members with diagnosis of Type 1 & 2 diabetes. <ref name = "2014, Nundy et al.">Nundy, 2014. Mobile phone diabetes project led to improved glycemic control and net savings for Chicago plan participants http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4034376/</ref><br />
<br />
== Results ==<br />
<br />
The authors reported <br />
* Statistically significant improvements in glycemic control and patients’ satisfaction with overall care in mHealth participants. <br />
* 64% of mHealth participants agreed that phone calls from nurses were helpful for education. <br />
* 70% of mHealth participants agreed that phone calls from nurses were helpful in the navigation of healthcare. <br />
* A net cost savings of $437 per mHealth participant and overall total of $32, 388 (8.8% savings) over pre-period costs were reported. <br />
* The number and cost of outpatient visits for the mHealth participants were significantly reduced. <br />
* Non-statistical significance decrease in the emergency service and hospital usage and costs.<br />
<br />
== Conclusion ==<br />
<br />
Mobile Health programs can support the aim of improving patients’ experience, population health and reducing per capita healthcare costs. <ref name = "2014, Nundy et al.">Nundy, 2014. Mobile phone diabetes project led to improved glycemic control and net savings for Chicago plan participants http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4034376/</ref><br />
<br />
== Remarks about the article ==<br />
<br />
This study is show how mobile technology can be leveraged to make existing health system resources more efficient in supporting chronic disease care. The study also emphasized self-management instead of clinical care. <ref name = "2014, Nundy et al.">Nundy, 2014. Mobile phone diabetes project led to improved glycemic control and net savings for Chicago plan participants http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4034376/</ref><br />
<br />
Technology can be wisely used to create an environment of "care" where patients feel that someone is not just "prescribing" but also is concerned to send personalized messages. This also leads to a better two way communication between the health care team and the patients.<br />
<br />
== Related Articles ==<br />
* [[Effect of home telemonitoring on glycemic and blood pressure control in primary care clinic patients with diabetes]]<br />
* [[Effect of Home Blood Pressure Telemonitoring and Pharmacist Management On Blood Pressure Control: The HyperLink Cluster Randomized Trial]]<br />
<br />
== Reference ==<br />
<references/><br />
<br />
[[Category: Reviews]]<br />
[[Category: mHealth]]<br />
[[Category: HI5313-2015-FALL]]<br />
[[Category: HIT]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Rights_and_responsibilities_of_users_of_electronic_health_recordsRights and responsibilities of users of electronic health records2015-11-30T00:05:28Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>==Introduction==<br />
Electronic Health records are routinely used in many countries costing them billions of dollars for the investments in electronic technology which replaces paper charts. The authors indicate primary reasons driving the initiatives are the desire to improve health and the system of health care delivery.<ref name=”Rights”> Sittig, D. F., & Singh, H. (2012). Rights and responsibilities of users of electronic health records. CMAJ : Canadian Medical Association Journal, 184(13), 1479-1483. http://doi.org/10.1503/cmaj.111599</ref><br />
<br />
==Background==<br />
The rationale stems from many years of concern for patient safety and quality care related to the inefficiencies of a paper based system. Unexpected consequences have surfaced in the day to day operations of using [[EHRs]]. It was noted that processing information electronically can reduce clinician productivity, increase work load, disruptive workflow and lead to the perception of the cost of EHRs outweigh the direct benefit of the system. Clinicians have sometimes see the use of the EHR as a loss of autonomy secondary to increased external oversight and loss of control over data management. <br />
<br />
==Analysis==<br />
The article offers a list of rights and responsibilities that can be used as a foundation on which designers, developers and policy makers can rely when implementing and using EHRs.<ref name=”Rights”> Sittig, D. F., & Singh, H. (2012). Rights and responsibilities of users of electronic health records. CMAJ : Canadian Medical Association Journal, 184(13), 1479-1483. http://doi.org/10.1503/cmaj.111599</ref><br />
Though these rights are not part of the Hippocratic Oath, they suggest professional privileges that front-line physicians should possess related to EHR features and functions, user privileges, and organizational processes.<br />
<br />
The 10 Rights are: <br />
* Uninterrupted access to records by providing fail-safes and downtime processes which ensure patient care continues in the event of an outage<br />
* No missing data from the patient’s profile<br />
* Succinct patient summaries of patients, medical problems, medications, lab results<br />
* Ability to override computer generated alerts<br />
* Safe electronic health records by ensuring errors related to EHRs will be reported, investigates and resolved in a timely manner<br />
* Training and assistance <br />
* Reliable performance and measurement<br />
* Compatibility with real world clinical workflows<br />
* Facilitation of communication, coordination and teamwork<br />
* Rationale for clinical decision support [[CDS]] should be evidence based<br />
<br />
==Conclusion==<br />
The article stated addressing these concerns will be challenging but can make the care delivered through<br />
EHR based systems safer and efficient.<br />
<br />
==Comments==<br />
The ability to obtain the summarized health data is very important. This depends on the ability to capture structured data in an easy way. If the process of data entry is difficult or cumbersome and data can be entered in a text format than it will be difficult to obtain reliable health summaries from the EHR.<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category: Reviews]]<br />
[[Category: EHR]]<br />
[[Category: HI5313-2015-FALL]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Rights_and_responsibilities_of_users_of_electronic_health_recordsRights and responsibilities of users of electronic health records2015-11-30T00:00:49Z<p>Arshad Ghauri: /* Conclusion */</p>
<hr />
<div>==Introduction==<br />
Electronic Health records are routinely used in many countries costing them billions of dollars for the investments in electronic technology which replaces paper charts. The authors indicate primary reasons driving the initiatives are the desire to improve health and the system of health care delivery.<ref name=”Rights”> Sittig, D. F., & Singh, H. (2012). Rights and responsibilities of users of electronic health records. CMAJ : Canadian Medical Association Journal, 184(13), 1479-1483. http://doi.org/10.1503/cmaj.111599</ref><br />
<br />
==Background==<br />
The rationale stems from many years of concern for patient safety and quality care related to the inefficiencies of a paper based system. Unexpected consequences have surfaced in the day to day operations of using [[EHRs]]. It was noted that processing information electronically can reduce clinician productivity, increase work load, disruptive workflow and lead to the perception of the cost of EHRs outweigh the direct benefit of the system. Clinicians have sometimes see the use of the EHR as a loss of autonomy secondary to increased external oversight and loss of control over data management. <br />
<br />
==Analysis==<br />
The article offers a list of rights and responsibilities that can be used as a foundation on which designers, developers and policy makers can rely when implementing and using EHRs.<ref name=”Rights”> Sittig, D. F., & Singh, H. (2012). Rights and responsibilities of users of electronic health records. CMAJ : Canadian Medical Association Journal, 184(13), 1479-1483. http://doi.org/10.1503/cmaj.111599</ref><br />
Though these rights are not part of the Hippocratic Oath, they suggest professional privileges that front-line physicians should possess related to EHR features and functions, user privileges, and organizational processes.<br />
<br />
The 10 Rights are: <br />
* Uninterrupted access to records by providing fail-safes and downtime processes which ensure patient care continues in the event of an outage<br />
* No missing data from the patient’s profile<br />
* Succinct patient summaries of patients, medical problems, medications, lab results<br />
* Ability to override computer generated alerts<br />
* Safe electronic health records by ensuring errors related to EHRs will be reported, investigates and resolved in a timely manner<br />
* Training and assistance <br />
* Reliable performance and measurement<br />
* Compatibility with real world clinical workflows<br />
* Facilitation of communication, coordination and teamwork<br />
* Rationale for clinical decision support [[CDS]] should be evidence based<br />
<br />
==Conclusion==<br />
The article stated addressing these concerns will be challenging but can make the care delivered through<br />
EHR based systems safer and efficient.<br />
<br />
==Comments==<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category: Reviews]]<br />
[[Category: EHR]]<br />
[[Category: HI5313-2015-FALL]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/BackupBackup2015-11-25T03:00:17Z<p>Arshad Ghauri: </p>
<hr />
<div>In computing technology, backup refers to the process of making a copy of or a duplicate of computer data periodically and archiving it for future use. Instances of future use can be in the event of data loss, corrupt data, deleted data or disaster recovery. Achieving is usually done in data storage devices.<br />
<br />
- Refers to the copying and archiving or computer data. Backing up is most useful to restore original data in case it is lost, or if it becomes corrupt.<br />
<br />
- Ideally, backups should be done to three locations: onsite, online, and (a secured) off site location. The online and off0site backups are especially important in case the on-site backup is lost (fire, flood, etc.) or stolen.<br />
<br />
- Backups can be made to physical media - CDs/DVDs/Hard Drives/Tapes, or online to the “cloud.”<br />
<br />
- Several services and softwares exist to help users backup their data.<br />
<br />
-Backups can be considered two kinds, Temporal or Sequential and Current or Duplicate<br />
<br />
-After an initial backup of the data, temporal backup keep a record of any changes that are made in the data. In case of data corruption one can go back in time and obtain the uncorrupted file from the older backup.<br />
<br />
-Current backup always keep the copy of the current data. This helps that if the data is lost in one location, one can start using the data from the other location. This minimizes work interruptions as a current copy of data is always available to the end user. However if a file gets corrupted or deleted than it can not be recovered.<br />
<br />
-For these reasons it may be best to have sequential or temporal backups combined with current or duplicate data backups.</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/The_Relationship_between_Electronic_Health_Record_Use_and_Quality_of_Care_over_TimeThe Relationship between Electronic Health Record Use and Quality of Care over Time2015-11-17T02:10:33Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>These are systematic review of the article entitled “The Relationship between Electronic Health Record Use and Quality of Care over Time” by Li Zhou <br />
==Abstract==<br />
*Objective: Electronic health records (EHRs) have the potential to advance the quality of care, but studies have shown mixed results. The authors sought to examine the extent of EHR usage and how the quality of care delivered in ambulatory care practices varied according to duration of EHR availability.<br />
<br />
*Methods: The study linked two data sources: a statewide survey of physicians' adoption and use of EHR and claims data reflecting quality of care as indicated by physicians' performance on widely used quality measures. Using four years of measurement, we combined 18 quality measures into 6 clinical condition categories. While the survey of physicians was cross-sectional, respondents indicated the year in which they adopted EHR. In an analysis accounting for duration of EHR use, we examined the relationship between EHR adoption and quality of care.<br />
<br />
*Results: The percent of physicians reporting adoption of EHR and availability of EHR core functions more than doubled between 2000 and 2005. Among EHR users in 2005, the average duration of EHR use was 4.8 years. For all 6 clinical conditions, there was no difference in performance between EHR users and non-users. In addition, for these 6 clinical conditions, there was no consistent pattern between length of time using an EHR and physicians performance on quality measures in both bivariate and multivariate analyses.<br />
<br />
*Conclusions: In this cross-sectional study, we found no association between duration of using an EHR and performance with respect to quality of care, although power was limited. Intensifying the use of key EHR features, such as clinical decision support, may be needed to realize quality improvement from EHRs. Future studies should examine the relationship between the extent to which physicians use key EHR functions and their performance on quality measures over time.<ref name= “Zhou 2009”> The Relationship between Electronic Health Record Use and Quality of Care over Time. DOI: http://dx.doi.org/10.1197/jamia.M3128 457-464 </ref><br />
<br />
==First review==<br />
<br />
[[EMR|Electronic health records(EHRs)]] have a great likelihood to enhance the quality of health care by offering real-time access to patients’ health information, tracking patients over time to make certain that they obtain guideline-recommended care, and offering decision-support mechanisms to minimize medical errors. However studies suggest that that simply having an EHR may not be adequate enough to improve quality and safety of health care. Additionally, it is possible that quality and safety benefits of EHR adoption and use may be time-dependent, perhaps taking several years after implementation to take place, as users become more knowledgeable about EHR applications. This article evaluated how the quality of care delivered in ambulatory care practices varied according to duration of EHR adoption and usage.<br />
<br />
===Methods===<br />
The study design involved two data sources: (1) a statewide survey of physicians’ adoption and use of EHR and (2) statewide data on physicians’ quality of care as indicated by their performance on widely used quality measures. <br />
====Statewide Survey of Physicians’ Use of Electronic Health Records====<br />
1,181 respondents were surveyed for this portion of the analysis. Respondents specified how long they had been associated with their main practice and if their main practice had an EHR. If a practice was presently using an EHR, respondents specified when their practice first began using it and designated which EHR features were available and, if available, the degree to which they used each feature. Also, in order to evaluate financial considerations, respondents were asked to signify whether their practice’s income or their personal earnings were eligible for incentive payments for quality of care, patient satisfaction, adoption of [[health information technology]] (HIT), or actual use of HIT.<br />
====Statewide Data on Physicians’ Quality of Care====<br />
Four years of data was collected on 445 physician respondents pertaining to n six previously defined clinical categories of quality from 2001-2005. If a physician pointed out in the 2005 survey that a feature was available in his or her EHR system, the author assumed that the feature had been available since the time when the practice first began using an EHR. The same theory was also applied to the extent of usage of the EHR feature. Based on these assumptions, projections for EHR adoption and availability and use of EHR core functions by year were obtained. <br />
<br />
===Results===<br />
====Characteristics of Survey Respondents====<br />
Physicians practicing in a metropolitan setting and in groups with more physicians were found to be more likely to have an EHR.<br />
==== EHR Adoption and Use of EHR Functions====<br />
137 physicians provided the year in which their practice first began using an EHR. By 2005, the average duration of using EHR in this study population was found to be 4.8 years. Also, the availability and use of core EHR functions increased over time from 2000 to 2005<br />
==== Quality Performance and EHR Adoption====<br />
Quality performance between EHR users and non-users regardless of when their EHRs were implemented was evaluated. For all 6 clinical conditions categories, there was no found difference in performance between EHR users and non-users.<br />
==== Financial Considerations Regarding EHR Usage and Quality of Care====<br />
It was found that having an EHR was not associated to physicians’ reported financial incentives for patient satisfaction or clinical quality.<br />
<br />
===Discussion===<br />
This study examined the relationship between EHRs and health care quality, particularly taking into consideration the changes in association over a period of time. No confirmation that quality of care improved with a longer interval of EHR usage was found. The results imply that merely implementing EHRs is unlikely to result in enhanced quality. Other approaches, such as paying more for higher quality care and ensuring that physicians are using EHRs to their full capacity through education and workflow renovation may be necessary. However, several studies have demonstrated that decision support delivered through electronic records can improve quality of care. For this study, usage of decision support among EHR users was quite low at only 23.5% in 2005, compared to its availability, which was 65.0% amid EHR adopters. As a result, it was agreed that quality of care improvement is achievable when EHRs are coupled with other system supports such as decision support and order entry. <br />
Several limitations were found to be of significance in this study:<br />
* Unknown factors may have masked true associations.<br />
* Even though the measures used in this study have been extensively used by researchers and other healthcare related entities, they are derived from claims data. Actual clinical data may provide a more precise representation of the quality of physician care.<br />
* EHR adoption and usage were self-reported by physicians, and social prestige bias may have led physicians to overrate actual EHR usage.<br />
* The survey was carried out in a single state therefore generalizing the findings to the rest of the United States may be inadequate.<br />
<br />
===Conclusion===<br />
There was no found association between length of time using an EHR and quality of ambulatory care. Also, EHR use was not linked with improved quality of care. Strategies to increase the efficient use of [clinical decision support] and other potential tools to improve quality of care should be considered. Future studies may be needed to re-evaluate the relationships between the quality of care and EHR use over time.<br />
<br />
===Comments===<br />
This study provides a straightforward qualitative and quantitative analysis of whether or not EHR usage provides improved quality of care over a period of time. Despite a few limitations to the study, it is evident that an EHR use alone will not necessarily enhance quality of care. Rather, the incorporation of system support tools such as [[CDS|clinical decision support]] and [[computerized physician order entry]] leads to better quality improvement outcomes. However, more research needs to be done in order to fully assess the benefits of EHR system tools in improving quality of care over a period of time.<br />
<br />
==Second Review==<br />
<br />
===Introduction===<br />
<br />
Electronic health records [[EHR]] have the possibility to increase the quality of care provided to a patient by allowing care providers quick access to detailed patient information, keeping track of patient’s health history over a length of time, and reducing medical errors. However, very few studies have been able to show a direct correlation between the use of EHRs and an advance in quality of care. A study was done to examine how the quality of care in an ambulatory practice changed with the adoption and use of an EHR.<br />
<br />
===Methods===<br />
<br />
In 2005, physicians in Massachusetts were surveyed about their EHR adoption and use. A total of 1,181 practices were used and one physician from each practice was randomly selected to be included in this study. A longitudinal analysis was used to view the trend of EHR adoption and use and to assess the correlation between the quality of care and duration of EHR use. <br />
<br />
===Results===<br />
<br />
It was found that the physicians most likely to have an EHR were those who were younger recently graduated from medical school, and practiced in an urban setting. The amount of physicians who adopted and used EHRs doubled between 2000 and 2005. However, there was no difference in the performance of physicians who used EHRs compared to those who didn’t. <br />
<br />
===Conclusion===<br />
There was no correlation found between the use of EHRs and improvements in quality of care. More studies are needed on this topic to examine if EHRs could improve quality of care in the future with use of key features such as clinical decision support [[CDS]].<br />
<br />
===Comments===<br />
Simply speaking this study has identified that EHRs are not the magic bullet solution to the US healthcare system problems.<br />
<br />
==References==<br />
<references/><br />
<br />
==Related Articles==<br />
* [[Impact of electronic health record systems on information integrity: quality and safety implications]]<br />
<br />
* [[The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview]]<br />
<br />
* [[EMR Benefits: Healthcare quality]]<br />
<br />
<br />
[[Category: Reviews]]<br />
[[Category: EHR]]<br />
[[Category: Usability]]<br />
[[Category: Quality of Care]]<br />
[[Category: HI5313-2015-FALL]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/The_Relationship_between_Electronic_Health_Record_Use_and_Quality_of_Care_over_TimeThe Relationship between Electronic Health Record Use and Quality of Care over Time2015-11-17T02:09:34Z<p>Arshad Ghauri: /* Conclusion */</p>
<hr />
<div>These are systematic review of the article entitled “The Relationship between Electronic Health Record Use and Quality of Care over Time” by Li Zhou <br />
==Abstract==<br />
*Objective: Electronic health records (EHRs) have the potential to advance the quality of care, but studies have shown mixed results. The authors sought to examine the extent of EHR usage and how the quality of care delivered in ambulatory care practices varied according to duration of EHR availability.<br />
<br />
*Methods: The study linked two data sources: a statewide survey of physicians' adoption and use of EHR and claims data reflecting quality of care as indicated by physicians' performance on widely used quality measures. Using four years of measurement, we combined 18 quality measures into 6 clinical condition categories. While the survey of physicians was cross-sectional, respondents indicated the year in which they adopted EHR. In an analysis accounting for duration of EHR use, we examined the relationship between EHR adoption and quality of care.<br />
<br />
*Results: The percent of physicians reporting adoption of EHR and availability of EHR core functions more than doubled between 2000 and 2005. Among EHR users in 2005, the average duration of EHR use was 4.8 years. For all 6 clinical conditions, there was no difference in performance between EHR users and non-users. In addition, for these 6 clinical conditions, there was no consistent pattern between length of time using an EHR and physicians performance on quality measures in both bivariate and multivariate analyses.<br />
<br />
*Conclusions: In this cross-sectional study, we found no association between duration of using an EHR and performance with respect to quality of care, although power was limited. Intensifying the use of key EHR features, such as clinical decision support, may be needed to realize quality improvement from EHRs. Future studies should examine the relationship between the extent to which physicians use key EHR functions and their performance on quality measures over time.<ref name= “Zhou 2009”> The Relationship between Electronic Health Record Use and Quality of Care over Time. DOI: http://dx.doi.org/10.1197/jamia.M3128 457-464 </ref><br />
<br />
==First review==<br />
<br />
[[EMR|Electronic health records(EHRs)]] have a great likelihood to enhance the quality of health care by offering real-time access to patients’ health information, tracking patients over time to make certain that they obtain guideline-recommended care, and offering decision-support mechanisms to minimize medical errors. However studies suggest that that simply having an EHR may not be adequate enough to improve quality and safety of health care. Additionally, it is possible that quality and safety benefits of EHR adoption and use may be time-dependent, perhaps taking several years after implementation to take place, as users become more knowledgeable about EHR applications. This article evaluated how the quality of care delivered in ambulatory care practices varied according to duration of EHR adoption and usage.<br />
<br />
===Methods===<br />
The study design involved two data sources: (1) a statewide survey of physicians’ adoption and use of EHR and (2) statewide data on physicians’ quality of care as indicated by their performance on widely used quality measures. <br />
====Statewide Survey of Physicians’ Use of Electronic Health Records====<br />
1,181 respondents were surveyed for this portion of the analysis. Respondents specified how long they had been associated with their main practice and if their main practice had an EHR. If a practice was presently using an EHR, respondents specified when their practice first began using it and designated which EHR features were available and, if available, the degree to which they used each feature. Also, in order to evaluate financial considerations, respondents were asked to signify whether their practice’s income or their personal earnings were eligible for incentive payments for quality of care, patient satisfaction, adoption of [[health information technology]] (HIT), or actual use of HIT.<br />
====Statewide Data on Physicians’ Quality of Care====<br />
Four years of data was collected on 445 physician respondents pertaining to n six previously defined clinical categories of quality from 2001-2005. If a physician pointed out in the 2005 survey that a feature was available in his or her EHR system, the author assumed that the feature had been available since the time when the practice first began using an EHR. The same theory was also applied to the extent of usage of the EHR feature. Based on these assumptions, projections for EHR adoption and availability and use of EHR core functions by year were obtained. <br />
<br />
===Results===<br />
====Characteristics of Survey Respondents====<br />
Physicians practicing in a metropolitan setting and in groups with more physicians were found to be more likely to have an EHR.<br />
==== EHR Adoption and Use of EHR Functions====<br />
137 physicians provided the year in which their practice first began using an EHR. By 2005, the average duration of using EHR in this study population was found to be 4.8 years. Also, the availability and use of core EHR functions increased over time from 2000 to 2005<br />
==== Quality Performance and EHR Adoption====<br />
Quality performance between EHR users and non-users regardless of when their EHRs were implemented was evaluated. For all 6 clinical conditions categories, there was no found difference in performance between EHR users and non-users.<br />
==== Financial Considerations Regarding EHR Usage and Quality of Care====<br />
It was found that having an EHR was not associated to physicians’ reported financial incentives for patient satisfaction or clinical quality.<br />
<br />
===Discussion===<br />
This study examined the relationship between EHRs and health care quality, particularly taking into consideration the changes in association over a period of time. No confirmation that quality of care improved with a longer interval of EHR usage was found. The results imply that merely implementing EHRs is unlikely to result in enhanced quality. Other approaches, such as paying more for higher quality care and ensuring that physicians are using EHRs to their full capacity through education and workflow renovation may be necessary. However, several studies have demonstrated that decision support delivered through electronic records can improve quality of care. For this study, usage of decision support among EHR users was quite low at only 23.5% in 2005, compared to its availability, which was 65.0% amid EHR adopters. As a result, it was agreed that quality of care improvement is achievable when EHRs are coupled with other system supports such as decision support and order entry. <br />
Several limitations were found to be of significance in this study:<br />
* Unknown factors may have masked true associations.<br />
* Even though the measures used in this study have been extensively used by researchers and other healthcare related entities, they are derived from claims data. Actual clinical data may provide a more precise representation of the quality of physician care.<br />
* EHR adoption and usage were self-reported by physicians, and social prestige bias may have led physicians to overrate actual EHR usage.<br />
* The survey was carried out in a single state therefore generalizing the findings to the rest of the United States may be inadequate.<br />
<br />
===Conclusion===<br />
There was no found association between length of time using an EHR and quality of ambulatory care. Also, EHR use was not linked with improved quality of care. Strategies to increase the efficient use of [clinical decision support] and other potential tools to improve quality of care should be considered. Future studies may be needed to re-evaluate the relationships between the quality of care and EHR use over time.<br />
<br />
===Comments===<br />
This study provides a straightforward qualitative and quantitative analysis of whether or not EHR usage provides improved quality of care over a period of time. Despite a few limitations to the study, it is evident that an EHR use alone will not necessarily enhance quality of care. Rather, the incorporation of system support tools such as [[CDS|clinical decision support]] and [[computerized physician order entry]] leads to better quality improvement outcomes. However, more research needs to be done in order to fully assess the benefits of EHR system tools in improving quality of care over a period of time.<br />
<br />
==Second Review==<br />
<br />
===Introduction===<br />
<br />
Electronic health records [[EHR]] have the possibility to increase the quality of care provided to a patient by allowing care providers quick access to detailed patient information, keeping track of patient’s health history over a length of time, and reducing medical errors. However, very few studies have been able to show a direct correlation between the use of EHRs and an advance in quality of care. A study was done to examine how the quality of care in an ambulatory practice changed with the adoption and use of an EHR.<br />
<br />
===Methods===<br />
<br />
In 2005, physicians in Massachusetts were surveyed about their EHR adoption and use. A total of 1,181 practices were used and one physician from each practice was randomly selected to be included in this study. A longitudinal analysis was used to view the trend of EHR adoption and use and to assess the correlation between the quality of care and duration of EHR use. <br />
<br />
===Results===<br />
<br />
It was found that the physicians most likely to have an EHR were those who were younger recently graduated from medical school, and practiced in an urban setting. The amount of physicians who adopted and used EHRs doubled between 2000 and 2005. However, there was no difference in the performance of physicians who used EHRs compared to those who didn’t. <br />
<br />
===Conclusion===<br />
There was no correlation found between the use of EHRs and improvements in quality of care. More studies are needed on this topic to examine if EHRs could improve quality of care in the future with use of key features such as clinical decision support [[CDS]].<br />
<br />
===Comments===<br />
Simply speaking this study has identified that EHRs are not the solution of problems plaguing the US healthcare system.<br />
<br />
==References==<br />
<references/><br />
<br />
==Related Articles==<br />
* [[Impact of electronic health record systems on information integrity: quality and safety implications]]<br />
<br />
* [[The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview]]<br />
<br />
* [[EMR Benefits: Healthcare quality]]<br />
<br />
<br />
[[Category: Reviews]]<br />
[[Category: EHR]]<br />
[[Category: Usability]]<br />
[[Category: Quality of Care]]<br />
[[Category: HI5313-2015-FALL]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Role_of_computerized_physician_order_entry_systems_in_facilitating_medication_errors.Role of computerized physician order entry systems in facilitating medication errors.2015-11-17T02:04:13Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>==Background==<br />
The study took place at a tertiary-care teaching hospital with 750 beds as well as a ([[CPOE|CPOE]]) system. The purpose of the study is to identify the role of CPOE in facilitating prescription errors. <ref name ="2005 Ross"> Ross, 2005. Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors . http://jama.jamanetwork.com.ezproxyhost.library.tmc.edu/article.aspx?articleid=200498 </ref><br />
<br />
==Methods==<br />
*Qualitative and quantitative study on the interaction with CPOE and staff <br />
*Focus groups, one on one interviews, expert interviews, shadowing and observation, surveys. <br />
<br />
== Results==<br />
22 types of medication errors resulted from this study. These [[unintended consequences]] included: information errors:Fragmentation and Systems Integration failure, Medication Discontinuation Failures, Antibiotic renewal failure, allergy information delay, and conflicting or duplicative medications.<br />
<br />
==Conclusions==<br />
In this study, it was found that this CPOE, often times, created medication errors and some were reported to have happened often.<br />
<br />
== Comments==<br />
CPOE systems are widely used in hospitals systems today. It is important that we recognize these errors as we are implementing these CPOE systems to prevent further errors or mistakes from occurring. Medication discontinuation errors are likely to happen if the medication falls off after a certain time period. I have observed that at times at the time a medication especially an antibiotic is entered with a stop date. If the patient stay continues beyond that date the medication may fall off resulting in a medication error.<br />
<br />
==References==<br />
<References/><br />
<br />
<br />
<br />
[[Category: Reviews]]<br />
[[Category: CPOE]]<br />
[[Category: HI5313-2015-FALL]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Computerized_Provider_Order_Entry_Adoption:_Implications_for_Clinical_WorkflowComputerized Provider Order Entry Adoption: Implications for Clinical Workflow2015-11-17T01:57:46Z<p>Arshad Ghauri: /* Additional Comments */</p>
<hr />
<div>==Abstract==<br />
*OBJECTIVE:To identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems.<br />
<br />
*METHODS:We analyzed qualitative data from field observations and formal interviews gathered over a three-year period at five hospitals in three organizations. Five multidisciplinary researchers worked together to identify themes related to the impacts of CPOE systems on clinical workflow.<br />
<br />
*RESULTS: CPOE systems can affect clinical work by 1) introducing or exposing human/computer interaction problems, 2) altering the pace, sequencing, and dynamics of clinical activities, 3) providing only partial support for the work activities of all types of clinical personnel, 4) reducing clinical situation awareness, and 5) poorly reflecting organizational policy and procedure.<br />
<br />
*CONCLUSIONS:As CPOE systems evolve, those involved must take care to mitigate the many unintended adverse effects these systems have on clinical workflow. Workflow issues resulting from CPOE can be mitigated by iteratively altering both clinical workflow and the CPOE system until a satisfactory fit is achieved.<br />
==Review==<br />
=== Background ===<br />
<br />
This article describes some of the impact that Computerized Provider Order Entry [[CPOE|(CPOE)]] can have on clinical workflow. Physicians use CPOE to order things such as labs, medications, and imaging. CPOEs can reduce costs, reduce errors, promote standardization, and reduce redundancy in orders. However, they can also negatively impact clinical workflow. <ref name="CPOE">Campbell, E.M., R.N., M.S., Guappone, K.P., M.D., PhD, Sittig, D.F., PhD, Dykstra, R.H., M.D., M.S., Ash, J.S., M.B.A., PhD (2009). Computerized Provider Order Entry Adoption: Implications for Clinical Workflow. Journal of General Internal Medicine, 24(1), 21-26. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607519/</ref><br />
<br />
=== Methods ===<br />
<br />
Researchers visited 5 hospitals over a period of three years to collect data. Data was collected through interviews and by shadowing physicians, nurses, pharmacists, and administrators. Clinicians were asked to report unintended consequences related to CPOEs. <br />
<br />
=== Results===<br />
<br />
Some of the issues or disruptions in workflow were reported as:<br />
* Functional design and shortage of workstations<br />
* Cluttered screen design and space<br />
* Lack of relevant safeguards<br />
* Lack of intraoperability with other systems, such as viewing lab results<br />
* Rigidity of ordering medications, with little room for modifying<br />
* Safety alerts appearing at non-applicable settings<br />
<br />
<br />
=== Conclusion ===<br />
<br />
Although CPOE can help increase efficiency, reduce costs and reduce errors, it can also have adverse consequences. Clinical workflow can be greatly impacted by CPOE due to concerns over rigidity of the system and workstation, accommodating different clinical specialists using CPOE, and lack of ability to function with other systems. Unintended consequences of CPOE implementation should be addressed through continuous (iterative) system and monitoring and improvement.<br />
<br />
=== Comments ===<br />
<br />
I can relate to some of the issues involving CPOE and workflow in the hospital setting. As a healthcare employee, I encountered some of the adverse consequences discussed in the article and agree that it should be tailored to users' needs. <br />
<br />
==Additional Comments==<br />
CPOE introduce a linear model of order entry, whereas in working environment, order entry does not have to be linear. As an example, it was not uncommon for providers to write orders as they are writing their progress notes on the order sheet. This results in less cognitive load as compared to when one completes their notes and then go the order section to enter orders.<br />
<br />
== Related Articles ==<br />
* [[The Impact of Computerized Provider Order Entry Systems on Inpatient Clinical Workflow: A Literature Review]]<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category: Reviews]]<br />
[[Category: EHR]]<br />
[[Category: Workflow]]<br />
[[Category: CPOE]]<br />
[[Category: HI5313-2015-FALL]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Computerized_Provider_Order_Entry_Adoption:_Implications_for_Clinical_WorkflowComputerized Provider Order Entry Adoption: Implications for Clinical Workflow2015-11-17T01:57:10Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>==Abstract==<br />
*OBJECTIVE:To identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems.<br />
<br />
*METHODS:We analyzed qualitative data from field observations and formal interviews gathered over a three-year period at five hospitals in three organizations. Five multidisciplinary researchers worked together to identify themes related to the impacts of CPOE systems on clinical workflow.<br />
<br />
*RESULTS: CPOE systems can affect clinical work by 1) introducing or exposing human/computer interaction problems, 2) altering the pace, sequencing, and dynamics of clinical activities, 3) providing only partial support for the work activities of all types of clinical personnel, 4) reducing clinical situation awareness, and 5) poorly reflecting organizational policy and procedure.<br />
<br />
*CONCLUSIONS:As CPOE systems evolve, those involved must take care to mitigate the many unintended adverse effects these systems have on clinical workflow. Workflow issues resulting from CPOE can be mitigated by iteratively altering both clinical workflow and the CPOE system until a satisfactory fit is achieved.<br />
==Review==<br />
=== Background ===<br />
<br />
This article describes some of the impact that Computerized Provider Order Entry [[CPOE|(CPOE)]] can have on clinical workflow. Physicians use CPOE to order things such as labs, medications, and imaging. CPOEs can reduce costs, reduce errors, promote standardization, and reduce redundancy in orders. However, they can also negatively impact clinical workflow. <ref name="CPOE">Campbell, E.M., R.N., M.S., Guappone, K.P., M.D., PhD, Sittig, D.F., PhD, Dykstra, R.H., M.D., M.S., Ash, J.S., M.B.A., PhD (2009). Computerized Provider Order Entry Adoption: Implications for Clinical Workflow. Journal of General Internal Medicine, 24(1), 21-26. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607519/</ref><br />
<br />
=== Methods ===<br />
<br />
Researchers visited 5 hospitals over a period of three years to collect data. Data was collected through interviews and by shadowing physicians, nurses, pharmacists, and administrators. Clinicians were asked to report unintended consequences related to CPOEs. <br />
<br />
=== Results===<br />
<br />
Some of the issues or disruptions in workflow were reported as:<br />
* Functional design and shortage of workstations<br />
* Cluttered screen design and space<br />
* Lack of relevant safeguards<br />
* Lack of intraoperability with other systems, such as viewing lab results<br />
* Rigidity of ordering medications, with little room for modifying<br />
* Safety alerts appearing at non-applicable settings<br />
<br />
<br />
=== Conclusion ===<br />
<br />
Although CPOE can help increase efficiency, reduce costs and reduce errors, it can also have adverse consequences. Clinical workflow can be greatly impacted by CPOE due to concerns over rigidity of the system and workstation, accommodating different clinical specialists using CPOE, and lack of ability to function with other systems. Unintended consequences of CPOE implementation should be addressed through continuous (iterative) system and monitoring and improvement.<br />
<br />
=== Comments ===<br />
<br />
I can relate to some of the issues involving CPOE and workflow in the hospital setting. As a healthcare employee, I encountered some of the adverse consequences discussed in the article and agree that it should be tailored to users' needs. <br />
<br />
==Additional Comments==<br />
CPOE introduce a linear model of order entry, whereas in working environment, order entry does not have to be linear. As an example, it was not uncommon for providers to write orders as they are writing their progress notes on the order sheet. This results in less cognitive load as compared to when one completes their notes and then go the the order section to enter orders.<br />
<br />
== Related Articles ==<br />
* [[The Impact of Computerized Provider Order Entry Systems on Inpatient Clinical Workflow: A Literature Review]]<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category: Reviews]]<br />
[[Category: EHR]]<br />
[[Category: Workflow]]<br />
[[Category: CPOE]]<br />
[[Category: HI5313-2015-FALL]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Better_transitions:_improving_comprehension_of_discharge_instructionsBetter transitions: improving comprehension of discharge instructions2015-11-17T01:45:11Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>This is a first review of the article "Better transitions: improving comprehension of discharge instructions." <ref name="Improving Comprehension">Chugh A, Williams M, Grigsby J, Coleman E. Better Transitions: Improving Comprehension of Discharge Instructions. Frontiers Of Health Services Management [serial online]. Spring2009 2009;25(3):11-32. Available from: Business Source Complete, Ipswich, MA. Accessed November 15, 2015.<br />
http://www.ncbi.nlm.nih.gov/pubmed/19382514</ref><br />
<br />
===BACKGROUND===<br />
In this review article authors have analyzed the effect of health literacy and cognition on the comprehension of hospital discharge instructions. The authors also present how to address the problem of low health literacy and cognition in the hospitalized patients. For patients to be able to provide self-care after discharge, they have to understand the discharge instructions. The discharge instructions may not only be complex but the time given to the patients and caregivers for this task is also relatively short. Due to illness, fatigue, effect of medications patients may not be at their best to understand these instructions. In addition to these factors, health literacy and undiagnosed cognitive dysfunction also is a significant contributor to the understanding of these discharge instructions.<br />
<br />
==DEFINITIONS OF HEALTH LITERACY AND EXECUTIVE COGNITIVE FUNCTION==<br />
Definition of health literacy, in short, is taken form Institute of Medicine (IOM) (2003) and is defined as the ability of a patient to “obtain, process and understand basic health information and services needed to make appropriate health decisions." In 2003 IOM estimated that over 47% of the adults in the US have limited health literacy skills.<br />
<br />
Cognition consists of three parts, short-term memory, recall of new information and executive functioning. Executive functioning is the most complex part and depends upon the short-term memory, processing of the new and old information to develop and implement an action plan while understanding the consequences of action or inaction.<br />
This article reports that about 30% of the adults over 55 years of age have some form of cognitive dysfunction.<br />
<br />
==COGNITION AND LITERACY AFFECT KNOWLEDGE OF DISCHARGE INSTRUCTIONS==<br />
The authors report that commonly discharge instructions are written at grade 8-13 level, while average patients read at level of grade six. Relatively complex language in discharge instructions, when combined with low health literacy and poor, either recognized or unrecognized, cognition results in poor comprehension of the discharge instructions.<br />
<br />
==SOLUTIONS==<br />
Authors have done a great job in reviewing literature and seeking expert opinion in trying to identify an approach to this problem. A systematic approach of identifying patients with low health literacy and or cognitive problems is recommended. Screening for low health literacy can be done through standardized but simple tests like Short Test of Functional Health Literacy in Adults (STOFHLA), Rapid Estimate of Adult Literacy in Medicine (REALM), and Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) tests. The staff trained in these methods, easily at the bedside, can administer these tests. Similarly tests likes Clock Drawing Test can be used to identify patients with poor cognition. The underlying recommendation is to use a systematic approach to identify these patients, irrespective of the methods employed.<br />
<br />
Authors recommend three-tiered approach for improving the comprehension of discharge instructions:<br />
<br />
Level I, approach consists of “Universal Precautions” methods by simplifying the discharge instructions for all patients. No one has ever complained that the discharge instructions are two simple. They also recommend that the process be patient centered and to involve the patient’s family or would be caregivers early in the discharge process.<br />
<br />
Level II, approach consists of identifying patients with cognitive impairment, adding fields in the EHR’s that can identify these patients easily, by allowing the patients to participate in self-care activities while hospitalized and calling the patients 72 hours after discharge to early identify any problems that may have occurred since discharge.<br />
<br />
Level III approach is recommended for the hospitals and systems that have already implemented above two approaches. This consists of employing specifically trained staff for discharge coordination and education, providing post discharge support for high-risk patients.<br />
<br />
==COMMENTS==<br />
This is a review article that focuses on improving transition of care by understanding factors that limit comprehension of discharge instructions. A comprehensive approach is required to solve this problem, though EHR’s and [[Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries |electronically created discharge instructions]] are a step in right direction but are not the complete solution to this problem.<br />
<br />
==References==<br />
<references/><br />
<br />
[[Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[Category:EHR ]]<br />
[[Category:Electronic discharge]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Relationship_of_health_literacy_to_intentional_and_unintentional_non-adherence_of_hospital_discharge_medications.Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications.2015-11-17T01:42:38Z<p>Arshad Ghauri: </p>
<hr />
<div>This is the first review of the article "Creating Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications".<ref name="Health literacy"> Lindquist LA, Go L, Fleisher J, Jain N, Friesema E, Baker DW. Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. J Gen Intern Med.2012;27:173–8. doi: 10.1007/s11606-011-1886-3. http://www.ncbi.nlm.nih.gov/pubmed/21971600 </ref><br />
==Introduction==<br />
In this article authors have explored the relationship between health literacy and medication compliance. Medication discrepancy is defined as the difference between the medications regimen prescribed at discharge versus the regimen taken at home. Adherence was described as decision to follow the prescribed plan of care.<br />
Medication discrepancy has been noted in the literature and is a significant cause of adverse events after discharge. Coleman et al.<ref name="Coleman">Coleman EA, Smith JD, Raha D, Min S. Posthospital Medication Discrepancies: Prevalence and Contributing Factors. Arch Intern Med. 2005;165(16):1842-1847. doi:10.1001/archinte.165.16.1842.</ref> found that more than double of the patients who experienced medication discrepancies were readmitted as compared to the ones who did not have any medication discrepancy. In this article authors have prospectively assessed the impact of health literacy in medication discrepancies post-hospitalization using the discharge instructions from [[EMR|Electronic Health Records (EHRs)]].<br />
<br />
==Methods==<br />
The patients under this study were community dwelling adults 70 years or older who resided within 60 miles radius of the research facility; these participants were competent, independent in their daily living situation and were managing their own medications. These patients with these characteristics were selected consecutively from the hospitalized patients who were discharged home from the inpatient hospital services. On the day of discharge these patients were evaluated for their health literacy and were grouped in adequate, marginal or poor health literacy. A pre-hospitalization medication history was also obtained and compiled by a researcher trained in this task. After the discharge, discharge medication list was obtained from the discharge instructions I the [[EMR|Electronic Medical Records (EMR)]]. Between 48-72 hours after the discharge, patients were contacted on the phone and were asked what medications they were taking. They were also asked open ended questions about any discrepancies between the discharge medications and the current medications.<br />
<br />
==Results==<br />
The mean age of the participants was slightly under 80, slightly over half were females and over half of them had some college education. Of the participants 32.3% had inadequate health literacy, 22.3% were marginal in health literacy and 56% had one or more mediation discrepancy. The most common reason was inaccurate discharge instructions (39.3%) followed by intentional non-adherence (22.4%) and unintentional non-adherence (21.9%). Multivariate analysis revealed that while unintentional non-adherence was more common in marginal and inadequate health literacy groups, intentional non-adherence was more common in patients with adequate health literacy group.<br />
<br />
<br />
==Discussion==<br />
Prior to this study, there was no concrete evidence of association between health literacy and medication discrepancies. However this study was able to unmask a relationship in which patient with poor health literacy are more likely to make an unintentional [[Medication errors|medication error]] and patients with adequate health literacy make a conscious decision for not adhering to the prescribed scheduled medications. Almost 40% of the medication discrepancies were due to inaccurate discharge instructions. This is a significant percentage and is an area for improvement.<br />
<br />
==My comments==<br />
Since primary care providers may not be affiliated with the hospitals in their practice areas at the time of patient hospitalization and discharge, there is a potential of developing medication discrepancies. Electronic Health Records--by allowing the flow of information between the inpatient and out-patient providers--may reduce medication discrepancies at discharge. In another article [[Communicating discharge instructions to patients: a survey of nurse, intern, and hospitalist practices]] a coordinated method to improve communication of discharge instructions to the patients. This coordinated effort may also result in better adherence to discharge instructions. In another article [[Better transitions: improving comprehension of discharge instructions]] authors outline an approach for patients with low health literacy and poor cognition. <br />
<br />
== Related Articles ==<br />
<br />
[[Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization]]<br />
<br />
[[Communicating discharge instructions to patients: a survey of nurse, intern, and hospitalist practices]]<br />
<br />
[[Medication errors]]<br />
<br />
== References ==<br />
<references/><br />
<br />
[[ Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[ Category:EHR ]]<br />
[[Category: Electronic discharge]]<br />
[[Category: Medication Error]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Better_transitions:_improving_comprehension_of_discharge_instructionsBetter transitions: improving comprehension of discharge instructions2015-11-17T01:41:34Z<p>Arshad Ghauri: Created page with "This is a first review of the article "Better transitions: improving comprehension of discharge instructions." <ref name="Improving Comprehension">Chugh A, Williams M, Grigsby..."</p>
<hr />
<div>This is a first review of the article "Better transitions: improving comprehension of discharge instructions." <ref name="Improving Comprehension">Chugh A, Williams M, Grigsby J, Coleman E. Better Transitions: Improving Comprehension of Discharge Instructions. Frontiers Of Health Services Management [serial online]. Spring2009 2009;25(3):11-32. Available from: Business Source Complete, Ipswich, MA. Accessed November 15, 2015.<br />
http://www.ncbi.nlm.nih.gov/pubmed/19382514</ref><br />
<br />
===BACKGROUND===<br />
In this review article authors have analyzed the effect of health literacy and cognition on the comprehension of hospital discharge instructions. The authors also present how to address the problem of low health literacy and cognition in the hospitalized patients. For patients to be able to provide self-care after discharge, they have to understand the discharge instructions. The discharge instructions may not only be complex but the time given to the patients and caregivers for this task is also relatively short. Due to illness, fatigue, effect of medications patients may not be at their best to understand these instructions. In addition to these factors, health literacy and undiagnosed cognitive dysfunction also is a significant contributor to the understanding of these discharge instructions.<br />
<br />
==DEFINITIONS OF HEALTH LITERACY AND EXECUTIVE COGNITIVE FUNCTION==<br />
Definition of health literacy, in short, is taken form Institute of Medicine (IOM) (2003) and is defined as the ability of a patient to “obtain, process and understand basic health information and services needed to make appropriate health decisions." In 2003 IOM estimated that over 47% of the adults in the US have limited health literacy skills.<br />
<br />
Cognition consists of three parts, short-term memory, recall of new information and executive functioning. Executive functioning is the most complex part and depends upon the short-term memory, processing of the new and old information to develop and implement an action plan while understanding the consequences of action or inaction.<br />
This article reports that about 30% of the adults over 55 years of age have some form of cognitive dysfunction.<br />
<br />
==COGNITION AND LITERACY AFFECT KNOWLEDGE OF DISCHARGE INSTRUCTIONS==<br />
The authors report that commonly discharge instructions are written at grade 8-13 level, while average patients read at level of grade six. Relatively complex language in discharge instructions, when combined with low health literacy and poor, either recognized or unrecognized, cognition results in poor comprehension of the discharge instructions.<br />
<br />
==SOLUTIONS==<br />
Authors have done a great job in reviewing literature and seeking expert opinion in trying to identify an approach to this problem. A systematic approach of identifying patients with low health literacy and or cognitive problems is recommended. Screening for low health literacy can be done through standardized but simple tests like Short Test of Functional Health Literacy in Adults (STOFHLA), Rapid Estimate of Adult Literacy in Medicine (REALM), and Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) tests. The staff trained in these methods, easily at the bedside, can administer these tests. Similarly tests likes Clock Drawing Test can be used to identify patients with poor cognition. The underlying recommendation is to use a systematic approach to identify these patients, irrespective of the methods employed.<br />
<br />
Authors recommend three-tiered approach for improving the comprehension of discharge instructions:<br />
<br />
Level I, approach consists of “Universal Precautions” methods by simplifying the discharge instructions for all patients. No one has ever complained that the discharge instructions are two simple. They also recommend that the process be patient centered and to involve the patient’s family or would be caregivers early in the discharge process.<br />
<br />
Level II, approach consists of identifying patients with cognitive impairment, adding fields in the EHR’s that can identify these patients easily, by allowing the patients to participate in self-care activities while hospitalized and calling the patients 72 hours after discharge to early identify any problems that may have occurred since discharge.<br />
<br />
Level III approach is recommended for the hospitals and systems that have already implemented above two approaches. This consists of employing specifically trained staff for discharge coordination and education, providing post discharge support for high-risk patients.<br />
<br />
==Comments==<br />
This is a review article that focuses on improving transition of care by understanding factors that limit comprehension of discharge instructions. A comprehensive approach is required to solve this problem, though EHR’s and [[Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries |electronically created discharge instructions]] are a step in right direction but are not the complete solution to this problem.<br />
<br />
==References==<br />
<references/><br />
<br />
[[Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[Category:EHR ]]<br />
[[Category:Electronic discharge]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Communicating_discharge_instructions_to_patients:_a_survey_of_nurse,_intern,_and_hospitalist_practicesCommunicating discharge instructions to patients: a survey of nurse, intern, and hospitalist practices2015-11-10T02:17:40Z<p>Arshad Ghauri: Created page with "This is a first review of the article "Communicating discharge instructions to patients: a survey of nurse, intern, and hospitalist practices." <ref name="Communicating Discha..."</p>
<hr />
<div>This is a first review of the article "Communicating discharge instructions to patients: a survey of nurse, intern, and hospitalist practices." <ref name="Communicating Discharge instructions">Ashbrook L, Mourad M & Sehgal N (2013) Communicating discharge instructions to patients: a survey of nurse, intern, and hospitalist practices. Journal of Hospital Medicine 8, 36–41.<br />
http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/23071078 <br />
</ref><br />
<br />
===Background===<br />
Transition from inpatient to home is a vulnerable time for the patients. Studies have shown that about 20% of the patients, experience an adverse event at the time of discharge and one third of these events are potentially preventable. Many patients leave the hospital without clear understanding of their discharge instructions. [[Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries |Electronically created discharge instructions]] have been shown to be more complete as compared to the handwritten ones. The use of discharge coordinators, improved patient teaching techniques and use of patient-centered education material all contribute towards better provider-patient communications at the time of discharge. However the roles of different providers, in communicating these discharge instructions to the patients, at best remains vague. In this study authors surveyed physicians and nurses in their hospital, to understand each groups’ own perceptions and roles in conveying these discharge instructions to the patients.<br />
<br />
==Methods==<br />
This study was done in University of California, San Francisco Medical Center (UCSFNC), which is a large tertiary care teaching hospital. A self-developed survey was administered to the interns, teaching hospitalist and daytime nursing staffs that were main participants in conveying these discharge instructions, at the time of discharge. The questions were selected to understand the perceptions of these providers about their role in patient discharge education; describe the current practice of conveying these discharge instructions to the patients and provider-nurse communication and to evaluate the willingness of these groups to embrace new communication tools.<br />
The authors also identified 13 critical discharge education elements, through literature search.<br />
The survey asked the respondents to identify parties (nurse, physician, both or neither) responsible for providing education for each of these elements and then to identify their own current practice of the same and in physician-nurse communication. The survey also elicited respondents’ interests in the use of new tools to improve provider communication at discharge.<br />
<br />
The 13 critical identified discharge instruction elements are listed below:<br />
<br />
1. Medication teaching and schedule <br />
2. Contact information for post-discharge questions <br />
3. Instructions for self-care <br />
4. Follow-up appointment dates and times <br />
5. Signs and symptoms that may develop and when to seek care <br />
6. Symptom management at home<br />
7. Home health services ordered <br />
8. Reason for follow-up appointments <br />
9. Changes to medication regimen made during hospitalization<br />
10. Discharge medical diagnoses <br />
11. Explanation of diagnosis in lay terms <br />
12. Summary of hospital findings and treatments<br />
13. Pending results from studies during hospitalization<br />
<br />
<br />
==Results==<br />
All providers considered 9 out of the 13 elements a shared responsibility, though more nurses than physicians felt that way. Out of these 13 domains, domains of explaining summary of hospital findings and pending results from studies during hospitalization were considered mainly physician responsibility. For the remaining two domains of explaining diagnosis in lay term, interns felt that this was a nursing responsibility and interns also felt that providing patients with contact information was also a unique nursing responsibility.<br />
<br />
Verbal communication as a method of communication between the providers on the day of discharge received most support and communication through the use of white board received the least support. Interns and hospitalists as compared to the nursing staff favored use of checklists to support communication though this difference did not reach statistically significant difference.<br />
<br />
==Discussion==<br />
This study correctly identifies that multiple providers feel the responsibility of providing patient education around discharge. This study also highlights that none of the providers felt that providing education to the patients at the time of discharge is their sole responsibility. A structured, tailored to the local conditions, approach may be needed to better and reliably communicate discharge instructions to the patients.<br />
<br />
==Comments==<br />
This study identified that though many providers are willing to educate but none felt that all education falls under their domain. This identifies an area for improvement by creating a discharge team composed of a nurse trained in patient education, a pharmacist who can perform medication reconciliation at the time of admission and discharge and also provide patient education during the hospital stay and a social worker who can identify factors that can lead to failed discharges. This team may become responsible for all the discharges in their area and overtime may impact readmissions and adverse events post-discharge.<br />
<br />
==References==<br />
<references/><br />
<br />
[[Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[Category:EHR ]]<br />
[[Category:Electronic discharge]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Relationship_of_health_literacy_to_intentional_and_unintentional_non-adherence_of_hospital_discharge_medications.Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications.2015-11-10T02:17:10Z<p>Arshad Ghauri: /* My comments */</p>
<hr />
<div>This is the first review of the article "Creating Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications".<ref name="Health literacy"> Lindquist LA, Go L, Fleisher J, Jain N, Friesema E, Baker DW. Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. J Gen Intern Med.2012;27:173–8. doi: 10.1007/s11606-011-1886-3. http://www.ncbi.nlm.nih.gov/pubmed/21971600 </ref><br />
==Introduction==<br />
In this article authors have explored the relationship between health literacy and medication compliance. Medication discrepancy is defined as the difference between the medications regimen prescribed at discharge versus the regimen taken at home. Adherence was described as decision to follow the prescribed plan of care.<br />
Medication discrepancy has been noted in the literature and is a significant cause of adverse events after discharge. Coleman et al.<ref name="Coleman">Coleman EA, Smith JD, Raha D, Min S. Posthospital Medication Discrepancies: Prevalence and Contributing Factors. Arch Intern Med. 2005;165(16):1842-1847. doi:10.1001/archinte.165.16.1842.</ref> found that more than double of the patients who experienced medication discrepancies were readmitted as compared to the ones who did not have any medication discrepancy. In this article authors have prospectively assessed the impact of health literacy in medication discrepancies post-hospitalization using the discharge instructions from [[EMR|Electronic Health Records (EHRs)]].<br />
<br />
==Methods==<br />
The patients under this study were community dwelling adults 70 years or older who resided within 60 miles radius of the research facility; these participants were competent, independent in their daily living situation and were managing their own medications. These patients with these characteristics were selected consecutively from the hospitalized patients who were discharged home from the inpatient hospital services. On the day of discharge these patients were evaluated for their health literacy and were grouped in adequate, marginal or poor health literacy. A pre-hospitalization medication history was also obtained and compiled by a researcher trained in this task. After the discharge, discharge medication list was obtained from the discharge instructions I the [[EMR|Electronic Medical Records (EMR)]]. Between 48-72 hours after the discharge, patients were contacted on the phone and were asked what medications they were taking. They were also asked open ended questions about any discrepancies between the discharge medications and the current medications.<br />
<br />
==Results==<br />
The mean age of the participants was slightly under 80, slightly over half were females and over half of them had some college education. 32.3% had inadequate health literacy and 22.3% were marginal in health literacy. 56% had one or more mediation discrepancy. The most common reason was inaccurate discharge instructions (39.3%) followed by intentional non-adherence (22.4%) and unintentional non-adherence (21.9%). Multivariate analysis revealed that while unintentional non-adherence was more common in marginal and inadequate health literacy groups, intentional non-adherence was more common in patients with adequate health literacy group.<br />
<br />
<br />
==Discussion==<br />
Prior to this study, there was no concrete evidence of association between health literacy and medication discrepancies. However this study was able to unmask a relationship in which patient with poor health literacy are more likely to make an unintentional [[Medication errors|medication error]] and patients with adequate health literacy make a conscious decision for not adhering to the prescribed scheduled medications. Almost 40% of the medication discrepancies were due to inaccurate discharge instructions. This is a significant percentage and is an area for improvement.<br />
<br />
==My comments==<br />
Since primary care providers may not be affiliated with the hospitals in their practice areas at the time of patient hospitalization and discharge, there is a potential of developing medication discrepancies. Electronic Health Records--by allowing the flow of information between the inpatient and out-patient providers--may reduce medication discrepancies at discharge. In another article [[Communicating discharge instructions to patients: a survey of nurse, intern, and hospitalist practices]] a coordinated method to improve communication of discharge instructions to the patients. This coordinated effort may also result in better adherence to discharge instructions.<br />
<br />
== Related Articles ==<br />
<br />
[[Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization]]<br />
<br />
== References ==<br />
<references/><br />
<br />
[[ Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[ Category:EHR ]]<br />
[[Category: Electronic discharge]]<br />
[[Category: Medication Error]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Evaluation_of_electronic_discharge_summaries:_A_comparison_of_documentation_in_electronic_and_handwritten_discharge_summariesEvaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries2015-11-10T02:13:44Z<p>Arshad Ghauri: /* Commentary */</p>
<hr />
<div>This is the first review of the article "Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries."<ref name="Discharge Summary">Joanne L. Callen, Melanie Alderton, Jean McIntosh, Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries, International Journal of Medical Informatics, Volume 77, Issue 9, September 2008, Pages 613-620, ISSN 1386-5056, http://dx.doi.org/10.1016/j.ijmedinf.2007.12.002.<br />
(http://www.sciencedirect.com/science/article/pii/S1386505608000026)<br />
Keywords: Electronic discharge summary; Handwritten discharge summary; Hospital discharge; Discharge communication; Australia</ref><br />
<br />
==Background and Objective==<br />
In this study a comparison between handwritten or dictated discharge summaries is done with the electronically created discharge summaries. This study was conducted in Australia after installing a system that can create discharge summaries electronically in a teaching hospital. The objectives of this study were two fold: first to evaluate the quality of discharge summaries per se and second to compare electronic discharge summaries with the handwritten or dictated ones for deficiencies or omissions. This was a retrospective study and compared electronic discharge summaries created using templates in [[EMR|Electronic Health Records (EHRs)]] with either handwritten or dictated ones.<br />
<br />
===Methods===<br />
A total of 245 eligible discharge summaries were identified. Out of these discharge summaries, 151 were electronically completed and 94 were handwritten. These discharge summaries were then evaluated for their completion. The following criteria were used: discharge date, additional diagnosis, summary of the hospital course; discharge medication and follow-up plans. These plans were to be executed by the PCP’s. <br />
<br />
===Results===<br />
Data analysis showed that electronic discharge summaries had a higher number of errors as compared to the handwritten ones. However, most errors were related to omission of discharge date. Handwritten discharge summaries on the other hand missed summary of the hospital course. One interesting finding was that overall medication error rate was small in both electronic and handwritten ones.<br />
<br />
<br />
===Conclusion===<br />
The authors concluded that electronic discharge summaries necessarily are not better as compared to the handwritten ones, but were unable to satisfactorily identify factors that led to incomplete discharge summaries. In addition, two physicians who completed the most electronic discharge summaries had most errors of omission in discharge date. This may be related to the inadequate training to these physicians and could have resulted in different findings had these physicians received a timely feedback.<br />
<br />
===Commentary===<br />
I used this article for many reasons; first of all with fragmented healthcare in US, a complete discharge summary is a very important tool to provide continuity of care. Second, though hospital bylaws usually dictate that a discharge summary should be completed in a timely manner and there is an expectation that discharge summaries should conform to some standards, there is generally no regular audit for the completeness or quality of the discharge summaries. EHR’s represents an opportunity to provide improvement in this area by creating a template in which specific components of the discharge summary can be auto-populated and allows for inclusion of other items from the coded data as needed. In addition a template that with some modification can duplicate as discharge instructions to the patient. This may help provide better discharge instructions and in an article [[Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications.]] <ref name="Lindquist (2012"> Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications.Lindquist LA1, Go L, Fleisher J, Jain N, Friesema E, Baker DW.J Gen Intern Med. 2012 Feb;27(2):173-8. doi: 10.1007/s11606-011-1886-3. Epub 2011 Oct 5.http://www.ncbi.nlm.nih.gov/pubmed/21971600 </ref> may help reduce medication errors. A properly developed electronic discharge summary template which may allow physicians to create discharge instructions may increase physician satisfaction. In a quasi experimental study [[Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure]] the authors compared the completeness of ED discharge instructions created through the use of an electronic discharge module with the hand written ones and found that the ED discharge instructions were more complete when the ED physicians used the electronic discharge instruction module.<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[Category:EHR ]]<br />
[[Category:Quality Analysis]]<br />
[[Category:Electronic discharge]]<br />
[[Category:Other Technologies]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/The_anatomy_of_decision_support_during_inpatient_care_provider_order_entry_(CPOE):_Empirical_observations_from_a_decade_of_CPOE_experience_at_VanderbiltThe anatomy of decision support during inpatient care provider order entry (CPOE): Empirical observations from a decade of CPOE experience at Vanderbilt2015-11-10T01:58:17Z<p>Arshad Ghauri: </p>
<hr />
<div>This is an article review of the article entitled The anatomy of decision support during inpatient care provider order entry (CPOE): Empirical observations from a decade of CPOE experience at Vanderbilt (Miller, R.A. et al 2005) <ref name = "Miller, 2005"> Miller, R. A., Waitman, L. R., Chen, S., & Rosenbloom, S. T. (2005). The anatomy of decision support during inpatient care provider order entry (CPOE): Empirical observations from a decade of CPOE experience at Vanderbilt. Journal of Biomedical Informatics, 38(6), 469-485. doi:http://dx.doi.org/10.1016/j.jbi.2005.08.009 retrieved from http://www.sciencedirect.com.ezproxyhost.library.tmc.edu/science/article/pii/S1532046405001000 </ref><br />
<br />
<br />
== Introduction ==<br />
<br />
The authors intended to evaluate [[CDS]] Interventions in the inpatient setting, hoping to answer the following questions: <br />
<br />
1. where in the CPOE process is it most appropriate to interrupt workflow with an alert? <br />
<br />
2. what categories of CDS are appropriate during CPOE<br />
<br />
3. what methods for workflow interruption are considered based on end-user tolerance of interruptions?<br />
<br />
== Methods ==<br />
<br />
The system evaluated was [http://www.mc.vanderbilt.edu:8080/reporter/index.html?ID=1608 Vanderbilt's WizOrder CPOE system]. Key considerations for CDS during CPOE were: <br />
* Content - what information to provide<br />
* Timing - at what point in the CPOE process should the intervention or aler occur<br />
* Method - how should the intervention or alert happen - both in terms of degree of interruption and mechanism<br />
<br />
== Results ==<br />
<br />
<b> Categories of interventions </b><br />
* Avert incomplete or incorrect orders by ensureing proper parameters and details included<br />
* Patient specific CDS - based on specific pt information<br />
* Optimized clinical care - improved compliance with regulations, etc.<br />
* Real-time, focused education through educational prompts and links to evidence<br />
<br />
<b> Critical points at which to implement </b><br />
* Initial launching of CPOE application<br />
* Selecting CPOE Patient from Census<br />
* Order entry session start<br />
* Selection of individual order<br />
* Selecting details for individual order<br />
* Completing (signing) order<br />
<br />
<b> Approaches - "subtle" to "intrusive" </b><br />
<br />
* Incidental - side text, within order entry window<br />
* Incidental link to additional information or evidence<br />
* Interactive - requires minimal user action to continue<br />
* Pop-Up alerts that user must acknowledge<br />
<br />
== Conclusion ==<br />
<br />
Implementing CDS during CPOE requires a good understanding of the different types of decision support as well as an appreciation for clinicians' workflow and tolerance (or lack of) for being interrupted. <br />
<br />
== Comments ==<br />
<br />
I would just add that the informaticist facilitating the development of CDSS for CPOE should also understand the culture of the medical staff and the tolerance for any interruption at all. As a teaching hospital, Vanderbilt was able to leverage more accepting residents as end users and champions. <br />
<br />
== References ==<br />
<br />
<references/><br />
<br />
[[Category: Reviews]]<br />
[[Category:CDS]]<br />
[[Category:CPOE]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[Category:EHR]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Physician_attitudes_toward_health_information_exchange:_Results_of_a_statewide_surveyPhysician attitudes toward health information exchange: Results of a statewide survey2015-11-10T01:55:05Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>This is a review of Wright’s article "Physician attitudes toward health information exchange: results of a statewide survey".<ref name="Wright 2010">Wright, A., Soran, C., Jenter, C., Volk, L., Bates, D., & Simon, S. (2010). Physician attitudes toward health information exchange: Results of a statewide survey. Journal of the American Medical Informatics Association, 66-70</ref> <br />
<br />
== Background ==<br />
[[HIE|Health Information Exchanges (HIE)]] are supposed to be enhance the continuity of patient care. It is an emerging technology and it is of high interest to increase the healthcare quality. However, like with any new technology, there needs to be awareness and adoption. This is an area HIEs may currently be lacking in, especially with physician groups. The purpose of the article is to assess physician attitudes towards HIE’s and their willingness to participate. <ref name="Wright 2010"> </ref><br />
<br />
== Methods ==<br />
The methodology used was a mail survey to physicians in the Massachusetts area. They were asked what effects they thought the HIE would have on healthcare cost, quality of patient care and time efficiency for physicians. They were also asked to indicate their attitude towards HIE as well as their concern for security/privacy. Lastly, they were questioned their willingness to pay for the technology.<ref name="Wright 2010"> </ref><br />
<br />
== Results ==<br />
From the survey, they received 77% response rate. 70% of physicians thought an HIE would reduce costs. 86% thought it would improve quality and lastly 76% thought it would be more time efficient for clinicians. In regards to privacy and security, 16% expressed concern for it. Over half (54%) stated they would be willing to pay for the technology at an unspecified fee. When a specified fee of $150 was mentioned, only 37% said they would be willing to pay for it. <ref name="Wright 2010”> </ref><br />
<br />
== Conclusion ==<br />
Based on the results, many physicians believe HIE can have a positive impact in healthcare. At the same time, they expressed concern on the privacy implications it may have. Overall, the majority are willing to participate but some may not want to pay. <ref name="Wright 2010"> </ref><br />
<br />
== Comments == <br />
There are many [[EMR_Benefits:_HIE|benefits]] of HIE. Physician awareness and attitude towards these benefits will greatly influence the adoption of the technology. Based on the article’s findings, positive attitudes exist as long as the cost is not too steep. Education on this technology and spreading awareness for its benefits appears to be key to adoption in the future. The other challenges to widespread adoption of the HIE is lack of standards of data definitions. Without these standards it may become very difficult for different EHR's to communicate with each other and exchange information.<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category:Reviews]]<br />
[[Category:HIE]]<br />
[[Category:Interoperability]]<br />
[[Category:HI5313-2015-FALL]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Redesigning_electronic_health_record_systems_to_support_public_health.Redesigning electronic health record systems to support public health.2015-11-10T01:38:04Z<p>Arshad Ghauri: /* Second Review */</p>
<hr />
<div>Redesigning electronic health record systems to support public health. <br />
<br />
Rita Kukafka , Jessica S Ancker , Connie Chan , John Chelico , Sharib Khan , Selasie Mortoti , Karthik Natarajan , Kempton Presley , Kayann Stephens <br />
J Biomed Inform. 2007 Jul 9; <br />
<br />
===First Review=== <br />
<br />
This article discusses the following question: Why current electronic health record systems need to be redesigned to better support public health goals and core functions (assessment, policy development, assurance). Current EHR systems are clinically oriented. Identification and discussion of design, implementation, and methodological issues.Current EHR systems focus on the individual patient care provided by clinicians. Recommendations are provided for changes to current EHR systems will benefit public health but also provide benefits to consumers and health care providers. The needs of public health are not met by the current clinically focused EHR systems. Changes in these EHR systems would benefit but also pose challenges to a number of stakeholders. Two broad suggestions are offered: reuse of clinical data for public health purposes and expansion of the clinical data model to collect and process public health data such as psychosocial, behavioral, and environmental variables. The article identifies a third issue as outside the scope of this discussion (privacy and security protections). The authors offer specific suggestions for expanding the current clinical model (to better reflect and address public health core functions) using informatics methods.<br />
<br />
As discussed by Kukafka and colleagues, in order to serve public health needs current (and by implication) future electronic health record systems should be redesigned. The authors identify specific public health data collection and reporting requirements that are not routinely met by current EHR systems. If EHR systems are modified, public health might be able to reduce the amount of reportable data collection that is currently conducted via surveys and paper-based processes, thus reducing the amount of redundant or duplicate data reporting by clinicians. The authors’ suggestion that “data should be collected once and only once” seems sensible but idealistic given the current complex health system and the diversity of data user needs and specifications. However, the authors make a good case for relooking at the data that are currently collected and proposing that current standards and data modeling efforts be enhanced to better address the (increasing) needs of public health. The authors pose relevant arguments that benefits would accrue to clinicians and public health by incorporating 2 major changes to current EHR systems (more reuse of currently collected data and collection of new data). <br />
<br />
reviewed by Meryl Bloomrosen <br />
<br />
===Second Review===<br />
<br />
Introduction- This article focuses on how EHRs (also known as [[EMR]]s) can be designed to help achieve the core functions of public health, which are: Assessment, Policy, and Assurance. It states that EHRs are mostly focused on the clinical aspects of care, and not on the socio-behavioral or economic. The authors examine ways that EHRs can be designed to assist with public health duties without intruding on the clinician’s workflow.<br />
<br />
Methods- The article is divided into sections, one for each core function of public health.<br />
Assessment: The sharing of data directly from EHRs to public health agencies would allow almost real-time collection of data and alleviate the paperwork that physicians must complete for disease reporting.<br />
Policy: With better data available, the public can be better informed and the best decisions can be made regarding what actions to take (policy) concerning the data results.<br />
Assurance: Providing EHRs to clinics and patients which are located in underserved areas will help ensure the continuity of care of the patients.<br />
<br />
Conclusion- The authors conclude that designing EHRs to better accommodate public health duties has benefits for all stakeholders. However, they also acknowledge that such a task will have its difficulties and require time.<br />
<br />
My comments- This article was published in 2007, when EHRs were significantly less implemented than they are today and their functions were still analyzed and debated. I like the idea of an EHR which is more suited for public health duties, and hopefully this will become a reality in the near future.<ref name="Kukafka et al. 2007"> Kukafka, R., Ancker, J.S., Chan, C., Chelico, J., Khan, S., Mortoti, S.,..., Stephens, K.(2007). Redesigning electronic health record systems to support public health. Journal of Biomedical Informatics, 40(4)398-409. http://dx.doi.org/10.1016/j.jbi.2007.07.001.</ref><br />
<br />
reviewed by Alexandra Zingg<br />
<br />
====Additional comments====<br />
This has obvious benefits that it reduces the work associated with reporting requirements and as well as has the potential of increased reporting hence allowing for better data. These EHR should not only be able to take care of the present requirements but also should be easily modifiable for the future needs. For diseases that do not require patient specific information how would the patient privacy be maintained?<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category: BMI-512-F-07]]<br />
[[Category: Reviews]]<br />
[[Category: Public Health]]<br />
[[Category: HI5313-2015-FALL]]<br />
[[Category: EHR]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Information_Technology_Improves_Emergency_Department_Patient_Discharge_Instructions_Completeness_and_Performance_on_a_National_Quality_MeasureInformation Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure2015-11-03T03:32:30Z<p>Arshad Ghauri: </p>
<hr />
<div>This is a first review of the article "Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure." <ref name="ED Discharge instructions">Bell, E. J., Takhar, S. S., Beloff, J. R., Schuur, J. D., & Landman, A. B. (2013). Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure: A Quasi-Experimental Study. Applied Clinical Informatics, 4(4), 499–514. http://doi.org/10.4338/ACI-2013-07-RA-0046</ref><br />
<br />
===Background===<br />
In US there were roughly 130 million ED visits in 2010. Out of these visits, roughly 87% were discharged home with discharge instructions. Discharge instructions with medication discrepancies or which are deficient in important patient information results in poor patient outcomes and increase resource utilization post discharge.<br />
Discharge summaries containing following criteria: principal diagnosis or chief complaint; major procedures and tests performed; patient care instructions; follow-up instructions; and new or changed medications are considered adequate discharge instructions. Centers for Medicare and Medicaid Services (CMS) developed Outpatient Measure 19 (OP-19) that includes all of these above criteria. Information technology is believed to improve the quality of discharge instructions. This study was done to evaluate the completeness of electronic discharge instructions after such a module was developed and implemented in the [[EMR|Electronic Health Records (EHRs)]] used in the study hospital using this CMS quality measure OP-19 as the benchmark.<br />
<br />
==Methods==<br />
Brigham and Women’s Hospital in Boston developed an electronic discharge instructions module, which was implemented in May 2012. This study was done to compare the quality of discharge instructions of random ED discharges from two time periods, pre and post-implementation of this module. A total of 300 patients, 150 each in two groups were randomly selected from a period of pre and post-implementation of the discharge instruction module. The selected patients, in short to be eligible for the study, had to have completed evaluation in the ED and were discharged home.<br />
<br />
==Results==<br />
Overall compliance for paper based and electronic discharge instructions with CMS measure OP-19 was 46.7% (70/150) and 97.3% (146/150). 40% of the paper based discharge instructions lacked major procedures and tests performed section, whereas all 4 of the incomplete electronic discharge instructions lacked patient instructions.<br />
<br />
==Comments==<br />
This study shows the impact of health information technology in improving the discharge instructions. Electronically created discharge instructions allow easy inclusion of the test results and therefore resulted in producing complete discharge instructions. In the, as fragmented as it could be, healthcare environment in US, a complete discharge instruction, may result in decreased resource utilization post ED visit but this remains to be proven.<br />
<br />
==References==<br />
<references/><br />
<br />
[[Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[Category:EHR ]]<br />
[[Category:Electronic discharge]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Evaluation_of_electronic_discharge_summaries:_A_comparison_of_documentation_in_electronic_and_handwritten_discharge_summariesEvaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries2015-11-03T03:29:38Z<p>Arshad Ghauri: /* Commentary */</p>
<hr />
<div>This is the first review of the article "Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries."<ref name="Discharge Summary">Joanne L. Callen, Melanie Alderton, Jean McIntosh, Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries, International Journal of Medical Informatics, Volume 77, Issue 9, September 2008, Pages 613-620, ISSN 1386-5056, http://dx.doi.org/10.1016/j.ijmedinf.2007.12.002.<br />
(http://www.sciencedirect.com/science/article/pii/S1386505608000026)<br />
Keywords: Electronic discharge summary; Handwritten discharge summary; Hospital discharge; Discharge communication; Australia</ref><br />
<br />
==Background and Objective==<br />
In this study a comparison between handwritten or dictated discharge summaries is done with the electronically created discharge summaries. This study was conducted in Australia after installing a system that can create discharge summaries electronically in a teaching hospital. The objectives of this study were two fold: first to evaluate the quality of discharge summaries per se and second to compare electronic discharge summaries with the handwritten or dictated ones for deficiencies or omissions. This was a retrospective study and compared electronic discharge summaries created using templates in [[EMR|Electronic Health Records (EHRs)]] with either handwritten or dictated ones.<br />
<br />
===Methods===<br />
A total of 245 eligible discharge summaries were identified. Out of these discharge summaries, 151 were electronically completed and 94 were handwritten. These discharge summaries were then evaluated for their completion. The following criteria were used: discharge date, additional diagnosis, summary of the hospital course; discharge medication and follow-up plans. These plans were to be executed by the PCP’s. <br />
<br />
===Results===<br />
Data analysis showed that electronic discharge summaries had a higher number of errors as compared to the handwritten ones. However, most errors were related to omission of discharge date. Handwritten discharge summaries on the other hand missed summary of the hospital course. One interesting finding was that overall medication error rate was small in both electronic and handwritten ones.<br />
<br />
<br />
===Conclusion===<br />
The authors concluded that electronic discharge summaries necessarily are not better as compared to the handwritten ones, but were unable to satisfactorily identify factors that led to incomplete discharge summaries. In addition, two physicians who completed the most electronic discharge summaries had most errors of omission in discharge date. This may be related to the inadequate training to these physicians and could have resulted in different findings had these physicians received a timely feedback.<br />
<br />
===Commentary===<br />
I used this article for many reasons; first of all with fragmented healthcare in US, a complete discharge summary is a very important tool to provide continuity of care. Second, though hospital bylaws usually dictate that a discharge summary should be completed in a timely manner and there is an expectation that discharge summaries should conform to some standards, there is generally no regular audit for the completeness or quality of the discharge summaries. EHR’s represents an opportunity to provide improvement in this area by creating a template in which specific components of the discharge summary can be auto-populated and allows for inclusion of other items from the coded data as needed. In addition a template that with some modification can duplicate as discharge instructions to the patient. This may help provide better discharge instructions and in an article [[Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications]] <ref name="Lindquist (2012"> Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications.Lindquist LA1, Go L, Fleisher J, Jain N, Friesema E, Baker DW.J Gen Intern Med. 2012 Feb;27(2):173-8. doi: 10.1007/s11606-011-1886-3. Epub 2011 Oct 5.http://www.ncbi.nlm.nih.gov/pubmed/21971600 </ref> may help reduce medication errors. A properly developed electronic discharge summary template which may allow physicians to create discharge instructions may increase physician satisfaction. In a quasi experimental study [[Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure]] the authors compared the completeness of ED discharge instructions created through the use of an electronic discharge module with the hand written ones and found that the ED discharge instructions were more complete when the ED physicians used the electronic discharge instruction module.<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[Category:EHR ]]<br />
[[Category:Quality Analysis]]<br />
[[Category:Electronic discharge]]<br />
[[Category:Other Technologies]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Information_Technology_Improves_Emergency_Department_Patient_Discharge_Instructions_Completeness_and_Performance_on_a_National_Quality_MeasureInformation Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure2015-11-03T03:22:01Z<p>Arshad Ghauri: Created page with "This is a first review of the article "Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality M..."</p>
<hr />
<div>This is a first review of the article "Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure." <ref name="ED Discharge instructions">Bell, E. J., Takhar, S. S., Beloff, J. R., Schuur, J. D., & Landman, A. B. (2013). Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure: A Quasi-Experimental Study. Applied Clinical Informatics, 4(4), 499–514. http://doi.org/10.4338/ACI-2013-07-RA-0046</ref><br />
<br />
===Background===<br />
In US there were roughly 130 million ED visits in 2010. Out of these visits, roughly 87% were discharged home with discharge instructions. Discharge instructions with medication discrepancies or which are deficient in important patient information results in poor patient outcomes and increase resource utilization post discharge.<br />
Discharge summaries containing following criteria: principal diagnosis or chief complaint; major procedures and tests performed; patient care instructions; follow-up instructions; and new or changed medications are considered adequate discharge instructions. Centers for Medicare and Medicaid Services (CMS) developed Outpatient Measure 19 (OP-19) that includes all of these above criteria. Information technology is believed to improve the quality of discharge instructions. This study was done to evaluate the completeness of electronic discharge instructions after such a module was developed and implemented in the [[EMR|Electronic Health Records (EHRs)]] used in the study hospital using this CMS quality measure op-19 as the benchmark.<br />
<br />
==Methods==<br />
Brigham and Women’s Hospital in Boston developed an electronic discharge instructions module, which was implemented in May 2012. This study was done to compare the quality of discharge instructions of random ED discharges from two time periods, pre and post-implementation of this module. A total of 300 patients, 150 each in two groups were randomly selected from a period of pre and post-implementation of the discharge instruction module. The selected patients, in short to be eligible for the study, had to have completed evaluation in the ED and were discharged home.<br />
<br />
==Results==<br />
Overall compliance for paper based and electronic discharge instructions with CMS measure OP-19 was 46.7% (70/150) and 97.3% (146/150). 40% of the paper based discharge instructions lacked major procedures and tests performed section, whereas all 4 of the incomplete electronic discharge instructions lacked patient instructions.<br />
<br />
==Comments==<br />
This study shows the impact of health information technology in improving the discharge instructions. Electronically created discharge instructions allow easy inclusion of the test results and therefore resulted in producing complete discharge instructions. In the, as fragmented as it could be, healthcare environment in US, a complete discharge instruction, may result in decreased resource utilization post ED visit but this remains to be proven.<br />
<br />
==References==<br />
<references/></div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/The_financial_impact_of_health_information_exchange_on_emergency_department_careThe financial impact of health information exchange on emergency department care2015-10-26T01:50:19Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>This is a review of Frisse’s article "The financial impact of health information exchange on emergency department care".<ref name="Frisse 2011">Frisse, M., Johnson, K., Hui,N., Davison, C., Gadd, C., & Unertl, K. (2011). The financial impact of health information exchange on emergency department care. Cost-effectiveness of informatics and health IT: impact on finances and quality of care. J Am Med Inform Assoc. 19(3), 328-333. Retrieved October 19, 2015 from http://jamia.oxfordjournals.org/content/19/3/328</ref> <br />
<br />
== Background ==<br />
Delivery of care usually occurs at multiple settings and sites. To help improve this coordination of care and the continuity of it, HIEs were formed. [[HIE|Health Information Exchanges (HIE)]] are supposed to be enhance the continuity of patient care. It allows clinicians to gain access to patient data coming from other locations of care. HIE is slowly growing on a national level, but since it is still a growing technology, most of its benefits have not truly been truly recorded and measured. The purpose of the article is to discover the impact health information exchanges have on hospital admission and diagnostic testing in the emergency department setting.<br />
<ref name="Frisse 2011”> </ref><br />
<br />
== Methods ==<br />
The methodology used for this study included studying all ED encounters over a 13 month period. Coming from all major EDs in Memphis, TN, all HIE data was accessed and pulled for. These HIE records were matched with similar encounter records without HIE access. The study focused on ED-originated hospital admissions, lab testing such as head CTs, body CTs, radiographs, and other actions related to ED encounters. The regression models used were to measure the admission type, length of stay and co-morbidity index. <ref name="Frisse 2011”> </ref><br />
<br />
== Results ==<br />
From their findings, HIE data was accessed about 6.8% of ED visits out of all 12 EDs in the city. 11 of these EDs used a secure web browser to access the HIE. These were associated with a decrease in hospital admissions. The 1 other ED used print summaries, the HIE data access was also associated with a decrease in hospital admissions. More notably, there was a significant decrease in head CT, body CT and lab orders. HIE access resulted in a $1.9 million cost in annual savings. It also reduced overall costs by $1.07 million. The reduction in hospital admissions accounted for 97.6% of these savings. <ref name="Frisse 2011”> </ref><br />
<br />
== Conclusion ==<br />
Based on the results, having the ability to access HIE data, thus more clinical data, was associated with a net saving in an emergency department setting. <ref name="Frisse 2011”> </ref><br />
<br />
== Comments == <br />
Studies like this need to be done more frequently to prove the value and [[EMR_Benefits:_HIE|benefits]] of HIE. It is very interesting how much cost savings there was in this study. While the HIE may not have significant impact in other specialties and departments, the study clearly shows the benefits it does have in an emergency department setting. The reduction in redundant testing and hospital admissions benefits both the patient and cost of healthcare.<br />
<br />
In addition to the cost of tests as mentioned in the study, there are potential benefits of saving the patients from extra radiation they receive due to extra CT scans. This in itself is a huge benefit to the patients. Patients with functional disorder tend to hop from ER to ER and receive numerous tests done including CT scans. With a reliable and real time access to the radiological studies done elsewhere, as it was noted in this study, there was less use of radiological test.<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[Category:HIE]]<br />
[[Category:Interoperability]]<br />
[[Category:Benefits and Costs]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/The_financial_impact_of_health_information_exchange_on_emergency_department_careThe financial impact of health information exchange on emergency department care2015-10-26T01:49:00Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>This is a review of Frisse’s article "The financial impact of health information exchange on emergency department care".<ref name="Frisse 2011">Frisse, M., Johnson, K., Hui,N., Davison, C., Gadd, C., & Unertl, K. (2011). The financial impact of health information exchange on emergency department care. Cost-effectiveness of informatics and health IT: impact on finances and quality of care. J Am Med Inform Assoc. 19(3), 328-333. Retrieved October 19, 2015 from http://jamia.oxfordjournals.org/content/19/3/328</ref> <br />
<br />
== Background ==<br />
Delivery of care usually occurs at multiple settings and sites. To help improve this coordination of care and the continuity of it, HIEs were formed. [[HIE|Health Information Exchanges (HIE)]] are supposed to be enhance the continuity of patient care. It allows clinicians to gain access to patient data coming from other locations of care. HIE is slowly growing on a national level, but since it is still a growing technology, most of its benefits have not truly been truly recorded and measured. The purpose of the article is to discover the impact health information exchanges have on hospital admission and diagnostic testing in the emergency department setting.<br />
<ref name="Frisse 2011”> </ref><br />
<br />
== Methods ==<br />
The methodology used for this study included studying all ED encounters over a 13 month period. Coming from all major EDs in Memphis, TN, all HIE data was accessed and pulled for. These HIE records were matched with similar encounter records without HIE access. The study focused on ED-originated hospital admissions, lab testing such as head CTs, body CTs, radiographs, and other actions related to ED encounters. The regression models used were to measure the admission type, length of stay and co-morbidity index. <ref name="Frisse 2011”> </ref><br />
<br />
== Results ==<br />
From their findings, HIE data was accessed about 6.8% of ED visits out of all 12 EDs in the city. 11 of these EDs used a secure web browser to access the HIE. These were associated with a decrease in hospital admissions. The 1 other ED used print summaries, the HIE data access was also associated with a decrease in hospital admissions. More notably, there was a significant decrease in head CT, body CT and lab orders. HIE access resulted in a $1.9 million cost in annual savings. It also reduced overall costs by $1.07 million. The reduction in hospital admissions accounted for 97.6% of these savings. <ref name="Frisse 2011”> </ref><br />
<br />
== Conclusion ==<br />
Based on the results, having the ability to access HIE data, thus more clinical data, was associated with a net saving in an emergency department setting. <ref name="Frisse 2011”> </ref><br />
<br />
== Comments == <br />
Studies like this need to be done more frequently to prove the value and [[EMR_Benefits:_HIE|benefits]] of HIE. It is very interesting how much cost savings there was in this study. While the HIE may not have significant impact in other specialties and departments, the study clearly shows the benefits it does have in an emergency department setting. The reduction in redundant testing and hospital admissions benefits both the patient and cost of healthcare.<br />
In addition to the cost of tests as mentioned in the study, there are potential benefits of saving the patients from extra radiation they receive due to extra CT scans. This in itself is a huge benefit to the patients. Patients with functional disorder tend to hop from ER to ER and gets numerous tests done including CT scans. With a reliable and real time access to the radiological studies done elsewhere, as it was noted in this study, there was less use of radiological test.<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[Category:HIE]]<br />
[[Category:Interoperability]]<br />
[[Category:Benefits and Costs]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/The_financial_impact_of_health_information_exchange_on_emergency_department_careThe financial impact of health information exchange on emergency department care2015-10-26T01:44:33Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>This is a review of Frisse’s article "The financial impact of health information exchange on emergency department care".<ref name="Frisse 2011">Frisse, M., Johnson, K., Hui,N., Davison, C., Gadd, C., & Unertl, K. (2011). The financial impact of health information exchange on emergency department care. Cost-effectiveness of informatics and health IT: impact on finances and quality of care. J Am Med Inform Assoc. 19(3), 328-333. Retrieved October 19, 2015 from http://jamia.oxfordjournals.org/content/19/3/328</ref> <br />
<br />
== Background ==<br />
Delivery of care usually occurs at multiple settings and sites. To help improve this coordination of care and the continuity of it, HIEs were formed. [[HIE|Health Information Exchanges (HIE)]] are supposed to be enhance the continuity of patient care. It allows clinicians to gain access to patient data coming from other locations of care. HIE is slowly growing on a national level, but since it is still a growing technology, most of its benefits have not truly been truly recorded and measured. The purpose of the article is to discover the impact health information exchanges have on hospital admission and diagnostic testing in the emergency department setting.<br />
<ref name="Frisse 2011”> </ref><br />
<br />
== Methods ==<br />
The methodology used for this study included studying all ED encounters over a 13 month period. Coming from all major EDs in Memphis, TN, all HIE data was accessed and pulled for. These HIE records were matched with similar encounter records without HIE access. The study focused on ED-originated hospital admissions, lab testing such as head CTs, body CTs, radiographs, and other actions related to ED encounters. The regression models used were to measure the admission type, length of stay and co-morbidity index. <ref name="Frisse 2011”> </ref><br />
<br />
== Results ==<br />
From their findings, HIE data was accessed about 6.8% of ED visits out of all 12 EDs in the city. 11 of these EDs used a secure web browser to access the HIE. These were associated with a decrease in hospital admissions. The 1 other ED used print summaries, the HIE data access was also associated with a decrease in hospital admissions. More notably, there was a significant decrease in head CT, body CT and lab orders. HIE access resulted in a $1.9 million cost in annual savings. It also reduced overall costs by $1.07 million. The reduction in hospital admissions accounted for 97.6% of these savings. <ref name="Frisse 2011”> </ref><br />
<br />
== Conclusion ==<br />
Based on the results, having the ability to access HIE data, thus more clinical data, was associated with a net saving in an emergency department setting. <ref name="Frisse 2011”> </ref><br />
<br />
== Comments == <br />
Studies like this need to be done more frequently to prove the value and [[EMR_Benefits:_HIE|benefits]] of HIE. It is very interesting how much cost savings there was in this study. While the HIE may not have significant impact in other specialties and departments, the study clearly shows the benefits it does have in an emergency department setting. The reduction in redundant testing and hospital admissions benefits both the patient and cost of healthcare.<br />
In addition to the cost of tests there are potential benefits of saving the patients from extra radiation they receive due to extra CT scans. Patients with functional disorder tend to hop from ER to ER and gets numerous tests done including CT scans. If the ER physicians can have reliable and real time access to the radiological studies they may be less inclined to repeat these studies.<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[Category:HIE]]<br />
[[Category:Interoperability]]<br />
[[Category:Benefits and Costs]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/PACS_-_Next_GenerationPACS - Next Generation2015-10-26T01:37:55Z<p>Arshad Ghauri: /* Impressions */</p>
<hr />
<div>Review: Parikh, A. & Mehta, N. (2015) PACS: next generation. ''Proc. SPIE 9418, Medical Imaging 2015: PACS and Imaging Informatics: Next Generation and Innovations. 9148''(94180G), 1-8. doi: [http://spie.org/Publications/Proceedings/Paper/10.1117/12.2081987 10.1117/12.2081987]<ref name=article>Parikh, A. & Mehta, N. (2015) PACS: next generation. ''Proc. SPIE 9418, Medical Imaging 2015: PACS and Imaging Informatics: Next Generation and Innovations. 9148''(94180G), 1-8. doi: [http://spie.org/Publications/Proceedings/Paper/10.1117/12.2081987 10.1117/12.2081987]. Retrieved via ILLiad Interlibrary Loan.</ref><br />
<br />
==Introduction==<br />
The authors argue that the future of Picture Archiving and Communication Systems ([[PACS]]) is web-based because the expense of building and supporting traditional PACS may be financially unrealistic in many environments, while a web-based system could be more compelling due to potential for reduced costs and increased flexibility.<br />
<br />
The authors' position is that web technologies have recently arrived at a point at which all the functionality of a traditional PACS can be replaced with web-based cloud infrastructure and "zero footprint viewers" that could run without installation, from a web page within a browser, securely without need of a dedicated VPN. They state that existing PACS technology is limited in that it cannot readily be used to push, for example, "send alerts to patient care providers" whereas a web-based platform could, using existing technology.<br />
<br />
The authors note that existing PACS deployments are aging, and they assert that now is the time for institutions ready to replace their PACS to consider the possibilities of a new web-based architecture.<br />
==Traditional PACS==<br />
The article defines a traditional PACS as consisting broadly of three component capabilities:<br />
# Image management and display, meaning the client functionality of viewing DICOM images<br />
# Communications, such as query-retrieve functionality<br />
# Administration, including filing of images, image storage, and access security.<br />
===Traditional PACS Limitations===<br />
The article outlines particular limitations of traditional PACS specific to each of these categories.<br />
# Image display<br />
#* The authors note that PACS tend to lack streaming support for a lot of media, so files may have to be downloaded completely before any viewing is possible. Relatedly, many vendors require workstations specific to their modalities, adding to procurement and maintenance cost.<br />
# Communications<br />
#* PACS traditionally being constrained to a LAN means that radiologists may have a hard time sharing images with outside providers; many hurdles exist to providing access to PACS data while maintaining security.<br />
#* PACS systems may not have a fully- or accurately-implemented DICOM API, meaning that some queries could fail under certain circumstances; that is, one PACS' results could be inconsistent with another for the same query.<br />
#* The DICOM standard is domain-specific, so a lot of specialized knowledge is needed to develop and support PACS systems, leading to cost increase.<br />
# Administration<br />
#* Some traditional PACS do not use relational databases, so data organization can be challenging.<br />
#* Traditional PACS reliance on hardware architecture also leads to many costs; hardware maintenance and management is expensive, and acquisition can be out of reach for institutions in developing countries.<br />
==Future of PACS - Web-Based==<br />
A web-based PACS solution, according to the authors, is particularly well-suited to limiting access to medical images to authorized users, and to using RDBMS to handle image organization.<br />
<br />
The HTML5 standard, only recently officially recommended, is crucial for displaying DICOM image data without lossy down-conversion, according to the article. Additionally, recent CSS3 standards are needed for certain display techniques that could be needed for prior image comparison. Thus, a web-based solution of the type they propose was impossible until recently. These standards along with cloud computing's current ubiquity makes implementing web-based PACS more attractive because hardware costs are abstracted away from the solution.<br />
<br />
The article outlines and describes in considerable, sometimes technical, detail how a web-based solution could address each of the shortcomings of traditional PACS described earlier.<br />
<ol><br />
<li>Image management and display<br />
<ol type=a><br />
<li>HTML5 <code><canvas></code> element "provides the ability to read image intensities" in the browser so no plugins are needed to implement functionality available on existing DICOM workstations, such as image density manipulation, using mouse gestures to activate client-side JavaScript code to manipulate image density and other properties.</li><br />
<li>The use of [http://en.wikipedia.org/wiki/Ajax_(programming) AJAX] techniques allows a web client programmer to specify that images be loaded partially, which can speed up loading times overall &mdash; that is, the first image in a series might load immediately and be available for the user while other images are still loading in the background, reducing the user's perception of system latency, and thereby eliminating the requirement of a low-latency LAN as a core component of a PACS. Advanced AJAX techniques taking advantage of features of HTML5 can also be used to load a lower resolution version of an image very quickly while in the background the full resolution version is loaded for display, reducing perceived latency even further.</li><br />
</ol><br />
</li><br />
<li>Communications<br />
<ol type=a><br />
<li>Streaming technologies mentioned above reduce image presentation latency significantly.</li><br />
<li>Querying traditional PACS is generally limited to using DICOM [http://nipy.bic.berkeley.edu/nightly/nibabel/doc/dicom/dicom_intro.html#dicom-services-dimse DIMSE] protocols for image retrieval, whereas web-based applications can use a number of options. The authors focus on [http://en.wikipedia.org/wiki/Representational_state_transfer REST] APIs as the presumed mode of operation, noting their strengths as being able to completely replicate functionality of DIMSE protocols and to provide a robust authentication/authorization capability.</li><br />
</ol><br />
</li><br />
<li>Administration<br />
<ol type=a><br />
<li>Cloud computing is cited as beneficial for a number of reasons:</li><br />
<ol type=i><br />
<li>The "pay as you go" model for storage and compute capacity offered by cloud providers provides a cost savings in that dedicated storage/compute need not be provisioned beforehand; fixed costs are therefore reduced.</li><br />
<li>Data replication between a number of global cloud data centers could provide for reduction of latency for images that must be accessed in a number of locations around the globe.</li><br />
<li>Cloud provisioning can provide built-in High Availability, data backups, and disaster recovery capabilities, reducing the IT workload for an institution.</li><br />
</ol><br />
<li>Security<br />
<ol type=i><br />
<li>The authors cite the availability of at-rest and on-wire encryption as a reasonable substitute for physical custody of data and devices.</li><br />
<li>They state that authentication models such as OAuth and two-factor authentication can be leveraged to provide a more distributed security model.</li><br />
</ol><br />
</li><br />
<li>Interoperability<br />
<ul><br />
<li>The authors note that the new HL7 [[FHIR]] standard uses XML natively, and as such could be readily used for data interchange in the context of a web-based PACS built on RESTful services and web protocols.</li><br />
</ul><br />
</ol><br />
</li><br />
<li>Additional Capabilities<br />
The authors assert that a web-based PACS could also provide a number of services traditional PACS cannot.<br />
<ol type=a><br />
<li>Notification - a web-based PACS could provide email notification based on any number of conditions, or when an item is shared.</li><br />
<li>Hyperlinking to images in PACS from other applications</li><br />
<li>Image sharing via emailed hyperlinks</li><br />
<li>Server-side image processing - the authors provide the example of creating edge detection overlays for images in the PACS that could be displayed on the PACS client on demand.</li><br />
<li>Image annotation - data added by radiologists could be stored as image metadata.</li><br />
<li>Image anonymization - The authors assert that "a web-based system can offer two type of anonymization techniques" but no details are provided. The phrasing seems to indicate that a portion of text was left out of the published paper.</li><br />
<li>Radiology report template matching based on image/study type could allow doctors to automatically load the appropriate interpretation report template for a given study based on the image metadata.</li><br />
</ol><br />
</li><br />
</ol><br />
==Conclusions==<br />
The authors conclude that new technologies will enable PACS to be deployed in a cloud environment, allowing developing countries to benefit from the associated cost savings, but they also predict that web-based cloud-enabled PACS deployments will generally supplant traditional PACS as well.<br />
==Impressions==<br />
I couldn't understand the authors' argument for the change in security model. While it's clear that a different model would be needed for a web-based PACS system vs a traditional one, it's not clear from their description that an OAuth or two-factor system would adequately address an institution's security concerns; they didn't clarify how such a model would serve business requirements. A federated authentication or single signon scheme could be implemented for a PACS such as what they describe; however, this would not address any of the concerns an institution might have about how to administer sharing of image resources, which is one of the benefits that the authors are touting with this piece.<br />
<br />
It was startling to encounter a plainly missing section of text; image anonymization is an important feature, but it is not described at all. That section of the paper ends with a colon, indicating that additional text was intended to be inserted but was not.<br />
<br />
The authors assertions about traditional PACS not having a variety of features that would be available in the proposed web-based system strike me as odd. I am somewhat familiar, at least, with two of the major mainstream PACS systems, specifically Philips iSite/IntelliSpace and the GE PACS product. Both of these use RDBMS, and have for many years. They have a number of features for dynamic loading of images in their (web-based!) clients; they can annotate images at the workstation and save those annotations as image metadata; the Philips PACS can use its Standard URL-Based Integration (SUBI) protocol to link directly to images in the PACS via web services. Because of all these factors, it seems to me that some of the authors criticisms of "traditional PACS" are misplaced.<br />
<br />
That being said, I agree with their conclusion; in fact the current state of PACS such as Philips' offering goes some way to support it. The Philips PACS is already web-based with a RDBMS backend, and is capable of using federated authentication. It would be a major leap, though, for commercial offerings such as theirs to move to the cloud, and to using shareable URLs and authentication protocols such as OAuth.<br />
<br />
Could having PACS in a cloud environment will allow improved working conditions for the radiologists? A study that is done at night time here can be read by a day time radiologists across the globe in a timely manner.<br />
<br />
==References==<br />
<references/><br />
Note: I was also able to download this paper directly from the authors' web site: http://www.netdicom.net/Uploads/Documents/94180G.pdf<br />
<br />
[[Category:Reviews]]<br />
[[Category:PACS]]<br />
[[Category:Interoperability]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/A_clinical_decision_support_needs_assessment_of_coummunity-based_physiciansA clinical decision support needs assessment of coummunity-based physicians2015-10-26T01:33:05Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>This is a qualitative study by Joshua E Richardson and Joan S Ash. (2011) in the Journal of American Medical Informatics Association, entitled “A clinical decision support needs assessment of community-based physicians.” <ref name ="Richardson"> Richardson et al, http://jamia.oxfordjournals.org/content/18/Supplement_1/i28.abstract</ref><br />
<br />
==Introduction==<br />
The Clinical Decision Support ([[CDS]]) Systems provide healthcare providers and consumers with knowledge and person-based information, intelligently filtered and presented at appropriate times to improve health and healthcare. <br />
<br />
CDS supports this knowledge to:<br />
#Clinician<br />
#Staff<br />
#Patients<br />
#Other individuals<br />
<br />
The goal of the study was to provide a user-centered perspective that could help developers optimize CDS functions to meet the needs of physicians in a community-based setting. <ref name ="Richardson"> Richardson et al, http://jamia.oxfordjournals.org/content/18/Supplement_1/i28.abstract</ref><br />
<br />
==Methods==<br />
The purpose of the study was to gain community-based physicians’ perspectives in decision-making, which include: <br />
# goals<br />
# Environments<br />
# Tasks<br />
# Desired support tools<br />
<br />
The study utilized human-computer interaction model<br />
# 30 recorded interviews <br />
# 25 Observations - primary care providers<br />
# 15 Observations - Urban and rural community based clinics<br />
<br />
==Conclusion==<br />
The findings from the study suggest that the decision support needs to be extended from current process. Two other opinions brought up by the physicians were:<br />
#Addition of wide range of clinical decision-making <br />
#Improvement in cognitive decision-making<br />
<br />
==Comments==<br />
A well designed CDS system can help clinicians in managing their patients effectively. As and example if CDS can track of routine health maintenance tasks of a provider panel of patients, and then send a reminder or having the ability to generate a list of patients with incomplete recommended health maintenance can help provide better and timely care.<br />
<br />
==Reference==<br />
<references/><br />
Richardson, J. E., & Ash, J. S. (2011). A clinical decision support needs assessment of community-based physicians. Journal of the American Medical Informatics Association, 18(Supplement 1), i28-i35.<br />
<br />
<br />
[[Category : Reviews]]<br />
<br />
[[Category : CDS]]<br />
<br />
[[ Category:EHR ]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/A_clinical_decision_support_needs_assessment_of_coummunity-based_physiciansA clinical decision support needs assessment of coummunity-based physicians2015-10-26T01:27:48Z<p>Arshad Ghauri: </p>
<hr />
<div>This is a qualitative study by Joshua E Richardson and Joan S Ash. (2011) in the Journal of American Medical Informatics Association, entitled “A clinical decision support needs assessment of community-based physicians.” <ref name ="Richardson"> Richardson et al, http://jamia.oxfordjournals.org/content/18/Supplement_1/i28.abstract</ref><br />
<br />
==Introduction==<br />
The Clinical Decision Support ([[CDS]]) Systems provide healthcare providers and consumers with knowledge and person-based information, intelligently filtered and presented at appropriate times to improve health and healthcare. <br />
<br />
CDS supports this knowledge to:<br />
#Clinician<br />
#Staff<br />
#Patients<br />
#Other individuals<br />
<br />
The goal of the study was to provide a user-centered perspective that could help developers optimize CDS functions to meet the needs of physicians in a community-based setting. <ref name ="Richardson"> Richardson et al, http://jamia.oxfordjournals.org/content/18/Supplement_1/i28.abstract</ref><br />
<br />
==Methods==<br />
The purpose of the study was to gain community-based physicians’ perspectives in decision-making, which include: <br />
# goals<br />
# Environments<br />
# Tasks<br />
# Desired support tools<br />
<br />
The study utilized human-computer interaction model<br />
# 30 recorded interviews <br />
# 25 Observations - primary care providers<br />
# 15 Observations - Urban and rural community based clinics<br />
<br />
==Conclusion==<br />
The findings from the study suggest that the decision support needs to be extended from current process. Two other opinions brought up by the physicians were:<br />
#Addition of wide range of clinical decision-making <br />
#Improvement in cognitive decision-making<br />
<br />
==Comments==<br />
<br />
==Reference==<br />
<references/><br />
Richardson, J. E., & Ash, J. S. (2011). A clinical decision support needs assessment of community-based physicians. Journal of the American Medical Informatics Association, 18(Supplement 1), i28-i35.<br />
<br />
<br />
[[Category : Reviews]]<br />
<br />
[[Category : CDS]]<br />
<br />
[[ Category:EHR ]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Readability_of_patient_discharge_instructions_with_and_without_the_use_of_electronically_available_disease-specific_templatesReadability of patient discharge instructions with and without the use of electronically available disease-specific templates2015-10-21T02:07:27Z<p>Arshad Ghauri: /* My comments */</p>
<hr />
<div>This is the first review of the article "Readability of patient discharge instructions with and without the use of electronically available disease-specific templates".<ref name="Discharge Template"> Mueller, S. K., Giannelli, K., Boxer, R., & Schnipper, J. L. (07/01/2015). Journal of the american medical informatics association : JAMIA: Readability of patient discharge instructions with and without the use of electronically available disease-specific templates BMJ. doi:10.1093/jamia/ocv005 <br />
http://dx.doi.org.ezproxyhost.library.tmc.edu/10.1093/jamia/ocv005</ref><br />
<br />
== Background and Significance ==<br />
At the time of discharge, patients may be preoccupied with the thoughts of coping after the hospitalization and may not recall verbal instructions given to them by their providers. Typically in US hospitals, discharge instructions are given in the written format. Due to low health literacy, many US adults may not understand these written discharge instructions. In this article authors have retrospectively reviewed the discharge instructions given to the patients for their readability through the use of templates in [[EMR|Electronic Health Records (EHRs)]].<br />
<br />
=== Materials and Methods ===<br />
A retrospective, cohort analysis technique was used in this study. The study was conducted at Brigham and Women’s Hospital (BWH), a large tertiary care center in Boston, Massachusetts. The subjects were randomly chosen from a population that comprised of adults that were 18 and older and who were discharged home and received discharge instructions. <br />
<br />
BWH implemented a web based “discharge module” in 2011.<ref name="Discharge Template"></ref> For this module, discharge instruction templates, templates that were diagnoses specific after the discharge and developed by obtaining the feedback from the appropriate specialties, were created. At the time of discharge, physicians had options to write their own discharge instructions even if a specific template was available, use the discharge instruction templates as such, or modify these templates. If no template existed for the patient diagnosis, physicians wrote their own discharge instructions.<br />
<br />
245 random subjects were chosen for this study. Out of this sample 233 were eligible. Data were analyzed for readability by using the Microsoft Office word 2007 for Flesch Reading Ease Level (FREL) scale and the Flesch-Kincaid Grade Level (FKGL) scale. <br />
<br />
The subjects were divided into two groups; one group consisted of patients who received clinician initiated discharge instructions. This group was divided into two subgroups, diagnosis specific discharge instruction template was available but not used and no diagnosis specific template was available. The other group consisted of subjects who received pre-developed diagnosis specific discharge instructions with or without modifications.<br />
<br />
=== Results ===<br />
Data analysis revealed that the pre-developed templates scored better in readability analysis. This pattern persisted even when the subjects, for which no diagnosis specific discharge template was available, were removed from the final analysis. It was done to remove a potential bias that the lack of diagnosis specific template may mean that these patients had complex illness requiring complex discharge instructions.<br />
<br />
=== Discussion ===<br />
In this study, authors found that pre-developed diagnosis specific discharge instructions even if modified resulted in better readability. This effect persisted even when after removing the subgroup from analysis for whom no diagnosis specific discharge template was available.<br />
<br />
=== My comments ===<br />
This study shows that it is possible to develop diagnosis specific discharge instructions that can be customized to meet the needs of a specific patient and still score better on readability as compared to the discharge instructions generated on the fly. However, it required a group of clinicians with the help of subject experts to develop such templates. It is not clear from this study whether this resulted in better outcomes. However, it makes sense to provide written helpful discharge instructions that can be easily understood by patients with inadequate literacy.<br />
In another article [[Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications]] the authors identified that up to 40% of discharge instructions have one or more medication discrepancy due to inaccurate discharge instructions, despite using EHR for these instructions. This highlights the importance of developing better communications between the hospitalists and primary care providers. An electronically created discharge summary [[Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries]] may be useful here.<br />
<br />
== Related Articles ==<br />
<br />
[[Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization]]<br />
<br />
== References ==<br />
<references/><br />
<br />
[[ Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[ Category:EHR ]]<br />
[[Category: Electronic discharge]]<br />
[[Category: Medication Error]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Evaluation_of_electronic_discharge_summaries:_A_comparison_of_documentation_in_electronic_and_handwritten_discharge_summariesEvaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries2015-10-21T02:02:57Z<p>Arshad Ghauri: Created page with "This is the first review of the article "Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries." <ref n..."</p>
<hr />
<div>This is the first review of the article "Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries." <ref name="Discharge Summary">oanne L. Callen, Melanie Alderton, Jean McIntosh, Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries, International Journal of Medical Informatics, Volume 77, Issue 9, September 2008, Pages 613-620, ISSN 1386-5056, http://dx.doi.org/10.1016/j.ijmedinf.2007.12.002.<br />
(http://www.sciencedirect.com/science/article/pii/S1386505608000026)<br />
Keywords: Electronic discharge summary; Handwritten discharge summary; Hospital discharge; Discharge communication; Australia</ref><br />
<br />
==Background and Objective==<br />
In this study a comparison between handwritten or dictated discharge summaries is done with the electronically created discharge summaries. This study was conducted in Australia, after installing a system that can create discharge summaries electronically, in a teaching hospital. The objectives of this study were two folds, first to evaluate the quality of discharge summaries per se and second to compare electronic discharge summaries with the handwritten or dictated ones for deficiencies or omissions.This was a retrospective study and compared electronic discharge summaries created using templates in [[EMR|Electronic Health Records (EHRs)]] with either handwritten or dictated ones.<br />
<br />
===Methods===<br />
A total of 245 eligible discharge summaries were identified. Out of these 151 were electronically completed and 94 were handwritten. These discharge summaries were then evaluated for their completion. Following criteria were used; discharge date; additional diagnosis; summary of the hospital course; discharge medication and follow-up plans. These plans were to be executed by the PCP’s. <br />
<br />
===Results===<br />
Data analysis showed that electronic discharge summaries had a higher number of errors as compared to the handwritten ones. However, most errors were related to omission of discharge date. Handwritten discharge summaries on the other hand missed summary of the hospital course. One interesting finding was that overall medication error rate was small in both electronic and handwritten ones.<br />
<br />
<br />
===Conclusion===<br />
The authors concluded that electronic discharge summaries necessarily are not better as compared to the handwritten ones, but were unable to satisfactorily identify factors that led to incomplete discharge summaries. In addition, two physicians who completed the most electronic discharge summaries had most errors of omission in discharge date. This may be related to the inadequate training to these physicians and could have resulted in different findings had these physicians received a timely feedback.<br />
<br />
===Commentary===<br />
I used this article for many reasons; first of all with fragmented healthcare in US, a complete discharge summary is a very important tool to provide continuity of care. Second, though hospital bylaws usually dictate that a discharge summary should be completed in a timely manner and there is an expectation that discharge summaries should conform to some standards, there is generally no regular audit for the completeness or quality of the discharge summaries. EHR’s represents an opportunity to provide improvement in this area by creating a template in which specific components of the discharge summary can be auto-populated and allows for inclusion of other items from the coded data as needed. In addition a template that with some modification can duplicate as discharge instructions to the patient. This may help provide better discharge instructions and in an article [[Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications]] may help reduce medication errors. A properly developed electronic discharge summary template which may allow physicians to create discharge instructions may increase physician satisfaction.<br />
<br />
<br />
== References ==<br />
<references/><br />
<br />
[[ Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[ Category:EHR ]]<br />
[[Category: Electronic discharge]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Improving_red_blood_cell_orders,_utilization,_and_management_with_point-of-care_clinical_decision_supportImproving red blood cell orders, utilization, and management with point-of-care clinical decision support2015-10-18T22:56:02Z<p>Arshad Ghauri: /* Comment */</p>
<hr />
<div>Written by: Zeke J. McKinney, Jessica M. Peters, Jed B. Gorlin, and Elizabeth H. Perry <ref name "McKinney 2015"> McKinney, Z. J., Peters, J. M., Gorlin, J. B. and Perry, E. H. (2015). Improving red blood cell orders, utilization, and management with point-of-care clinical decision support. ''Transfusion, 55'', 2086–2094. doi: 10.1111/trf.13103 </ref><br />
<br />
== Introduction ==<br />
Blood management is one of the top five concerns in considering efficiency and cost effectiveness. Interventions, such as [[CDS | clinical decision support (CDS)]] and alerting systems, apart of transfusion policies in hospitals have increased benefits for inpatient outcomes, blood utilization, and lower costs.<br />
<br />
== Methods ==<br />
The study takes place in a 455 bed hospital using [[Epic|EPIC]] as the [[EHR|EHR ]]. This study wishes to assess the change in the ratio of 1-unit to 2-unit red blood cell (RBC) orders throughout hospital. Several additions were added during post-implementation: 1) addition of CDS text, 2) addition of last measured Hb, 3) removal of choice for ordering frequency, 4) reordering of existing order elements, 5) modification of order questions, and 6) removal of free-text general comment field.<br />
<br />
==== Data Collection and Analysis ====<br />
For 3 years, standard query language queries extracted information from the HER in order to analyze the data sets. A statistical analysis program was used to conduct chi-square analyses and comparisons of means occurred via analysis of variance for repeated measures.<br />
<br />
== Results ==<br />
The study considered the ratio for 1-unit:2-unit orders on a sub-period scale and a monthly scale. There was a significant increase in the ratio in all three sub-periods. The monthly scale shows changes within the ratio associated with the changes in RBC orders. <br />
<br />
== Conclusion ==<br />
There was a decrease in blood utilization in the hospital but the hemoglobin triggers show mixed results. There was also no change in repeat orders. There was also little change in the workflow in making orders. Overall, the authors of the study felt that the implementation of a more restricted transfusion policy was highly successful.<br />
<br />
== Comment ==<br />
This is an interesting study because it considers the importance of transfusion policy especially to those making orders. However, it really doesn’t take into count how useful it is towards patients. There are multiple studies that show that restrictive transfusion may be safer than liberal transfusion strategy. I have included a link <ref name= "Transfusion">Qaseem A, Humphrey LL, Fitterman N, Starkey M, Shekelle P, for the Clinical Guidelines Committee of the American College of Physicians. Treatment of Anemia in Patients With Heart Disease: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2013;159:770-779. doi:10.7326/0003-4819-159-11-201312030-00009/</ref> for one such study.<br />
<br />
== References ==<br />
<references /><br />
<br />
[[Category: Reviews]]<br />
[[Category: CDS]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Improving_red_blood_cell_orders,_utilization,_and_management_with_point-of-care_clinical_decision_supportImproving red blood cell orders, utilization, and management with point-of-care clinical decision support2015-10-18T22:55:46Z<p>Arshad Ghauri: /* Comment */</p>
<hr />
<div>Written by: Zeke J. McKinney, Jessica M. Peters, Jed B. Gorlin, and Elizabeth H. Perry <ref name "McKinney 2015"> McKinney, Z. J., Peters, J. M., Gorlin, J. B. and Perry, E. H. (2015). Improving red blood cell orders, utilization, and management with point-of-care clinical decision support. ''Transfusion, 55'', 2086–2094. doi: 10.1111/trf.13103 </ref><br />
<br />
== Introduction ==<br />
Blood management is one of the top five concerns in considering efficiency and cost effectiveness. Interventions, such as [[CDS | clinical decision support (CDS)]] and alerting systems, apart of transfusion policies in hospitals have increased benefits for inpatient outcomes, blood utilization, and lower costs.<br />
<br />
== Methods ==<br />
The study takes place in a 455 bed hospital using [[Epic|EPIC]] as the [[EHR|EHR ]]. This study wishes to assess the change in the ratio of 1-unit to 2-unit red blood cell (RBC) orders throughout hospital. Several additions were added during post-implementation: 1) addition of CDS text, 2) addition of last measured Hb, 3) removal of choice for ordering frequency, 4) reordering of existing order elements, 5) modification of order questions, and 6) removal of free-text general comment field.<br />
<br />
==== Data Collection and Analysis ====<br />
For 3 years, standard query language queries extracted information from the HER in order to analyze the data sets. A statistical analysis program was used to conduct chi-square analyses and comparisons of means occurred via analysis of variance for repeated measures.<br />
<br />
== Results ==<br />
The study considered the ratio for 1-unit:2-unit orders on a sub-period scale and a monthly scale. There was a significant increase in the ratio in all three sub-periods. The monthly scale shows changes within the ratio associated with the changes in RBC orders. <br />
<br />
== Conclusion ==<br />
There was a decrease in blood utilization in the hospital but the hemoglobin triggers show mixed results. There was also no change in repeat orders. There was also little change in the workflow in making orders. Overall, the authors of the study felt that the implementation of a more restricted transfusion policy was highly successful.<br />
<br />
== Comment ==<br />
This is an interesting study because it considers the importance of transfusion policy especially to those making orders. However, it really doesn’t take into count how useful it is towards patients. There are multiple studies that show that restrictive transfusion may be safer than liberal transfusion strategy. I have included a link <ref name= "Transfusion">Qaseem A, Humphrey LL, Fitterman N, Starkey M, Shekelle P, for the Clinical Guidelines Committee of the American College of Physicians. Treatment of Anemia in Patients With Heart Disease: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2013;159:770-779. doi:10.7326/0003-4819-159-11-201312030-00009/</ref>t for one such study.<br />
<br />
== References ==<br />
<references /><br />
<br />
[[Category: Reviews]]<br />
[[Category: CDS]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Improving_red_blood_cell_orders,_utilization,_and_management_with_point-of-care_clinical_decision_supportImproving red blood cell orders, utilization, and management with point-of-care clinical decision support2015-10-18T22:53:24Z<p>Arshad Ghauri: /* Comment */</p>
<hr />
<div>Written by: Zeke J. McKinney, Jessica M. Peters, Jed B. Gorlin, and Elizabeth H. Perry <ref name "McKinney 2015"> McKinney, Z. J., Peters, J. M., Gorlin, J. B. and Perry, E. H. (2015). Improving red blood cell orders, utilization, and management with point-of-care clinical decision support. ''Transfusion, 55'', 2086–2094. doi: 10.1111/trf.13103 </ref><br />
<br />
== Introduction ==<br />
Blood management is one of the top five concerns in considering efficiency and cost effectiveness. Interventions, such as [[CDS | clinical decision support (CDS)]] and alerting systems, apart of transfusion policies in hospitals have increased benefits for inpatient outcomes, blood utilization, and lower costs.<br />
<br />
== Methods ==<br />
The study takes place in a 455 bed hospital using [[Epic|EPIC]] as the [[EHR|EHR ]]. This study wishes to assess the change in the ratio of 1-unit to 2-unit red blood cell (RBC) orders throughout hospital. Several additions were added during post-implementation: 1) addition of CDS text, 2) addition of last measured Hb, 3) removal of choice for ordering frequency, 4) reordering of existing order elements, 5) modification of order questions, and 6) removal of free-text general comment field.<br />
<br />
==== Data Collection and Analysis ====<br />
For 3 years, standard query language queries extracted information from the HER in order to analyze the data sets. A statistical analysis program was used to conduct chi-square analyses and comparisons of means occurred via analysis of variance for repeated measures.<br />
<br />
== Results ==<br />
The study considered the ratio for 1-unit:2-unit orders on a sub-period scale and a monthly scale. There was a significant increase in the ratio in all three sub-periods. The monthly scale shows changes within the ratio associated with the changes in RBC orders. <br />
<br />
== Conclusion ==<br />
There was a decrease in blood utilization in the hospital but the hemoglobin triggers show mixed results. There was also no change in repeat orders. There was also little change in the workflow in making orders. Overall, the authors of the study felt that the implementation of a more restricted transfusion policy was highly successful.<br />
<br />
== Comment ==<br />
This is an interesting study because it considers the importance of transfusion policy especially to those making orders. However, it really doesn’t take into count how useful it is towards patients. There are multiple studies that show taht restrictive transfusion may be safer than liberal strategy. I have included a link <ref name= "Transfusion">Qaseem A, Humphrey LL, Fitterman N, Starkey M, Shekelle P, for the Clinical Guidelines Committee of the American College of Physicians. Treatment of Anemia in Patients With Heart Disease: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2013;159:770-779. doi:10.7326/0003-4819-159-11-201312030-00009/</ref>to such a study.<br />
<br />
== References ==<br />
<references /><br />
<br />
[[Category: Reviews]]<br />
[[Category: CDS]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Improving_red_blood_cell_orders,_utilization,_and_management_with_point-of-care_clinical_decision_supportImproving red blood cell orders, utilization, and management with point-of-care clinical decision support2015-10-18T22:51:10Z<p>Arshad Ghauri: /* Comment */</p>
<hr />
<div>Written by: Zeke J. McKinney, Jessica M. Peters, Jed B. Gorlin, and Elizabeth H. Perry <ref name "McKinney 2015"> McKinney, Z. J., Peters, J. M., Gorlin, J. B. and Perry, E. H. (2015). Improving red blood cell orders, utilization, and management with point-of-care clinical decision support. ''Transfusion, 55'', 2086–2094. doi: 10.1111/trf.13103 </ref><br />
<br />
== Introduction ==<br />
Blood management is one of the top five concerns in considering efficiency and cost effectiveness. Interventions, such as [[CDS | clinical decision support (CDS)]] and alerting systems, apart of transfusion policies in hospitals have increased benefits for inpatient outcomes, blood utilization, and lower costs.<br />
<br />
== Methods ==<br />
The study takes place in a 455 bed hospital using [[Epic|EPIC]] as the [[EHR|EHR ]]. This study wishes to assess the change in the ratio of 1-unit to 2-unit red blood cell (RBC) orders throughout hospital. Several additions were added during post-implementation: 1) addition of CDS text, 2) addition of last measured Hb, 3) removal of choice for ordering frequency, 4) reordering of existing order elements, 5) modification of order questions, and 6) removal of free-text general comment field.<br />
<br />
==== Data Collection and Analysis ====<br />
For 3 years, standard query language queries extracted information from the HER in order to analyze the data sets. A statistical analysis program was used to conduct chi-square analyses and comparisons of means occurred via analysis of variance for repeated measures.<br />
<br />
== Results ==<br />
The study considered the ratio for 1-unit:2-unit orders on a sub-period scale and a monthly scale. There was a significant increase in the ratio in all three sub-periods. The monthly scale shows changes within the ratio associated with the changes in RBC orders. <br />
<br />
== Conclusion ==<br />
There was a decrease in blood utilization in the hospital but the hemoglobin triggers show mixed results. There was also no change in repeat orders. There was also little change in the workflow in making orders. Overall, the authors of the study felt that the implementation of a more restricted transfusion policy was highly successful.<br />
<br />
== Comment ==<br />
This is an interesting study because it considers the importance of transfusion policy especially to those making orders. However, it really doesn’t take into count how useful it is towards patients. There are multiple studies that show taht restrictive transfusion may be safer than liberal strategy. I have included a link to such a study. Qaseem A, Humphrey LL, Fitterman N, Starkey M, Shekelle P, for the Clinical Guidelines Committee of the American College of Physicians. Treatment of Anemia in Patients With Heart Disease: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2013;159:770-779. doi:10.7326/0003-4819-159-11-201312030-00009<br />
<br />
== References ==<br />
<references /><br />
<br />
[[Category: Reviews]]<br />
[[Category: CDS]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Making_Sense_of_Clinical_Practice:_Order_Set_Design_Strategies_in_CPOEMaking Sense of Clinical Practice: Order Set Design Strategies in CPOE2015-10-18T22:36:46Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>Article Review Novak, L. L. (2007). Making Sense of Clinical Practice: Order Set Design Strategies in CPOE. AMIA Annual Symposium Proceedings, 2007, 568–572. <ref name= "Orsetdesign">Novak, L. L. (2007). Making Sense of Clinical Practice: Order Set Design Strategies in CPOE. AMIA Annual Symposium Proceedings, 2007, 568–572. http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pmc/articles/PMC2655828/</ref><br />
<br />
== Introduction ==<br />
The development and implementation of a [[CPOE|CPOE]] system is a complex matter that requires attention to the details of clinical decision-making and how those details fit into everyday clinical workflow and the overall clinical strategy of an institution.<br />
Order set development is a rationalization of practice, and proceeds from some underlying strategy, approach or philosophy.<br />
This study reported on three approaches to developing order sets observed in this case, referred to as Empirical, Local Consensus, and Departmental.<br />
<br />
== Methods ==<br />
<br />
The research was conducted in a multi-hospital, academic health system in the Midwestern United States. The case was conducted to explore the strategies used to design order sets. Methods include 64 observation meetings and 15 key participants interviews.<br />
<br />
== Results ==<br />
<br />
Three approaches were identified for the development of order sets:<br />
<br />
1. '''Empirical approach''' - It uses clinical data to depict current practice and map the order set to that practice.<br />
<br />
2. '''Local Consensus approach''' - It is more informed by the politics and practices of the institution implementing the order set.<br />
<br />
3. '''Departmental approach''' - It was used in the complex area of Respiratory Therapy. In this case, the physicians were not involved in the development of the order set. <br />
<br />
== Conclusion ==<br />
<br />
In this case study conducted in 2007, [[Evidence based medicine| EBM]] was not considered as an approach to development on the order sets. Personal theories of acceptability, appropriateness and role within a clinical department trumped EBM. The development committee was focused on the success of the implementation in a more practical way instead of a theoretical approach.<ref name= "Orsetdesign"></ref><br />
<br />
== Comments ==<br />
<br />
This article was conducted about eight years ago; however, the approaches identified by it are currently been used to define and create order sets. It is important to focus on evidence-based medicine and incorporate the other approaches to better design order sets. Physicians need to have input in the creation to ensure the usability of the sets. It may not be possible to have a single strategy for developing order sets for CPOE. From our own experience in developing such order sets for CPOE is that the team should agree upon certain rules for developing these order sets, with the understanding that if it seems that if it seems that a rule is impeding the development of the order set that rule should be reviewed again and modified. First a skeletal order set is created, which is then filled with details. Then this order set is sent to the respective specialties for feedback and based upon the feedback order sets are modified. This process continues till a satisfactory order set is created. Our goal was not to create a perfect order set but an acceptable order set, that can work for majority of times and also to develop work flow that can accommodate additional orders.<br />
<br />
== Related Articles ==<br />
<br />
[[Enhancing Physician Adoption of CPOE: The Search for a Perfect Order Set]]<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category: Reviews]]<br />
[[Category: CPOE]]<br />
[[Category: Order Sets]]<br />
[[Category: HI5313-2015-FALL]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Making_Sense_of_Clinical_Practice:_Order_Set_Design_Strategies_in_CPOEMaking Sense of Clinical Practice: Order Set Design Strategies in CPOE2015-10-18T22:35:57Z<p>Arshad Ghauri: /* Comments */</p>
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<div>Article Review Novak, L. L. (2007). Making Sense of Clinical Practice: Order Set Design Strategies in CPOE. AMIA Annual Symposium Proceedings, 2007, 568–572. <ref name= "Orsetdesign">Novak, L. L. (2007). Making Sense of Clinical Practice: Order Set Design Strategies in CPOE. AMIA Annual Symposium Proceedings, 2007, 568–572. http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pmc/articles/PMC2655828/</ref><br />
<br />
== Introduction ==<br />
The development and implementation of a [[CPOE|CPOE]] system is a complex matter that requires attention to the details of clinical decision-making and how those details fit into everyday clinical workflow and the overall clinical strategy of an institution.<br />
Order set development is a rationalization of practice, and proceeds from some underlying strategy, approach or philosophy.<br />
This study reported on three approaches to developing order sets observed in this case, referred to as Empirical, Local Consensus, and Departmental.<br />
<br />
== Methods ==<br />
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The research was conducted in a multi-hospital, academic health system in the Midwestern United States. The case was conducted to explore the strategies used to design order sets. Methods include 64 observation meetings and 15 key participants interviews.<br />
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== Results ==<br />
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Three approaches were identified for the development of order sets:<br />
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1. '''Empirical approach''' - It uses clinical data to depict current practice and map the order set to that practice.<br />
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2. '''Local Consensus approach''' - It is more informed by the politics and practices of the institution implementing the order set.<br />
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3. '''Departmental approach''' - It was used in the complex area of Respiratory Therapy. In this case, the physicians were not involved in the development of the order set. <br />
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== Conclusion ==<br />
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In this case study conducted in 2007, [[Evidence based medicine| EBM]] was not considered as an approach to development on the order sets. Personal theories of acceptability, appropriateness and role within a clinical department trumped EBM. The development committee was focused on the success of the implementation in a more practical way instead of a theoretical approach.<ref name= "Orsetdesign"></ref><br />
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== Comments ==<br />
<br />
This article was conducted about eight years ago; however, the approaches identified by it are currently been used to define and create order sets. It is important to focus on evidence-based medicine and incorporate the other approaches to better design order sets. Physicians need to have input in the creation to ensure the usability of the sets. It may not be possible to have a single strategy for developing order sets for CPOE. From our own experience in developing such order sets for CPOE is that the team should agree upon certain rules for developing these oder sets, with the understanding that if it seems that if it seems that a rule is impeding the development of the order set that rule should be reviewed again and modified. First a skeletal order set is created, which is then filled with details. Then this order set is sent to the respective specialties for feedback and based upon the feedback order sets are modified. This process continues till a satisfactory order set is created. Our goal was not to create a perfect order set but an acceptable order set, that can work for majority of times and also to develop work flow that can accommodate additional orders.<br />
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== Related Articles ==<br />
<br />
[[Enhancing Physician Adoption of CPOE: The Search for a Perfect Order Set]]<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category: Reviews]]<br />
[[Category: CPOE]]<br />
[[Category: Order Sets]]<br />
[[Category: HI5313-2015-FALL]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Standardized_Glycemic_Management_with_a_Computerized_Workflow_and_Decision_Support_System_for_Hospitalized_Patients_with_Type_2_Diabetes_on_Different_WardsStandardized Glycemic Management with a Computerized Workflow and Decision Support System for Hospitalized Patients with Type 2 Diabetes on Different Wards2015-10-18T22:14:50Z<p>Arshad Ghauri: /* Comments */</p>
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<div>The following is a review of Neubauer et al.(2015) study on the management of glycemic standards using computerized workflow and decision support systems. <ref name="Neubauer et al. 2015"> Neubauer, K. M., Mader, J. K., Höll, B., Aberer, F., Donsa, K., Augustin, T., ... & Pieber, T. R. (2015). Standardized glycemic management with a computerized workflow and decision support system for hospitalized patients with type 2 diabetes on different wards. Diabetes technology & therapeutics, 17(10), 685-692. http://www.ncbi.nlm.nih.gov/pubmed/26355756 </ref><br />
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== Introduction ==<br />
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[[CDS]] technology is an emerging field in health informatics which combines the critical thinking of men, and optimizes it with the aid of a computerized system to yield better funded and conclusions based on evidence based medicine.The implementation tools provided by this system have promising features for physicians and their teams to arrive to optimal conclusions in the patient health delivery system. Diabetes is a well known public health issue and its management represent a greater challenge in present years. Using a paper-based algorithm for basal bolus insulin therapy developed to improve the quality of glycemic control and hospital complications, Neubauer and her team adapted it into a [[MHealth#Clinical Decision Support (CDS)|moblie decision support system]] named GlucoTab® system.<br />
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== Methods ==<br />
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This study was an open, noncontrolled interventional study in hospitalized patients with Type 2 diabetes. The study was conducted on four general wards of a tertiary-care hospital: Endocrinology, Cardiology, Nephrology and Plastic Surgery. 99 hospitalized patients were recruited from 5/2013-12/2013. <br />
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GlucoTab® system applied a daily dose of basal insulin, bolus insulin before each meal, and a correctional dose at bedtime to achieve fasting and premeal BG (Blood Glucose) values of less than 140 mg/dL. One-half of the total daily dose was administered as basal insulin once a day before lunch. The other half was administered as bolus insulin three times a day (45% of the total dose for breakfast bolus, 25% for lunch bolus, and 30% for dinner bolus).<br />
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* Daily dose: 0.5 units/kg <br />
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In order to yield the results from the study the following procedures were conducted: <br />
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* To test if the mean percentage of BG measurements in the target range 70–140 mg/dL were greater than the ones in the recent best-practice study with the criterion value of 42%, they applied a one-tailed one-sample t test. <ref name="Umpierrez et al. 2013"> Umpierrez GE, Smiley D, Hermayer K, et al.: Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care 2013;36:2169–2174 </ref><br />
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* The wards were compared using the Kruskal–Wallis rank sum test for secondary outcome since patients were unequally distributed among the wards.<br />
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*Finally, a multiple regression model to predict the mean daily BG value over all study days, except study Day 1, was fitted to the data.<br />
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== Results == <br />
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* GlucoTab® system was highly accepted; Physicians adhered to the suggested total daily insulin doses in 97.5% of cases, and nurses' adherence rates with suggested bolus insulin doses and basal insulin doses were 96.5% and 96.7%<br />
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* The mean percentage of BG measurements in the target range 70–140 mg/dL was 50.2±22.2%; Higher than the criterion value of 42% derived from the recent best-practice study<br />
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* Twenty-eight mild and moderate adverse events and one serious adverse event occurred, nonetheless not a single one was attributed to the GlucoTab® system<br />
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* GlucoTab® system received positive feedback through a questionnaire from 59 of 65 physicians <br />
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== Conclusion ==<br />
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The GlucoTab® system can be implemented in the clinical setting according to the results yield by the study. Factors such as preexisting home insulin therapy and the HbA1c values in addition to the type of hospital admission and the first total daily insulin dose can be pointed as the cause for the high BG mean values yielded during hospitalization. Inclusion criteria of the patients as them been non-controlled and open, represent a serious implication to asses the results as reliable. <br />
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== Comments == <br />
GlucoTab® system allowed an efficient, safe, and friendly-user implementation of a standardized glycemic management system throughout the different wards of the hospital. Data in such study further only supports the claim that systems such as this can improve the health care delivery of diabetes with confidence of not expecting consequences due to their implementation. This study not only highlights the fact that if a CDS tool is implemented properly can have a positive impact in clinical outcomes but also become a powerful teaching tool for the physicians in training.<br />
<br />
== Related Articles ==<br />
*[[Benefits of Information Technology-Enabled Diabetes Management]]<br />
*[[Impact of electronic health record clinical decision support on diabetes care: a randomized trial]]<br />
<br />
== References ==<br />
<references/><br />
<br />
<br />
[[Category:Reviews]]<br />
[[Category:CDS]]<br />
[[Category:MHealth]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Relationship_of_health_literacy_to_intentional_and_unintentional_non-adherence_of_hospital_discharge_medications.Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications.2015-10-12T18:55:23Z<p>Arshad Ghauri: Created page with "This is the first review of the article "Creating Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications".<ref name="..."</p>
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<div>This is the first review of the article "Creating Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications".<ref name="Health literacy"> Lindquist LA, Go L, Fleisher J, Jain N, Friesema E, Baker DW. Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. J Gen Intern Med.2012;27:173–8. doi: 10.1007/s11606-011-1886-3. http://www.ncbi.nlm.nih.gov/pubmed/21971600 </ref><br />
==Introduction==<br />
In this article authors have explored the relationship between health literacy and medication compliance. Medication discrepancy is defined as the difference between the medications regimen prescribed at discharge versus the regimen taken at home. Adherence was described as decision to follow the prescribed plan of care.<br />
Medication discrepancy has been noted in the literature a significant cause of adverse events after discharge and Coleman et al. <ref name="Coleman">Coleman EA, Smith JD, Raha D, Min S. Posthospital Medication Discrepancies: Prevalence and Contributing Factors. Arch Intern Med. 2005;165(16):1842-1847. doi:10.1001/archinte.165.16.1842.</ref>found that more than double of the patients who experienced medication discrepancies were readmitted as compared to the ones who did not have any medication discrepancy. In this article authors have prospectively assessed the impact of health literacy in medication discrepancies post-hospitalization using the discharge instructions from [[EMR|Electronic Health Records (EHRs)]].<br />
<br />
==Methods==<br />
Community dwelling adults 70 years or older, who resided within 60 miles radius of the research facility, who were, competent, independent in their daily living situation and were managing their own medications. These patients with these characteristics were selected consecutively from the hospitalized patients from inpatient hospitalist services who were discharged home. On the day of discharge these patients were evaluated for their health literacy, and were grouped in adequate, marginal or poor health literacy. A pre-hospitalization medication history was also obtained and compiled by a researcher trained in this task. After the discharge, discharge medication list was obtained from the discharge instructions I the Electronic Medical Records (EMR). Between 48-72 hours after the discharge, patients were contacted on the phone and were asked what medications they were taking. They were also asked open ended questions about any discrepancies between the discharge medications and the current medications.<br />
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==Results==<br />
Mean age of the participants was slightly under 80, slightly over half were females and over half of them had some college education. 32.3% had inadequate health literacy and 22.3% were marginal in health literacy. 56% had one or more mediation discrepancy. The most common reason was inaccurate discharge instructions (39.3%) followed by intentional non-adherence (22.4%) and unintentional non-adherence (21.9%). Multivariate analysis revealed that while unintentional non-adherence was more common in marginal and inadequate health literacy groups, intentional non-adherence was more common in patients with adequate health literacy group.<br />
<br />
<br />
==Discussion==<br />
Prior to this study, there was no concrete evidence of association between health literacy and medication discrepancies. However this study was able to unmask a relationship in which patient with poor health literacy are more likely to make an unintentional medication error and patients with adequate health literacy make a conscious decision for not adhering to the prescribed scheduled mediations. Almost 40% of the medication discrepancies were due to inaccurate discharge instructions. This is a significant percentage and is an area for improvement.<br />
<br />
==My comments==<br />
Since primary care providers may not be affiliated with the hospitals in their practice areas, at the time of patient hospitalization and discharge, there is a potential of developing medication discrepancies. Electronic Health records by allowing the flow of information between the inpatient and out-patient providers may reduce medication discrepancies at discharge.<br />
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== Related Articles ==<br />
<br />
[[Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization]]<br />
<br />
== References ==<br />
<references/><br />
<br />
[[ Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[ Category:EHR ]]<br />
[[Category: Electronic discharge]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Readability_of_patient_discharge_instructions_with_and_without_the_use_of_electronically_available_disease-specific_templatesReadability of patient discharge instructions with and without the use of electronically available disease-specific templates2015-10-12T18:53:07Z<p>Arshad Ghauri: </p>
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<div>This is the first review of the article "Readability of patient discharge instructions with and without the use of electronically available disease-specific templates".<ref name="Discharge Template"> Mueller, S. K., Giannelli, K., Boxer, R., & Schnipper, J. L. (07/01/2015). Journal of the american medical informatics association : JAMIA: Readability of patient discharge instructions with and without the use of electronically available disease-specific templates BMJ. doi:10.1093/jamia/ocv005 <br />
http://dx.doi.org.ezproxyhost.library.tmc.edu/10.1093/jamia/ocv005</ref><br />
<br />
== Background and Significance ==<br />
At the time of discharge, patients may be preoccupied with the thoughts of coping after the hospitalization and may not recall verbal instructions given to them by their providers. Typically in US hospitals, discharge instructions are given in the written format. Due to low health literacy, many US adults may not understand these written discharge instructions. In this article authors have retrospectively reviewed the discharge instructions given to the patients for their readability through the use of templates in [[EMR|Electronic Health Records (EHRs)]].<br />
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=== Materials and Methods ===<br />
A retrospective, cohort analysis technique was used in this study. The study was conducted at Brigham and Women’s Hospital (BWH), a large tertiary care center in Boston, Massachusetts. The subjects were randomly chosen from a population that comprised of adults that were 18 and older and who were discharged home and received discharge instructions. <br />
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BWH implemented a web based “discharge module” in 2011.<ref name="Discharge Template"></ref> For this module, discharge instruction templates, templates that were diagnoses specific after the discharge and developed by obtaining the feedback from the appropriate specialties, were created. At the time of discharge, physicians had options to write their own discharge instructions even if a specific template was available, use the discharge instruction templates as such, or modify these templates. If no template existed for the patient diagnosis, physicians wrote their own discharge instructions.<br />
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245 random subjects were chosen for this study. Out of this sample 233 were eligible. Data were analyzed for readability by using the Microsoft Office word 2007 for Flesch Reading Ease Level (FREL) scale and the Flesch-Kincaid Grade Level (FKGL) scale. <br />
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The subjects were divided into two groups; one group consisted of patients who received clinician initiated discharge instructions. This group was divided into two subgroups, diagnosis specific discharge instruction template was available but not used and no diagnosis specific template was available. The other group consisted of subjects who received pre-developed diagnosis specific discharge instructions with or without modifications.<br />
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=== Results ===<br />
Data analysis revealed that the pre-developed templates scored better in readability analysis. This pattern persisted even when the subjects, for which no diagnosis specific discharge template was available, were removed from the final analysis. It was done to remove a potential bias that the lack of diagnosis specific template may mean that these patients had complex illness requiring complex discharge instructions.<br />
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=== Discussion ===<br />
In this study, authors found that pre-developed diagnosis specific discharge instructions even if modified resulted in better readability. This effect persisted even when after removing the subgroup from analysis for whom no diagnosis specific discharge template was available.<br />
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=== My comments ===<br />
This study shows that it is possible to develop diagnosis specific discharge instructions that can be customized to meet the needs of a specific patient and still score better on readability as compared to the discharge instructions generated on the fly. However, it required a group of clinicians with the help of subject experts to develop such templates. It is not clear from this study whether this resulted in better outcomes. However, it makes sense to provide written helpful discharge instructions that can be easily understood by patients with inadequate literacy.<br />
In another article [[Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications]] the authors identified that up to 40% of discharge instructions have one or more medication discrepancy due to inaccurate discharge instructions, despite using EHR for these instructions. This highlights the importance of developing better communications between the hospitalists and primary care providers.<br />
<br />
<br />
== Related Articles ==<br />
<br />
[[Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization]]<br />
<br />
== References ==<br />
<references/><br />
<br />
[[ Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[ Category:EHR ]]<br />
[[Category: Electronic discharge]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Main_Page/The_Use_of_Electronic_Medical_Records:_Communication_Patterns_in_Outpatient_EncountersMain Page/The Use of Electronic Medical Records: Communication Patterns in Outpatient Encounters2015-10-12T17:39:06Z<p>Arshad Ghauri: /* Discussion */</p>
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<div>The is a review of the article, “The Use of Electronic Medical Records: Communication Patterns in Outpatient Encounters. The article was written by Makoul, Curry and Tang.<br />
<br />
==Introduction==<br />
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The article summarizes the use of electronic medical records. The purpose of the study was to determine if communication patterns change when physicians use EMR as supposed to using paper records of patients. They also wanted to determine do determine if the ordering of particular labs and length of stay increase compared to physicians who use paper records.<br />
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<br />
==Methods==<br />
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The study was conducted at the general medical faculty practice of an urban medical center in Chicago. The physicians use the EMR system were using EpicCare for about 18 months. The participants of the study were three physicians who were using EMR system already implemented in their facility. The other three physicians use paper charting. The study also included a wide range of patients to participate in. All the subjects use in the study were male, due to the fact that the women that use the EMR only use the system outside of the examination room. The physicians that participated in the study were told to focus on physician and patient communication.<br />
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==Results==<br />
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The results of the study shows that the physicians that use the EMR were able to checked and clarify information better than the physicians that use the paper charting. When it came to time and how the test were ordered, there was no difference between the physicians that use paper charting and the physicians that use the EMR. The physicians that used the paper charting spent less time with their patients then the physicians that used the EMR system. The study also showed that there was a lack of personal interaction with the physicians that use the EMR. The physicians were often looking at their computer screens to type in data, which let to long periods of silence. The physicians using the paper chart had more personal interaction with their patient. <br />
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==Discussion==<br />
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During the study many different findings were discovered. The Physicians that used the EMRs were more active in clarifying information more efficiently. The EMRs that were being used gave them the proper tools needed to be more effective in their work. It also allow them to complete their tasks. The EMR physicians spend more time looking between the patient and screen, which made them look less sincere. The interaction that the physician has with their patient are very important. The EMRs were effectively when it came to workflow, but the small distractions with computer screen and recording information divides the attention of the physician. The information gathered in this study can be used to learn how to minimize these distractions.<br />
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==Comments==<br />
Having access to patient medical records at the face to face encounter is needed to make sure that patient concerns can be answered in real time. This access to medical records is also need to reduce the reliance from memory during the encounter. Paper and electronic medical records both have their benefits, in paper world it was easy to start a note and record important parts of history and physical exam findings during the interview, whereas depending upon the EMR it may not be that easy in the EMR, but all relevant information is at fingertips. Each facility may have to design their exam/encounter rooms in a way that minimizes these distractions.<br />
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== Related Article Reviews ==<br />
[[Heuristic evaluation of eNote: an electronic notes system]]<br />
<br />
==References==<br />
<references/><br />
Makoul, G., Curry, R., & Tang, P. (2001). The Use of Electronic Medical Records: Communication Patterns in Outpatient Encounters. Journal of the American Medical Informatics Association, 8(6), 610-615. http://www.ncbi.nlm.nih.gov/pubmed/11687567<br />
<br />
[[Category:Reviews]]<br />
[[Category:Usability]]<br />
[[Category:Technologies]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Enhancing_Physician_Adoption_of_CPOE:_The_Search_for_a_Perfect_Order_SetEnhancing Physician Adoption of CPOE: The Search for a Perfect Order Set2015-10-12T16:59:43Z<p>Arshad Ghauri: </p>
<hr />
<div>== First Review ==<br />
<br />
This is a review for Samuel Alfano's ''Enhancing Physician Adoption of [[CPOE]]: The Search for a Perfect [[Order Set]]''. <ref name="Alfano"> Samuel Alfano, D. O. (2013). Enhancing Physician Adoption of CPOE: The Search for a Perfect Order Set. Physician executive, 39(5), 30. http://acpe.physicianleaders.org/docs/default-source/pej/enhancing-physician-adoption-of-cpoe.pdf?sfvrsn=4</ref><br />
<br />
=== Abstract ===<br />
<br />
"As hospitals and health care providers throughout the US evaluate the impact of the 2009 [[ARRA| American Recovery and Reinvestment Act]], provisions in the package that call for the "[[meaningful use]]" of electronic medical records are prompting rapid growth in the implementation of computerized physician order entry ([[CPOE|CPOE]]). Despite this incentive, only 21.7% of hospitals had successfully implemented CPOE systems according to a 2011 KLAS report. Catholic Health Initiatives (CHI) is a large national hospital system consisting of 76 hospitals in 19 states. Several years ago they started a project called ONECARE. Their goal was to roll out an electronic medical record and CPOE to all hospitals and providers within five years. During the first few weeks most, if not all physicians, customized the order sets they commonly used. Even though they could share these sets with other members of their group or department, they rarely shared these widely." <ref name="Alfano"> Samuel Alfano, D. O. (2013). Enhancing Physician Adoption of CPOE: The Search for a Perfect Order Set. Physician executive, 39(5), 30.</ref><br />
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=== Methods ===<br />
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The author and colleagues developed a portfolio of national order sets and posted them on the internet using XML and SharePoint. They then opened them to physicians within their system and allowed them to make comments as well as see other contributors' comments. <br />
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=== Results ===<br />
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Discovery of important considerations while negotiating the process to improve acceptability of the order sets developed. Attention to issues helps improve adoption of order sets to provide safe care to patients. <br />
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=== Conclusion ===<br />
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It is important to give physicians' input on order sets and allow them to customize specific order sets in orders to enhance the adoption of CPOE. <br />
<br />
=== Comments ===<br />
<br />
This article gives insight to the steps taken to adopt CPOE in a large national hospital system. While the author explains different measure that are important to consider when implementing CPOE, there is no information on whether the implementation within the system as successful or not.<br />
This study also highlights some other important considerations while building order sets. First, a single set of orders even for a single disease may not be acceptable to all and would require modifications. These modifications while useful to the individual providers can introduce medication or other errors as other providers may not realize the omission or inclusion of medication, lab test in the variation of the order set. Also as medical knowledge evolves, one may have now to modify all order sets for the given condition and there is risk that some old unmodified order sets may still remain in production resulting in unforced errors.<br />
<br />
== Second Review ==<br />
<br />
Add next review here.<br />
<br />
== Related Article Reviews ==<br />
[[Main Page/The Use of Electronic Medical Records: Communication Patterns in Outpatient Encounters]]<br />
<br />
[[Computerized Provider Order Entry Reduces Length of Stay in a Community Hospital]]<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[Category:CPOE]]<br />
[[Category:EMR]]<br />
[[Category: Technologies]]<br />
[[Category:Order Sets]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Does_Health_Information_Exchange_Reduce_Redundant_ImagingDoes Health Information Exchange Reduce Redundant Imaging2015-10-12T16:46:43Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>This is a review of Lammers’ article "Does Health Information Exchange Reduce Redundant Imaging? Evidence From Emergency Departments".<ref name="Lammers 2014">Lammers, E., Adler-Milstein, J., & Kocher, K. (2014). Does Health Information Exchange Reduce Redundant Imaging? Evidence From Emergency Departments. Medical Care, 52(3), 227-234. Retrieved October 5, 2015 from http://journals.lww.com/lww-medicalcare/pages/default.aspx</ref> <br />
<br />
== Background ==<br />
[[HIE|Health Information Exchanges (HIE)]] are supposed to be enhance the continuity of patient care. It allows the sharing of patient data between different points of care. In an ideal world, HIEs should provide great benefit including quality gains and cost savings. Despite this notion, there has been limited supporting evidence and research done to prove that HIEs produce these results. The purpose of the article is to evaluate the use of HIE and whether it is associated with a decline in repeat imaging in emergency departments. <ref name="Lammers 2014"> </ref><br />
<br />
== Methods ==<br />
The methodology used for this research was used to compare the effects and trends of 37 EDs utilized by HIE during a time period to 410 EDs that did not participate in an HIE. The 3 imaging orders accounted for were CT Scans(computed tomography), ultrasounds, and chest x-rays. The data used came from the State Emergency Department Databases for California and Florida in 2007-2010 along with HIMSS data of hospitals participating in HIE. The article defined repeat image test as the same test done in the same body region within 30 days at unaffiliated EDs.<ref name="Lammers 2014"> </ref><br />
<br />
== Results ==<br />
From the samples, they discovered that there were repeats of the following 14.7% of CTs, 20.7 of Ultrasounds, 19.5% of chest x-rays. HIE was then associated to reduced probability of repeats in all 3 tests with about 95% confidence level. <ref name="Lammers 2014"> </ref><br />
<br />
== Conclusion ==<br />
Based on the results, they have found a relationship between HIE and repeat imaging in an ED environment. Thus HIE can be a potential tool in decreasing redundant medical services, creating savings in cost and care. <ref name="Lammers 2014"> </ref><br />
<br />
== Comments == <br />
This is an interesting article as it is the first of its kind to assess and provide evidence of the benefits of HIE. By decreasing redundant tests (among other things), HIE can reduce the costs of healthcare. However, many organizations have been slow to adopt due to strict data sharing policies and lack of trust between providers. I believe more studies like this need to be done to prove the value and [[EMR_Benefits:_HIE|benefits]] of HIE.<br />
In my own experience having the ability to having access to the images done in outside facilities also has the potential of improving care. While working in a TB clinic, it was easy for us to compare CXR's from two different facilities with our own CXR's and allowed us to provide timely care.<br />
<br />
==Related Articles==<br />
[[Health information exchange and patient safety]]<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category:Reviews]]<br />
[[Category:HIE]]<br />
[[Category:Interoperability]]<br />
[[Category:Medical Imaging]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Does_Health_Information_Exchange_Reduce_Redundant_ImagingDoes Health Information Exchange Reduce Redundant Imaging2015-10-12T15:49:57Z<p>Arshad Ghauri: /* Comments */</p>
<hr />
<div>This is a review of Lammers’ article "Does Health Information Exchange Reduce Redundant Imaging? Evidence From Emergency Departments".<ref name="Lammers 2014">Lammers, E., Adler-Milstein, J., & Kocher, K. (2014). Does Health Information Exchange Reduce Redundant Imaging? Evidence From Emergency Departments. Medical Care, 52(3), 227-234. Retrieved October 5, 2015 from http://journals.lww.com/lww-medicalcare/pages/default.aspx</ref> <br />
<br />
== Background ==<br />
[[HIE|Health Information Exchanges (HIE)]] are supposed to be enhance the continuity of patient care. It allows the sharing of patient data between different points of care. In an ideal world, HIEs should provide great benefit including quality gains and cost savings. Despite this notion, there has been limited supporting evidence and research done to prove that HIEs produce these results. The purpose of the article is to evaluate the use of HIE and whether it is associated with a decline in repeat imaging in emergency departments. <ref name="Lammers 2014"> </ref><br />
<br />
== Methods ==<br />
The methodology used for this research was used to compare the effects and trends of 37 EDs utilized by HIE during a time period to 410 EDs that did not participate in an HIE. The 3 imaging orders accounted for were CT Scans(computed tomography), ultrasounds, and chest x-rays. The data used came from the State Emergency Department Databases for California and Florida in 2007-2010 along with HIMSS data of hospitals participating in HIE. The article defined repeat image test as the same test done in the same body region within 30 days at unaffiliated EDs.<ref name="Lammers 2014"> </ref><br />
<br />
== Results ==<br />
From the samples, they discovered that there were repeats of the following 14.7% of CTs, 20.7 of Ultrasounds, 19.5% of chest x-rays. HIE was then associated to reduced probability of repeats in all 3 tests with about 95% confidence level. <ref name="Lammers 2014"> </ref><br />
<br />
== Conclusion ==<br />
Based on the results, they have found a relationship between HIE and repeat imaging in an ED environment. Thus HIE can be a potential tool in decreasing redundant medical services, creating savings in cost and care. <ref name="Lammers 2014"> </ref><br />
<br />
== Comments == <br />
This is an interesting article as it is the first of its kind to assess and provide evidence of the benefits of HIE. By decreasing redundant tests (among other things), HIE can reduce the costs of healthcare. However, many organizations have been slow to adopt due to strict data sharing policies and lack of trust between providers. I believe more studies like this need to be done to prove the value and [[EMR_Benefits:_HIE|benefits]] of HIE.<br />
In my own own experience having the ability to having access to the images done in outside facilities also has the potential of improving care. While working in a TB clinic, it was easy for me to compare CXR's from two different facilities<br />
<br />
==Related Articles==<br />
[[Health information exchange and patient safety]]<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category:Reviews]]<br />
[[Category:HIE]]<br />
[[Category:Interoperability]]<br />
[[Category:Medical Imaging]]</div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Readability_of_patient_discharge_instructions_with_and_without_the_use_of_electronically_available_disease-specific_templatesReadability of patient discharge instructions with and without the use of electronically available disease-specific templates2015-10-07T00:48:51Z<p>Arshad Ghauri: </p>
<hr />
<div>This is the first review of the article "Readability of patient discharge instructions with and without the use of electronically available disease-specific templates". <br />
<br />
== Background and Significance ==<br />
At the time of discharge patients may be preoccupied with the thoughts of coping after the hospitalization and may not recall verbal instructions given to them by their providers. Typically in US hospitals discharge instructions are given in the written format. Due to low health literacy, many US adults may not understand these written discharge instructions. In this article authors have retrospectively reviewed the discharge instructions given to the patients for their readability through the use of templates in [[EMR|Electronic Health Records (EHRs)]].<br />
<br />
=== Materials and Methods ===<br />
A retrospective, cohort analysis, technique was used in this study. The study was conducted at Brigham and Women’s Hospital (BWH) a large tertiary care center in Boston, Massachusetts. The subjects were randomly chosen from an adult, 18 and over population who were discharged home and received discharge instructions. <br />
<br />
BWH implemented a web based “discharge module” in 2011. For this module, discharge instruction templates were created, which were diagnoses specific after and were developed by obtaining the feedback from the appropriate specialties. At the time of discharge, physicians were free to write their own discharge instructions even if a specific template was available, use these templates as such or modify these templates. If no template existed for the patient diagnosis physicians wrote their own discharge instructions.<br />
<br />
245 random subjects were chosen for this study. Out of this sample 233 were eligible. Data was analyzed for readability by using the Microsoft Office word 2007 for Flesch Reading Ease Level (FREL) scale and the Flesch-Kincaid Grade Level (FKGL) scale. <br />
<br />
The subjects were divided into two groups; one group consisted of patients who received clinician initiated discharge instructions. This group was divided into two subgroups, diagnosis specific discharge instruction template was available but not used and no diagnosis specific template was available. The other group consisted of subjects who received pre-developed diagnosis specific discharge instructions with or without modifications.<br />
<br />
=== Results ===<br />
Data analysis revealed that the pre-developed templates scored better in readability analysis. This pattern persisted even when the subjects, for which no diagnosis specific discharge template was available were removed from the final analysis. It was done to remove a potential bias that the lack of diagnosis specific template may mean that these patients had complex illness requiring complex discharge instructions.<br />
<br />
=== Discussion ===<br />
In this study, authors found that pre-developed diagnosis specific discharge instructions even if modified resulted in better readability. This effect persisted even when after removing the subgroup from analysis for whom no diagnosis specific discharge template was available.<br />
<br />
=== My comments ===<br />
This study shows that it is possible to develop diagnosis specific discharge instructions that can be customized to meet the needs of a specific patient and still score better on readability as compared to the discharge instructions generated on the fly. However, it required a group of clinicians with the help of subject experts to develop such templates. It is not clear from this study whether this resulted in better outcomes. However, it makes sense to provide written helpful discharge instructions that can be easily understood by patients with inadequate literacy.<br />
<br />
[[ Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[ Category:EHR ]]<br />
[[Category: Electronic discharge]]<br />
<br />
<br />
Reference:<br />
<ref name="Discharge Template"> Mueller, S. K., Giannelli, K., Boxer, R., & Schnipper, J. L. (07/01/2015). Journal of the american medical informatics association : JAMIA: Readability of patient discharge instructions with and without the use of electronically available disease-specific templates BMJ. doi:10.1093/jamia/ocv005 <br />
http://dx.doi.org.ezproxyhost.library.tmc.edu/10.1093/jamia/ocv005</ref> <references/></div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Effect_of_Standardized_Electronic_Discharge_Instructions_on_Post-Discharge_Hospital_UtilizationEffect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization2015-10-06T01:47:35Z<p>Arshad Ghauri: /* My thoughts */</p>
<hr />
<div>''A review of the article by Showalter, "Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization". ''<br />
<br />
=== Introduction ===<br />
Readmissions to the hospital or the visits to the emergency department within 30 days of discharge are considered failed discharges. Jenck and colleagues, according to this article, estimated that these readmissions in 2004 alone cost the health care system $17.4 billion.[[ Centers for Medicare and Medicaid Services (CMS)|Centers of Medicare and Medicaid Services (CMS)]] estimates that some of these readmissions can be prevented by clear and concise discharge instruction given to the patients at the time of discharge. [[EMR|Electronic Health Records (EHRs)]] has the [[EMR Benefits and Return on Investment Categories | potential benefit]] to reduce readmission and ED use post hospital discharge by standardizing and producing comprehensive discharge instructions. Though studies have shown that comprehensive post discharge interventions have beneficial effects but the effect of standardized discharge instructions created electronically is not clear.<br />
<br />
=== Methods ===<br />
<br />
== Settings and Interventions ==<br />
This study was conducted in [http://www.pennstatehershey.org/web/guest/welcome Penn State Hershey Medical Center], which is a large academic medical center. Discharge instructions were typed in a word document template prior to the implementation of the study, however there were no mandatory fields that were required to be filled. Also medication reconciliation was done by hand. An electronic standardized discharge template was created that the CMS regulatory requirements. In this new form some data like admission and discharge date, medications were auto populated and other fields were typed but now were mandatory.<br />
<br />
== Participants ==<br />
A pre-implementation cohort of patients aged 18 and over was compared with compared with a post-implementation cohort. Post implementation cohort was selected 3 months after the new discharge template was implemented.<br />
<br />
== Outcome ==<br />
Primary outcome of the study was either a readmission or an ED visit within 30 days of the index discharge.<br />
<br />
== Covariates ==<br />
In order to account for already known risk factors for readmissions, data was analyzed with multiple covariates. These variables were, age, sex, race, severity of illness, diagnoses, disposition home versus others. Also included were patients on dialysis.<br />
<br />
== Data Management and Statistical Analysis ==<br />
Pre-implementation and post–implementation cohorts were compared for primary and secondary outcomes through multivariable logistic regression analysis done through SAS, Version 9.1 (SAS Institute, Cary, NC). Study had the power to estimate a difference of 1% in readmissions or ED use.<br />
<br />
<br />
=== Results ===<br />
A total of about 34,000 patients were studied with slightly over half of these were in post-implementation group. The groups had small but statistically difference in race, discharge destination and severity of illness. Pre-implementation group had more whites and were sent home or to an acute rehabilitation place. <br />
In unadjusted analyses, small but statistically significant difference in readmission rates was seen in the post-implementation cohort for secondary outcomes. Age, severity of illness, and discharge diagnoses of COPD, CHF, Pneumonia and ESRD were associated with higher odds of readmissions.<br />
<br />
=== Discussion ===<br />
Other studies have shown that discharge instructions with medication reconciliation alone may not be sufficient to reduce readmissions or use of the ED post-discharge. However the authors were unable to find a good explanation to why an electronic discharge instruction would be associated with a small but statistically increase in the readmission rate. This increase could be due to slight differences between the two cohorts with regard to age and having more patients with diagnoses with higher than average readmission rates. A more comprehensive study analyzing the factors leading to readmission or ED use may be needed.<br />
<br />
=== My thoughts ===<br />
This study fails to show any decreased utilization of hospital resources post implementation of standardized electronic discharge instructions. In my opinion this means that a more comprehensive approach is needed to reduce failed discharges, that includes a standard method of communication information to the patient and other healthcare workers like it was done in this study and improving the environment to which the patient is discharged to. We need to provide better mechanisms of getting the patients followed up with their physicians and also work on developing a better primary care system. It may be the case that the hypothesis that CMS maintains may be fundamentally incorrect, and there is no achievable benefit in regard to the quality of passive written discharge instructions. In this case efforts would be better spent on maximizing post-discharge patient engagement through more active methods. In a study [[Readability of patient discharge instructions with and without the use of electronically available disease-specific templates |use of templates to improve readability of discharge instructions]] authors Mueller et. al <ref name="Discharge Template"> Mueller, S. K., Giannelli, K., Boxer, R., & Schnipper, J. L. (07/01/2015). Journal of the american medical informatics association : JAMIA: Readability of patient discharge instructions with and without the use of electronically available disease-specific templates BMJ. doi:10.1093/jamia/ocv005 <br />
http://dx.doi.org.ezproxyhost.library.tmc.edu/10.1093/jamia/ocv005</ref> showed that a well thought pre-developed discharge instructions templates help user readability of discharge instructions.<br />
<br />
[[ Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[ Category:EHR ]]<br />
[[Category: Electronic discharge]]<br />
<br />
==References ==<br />
<ref name="Electronic Discharge instructions"> Showalter, J. W., Rafferty, C. M., Swallow, N. A., DaSilva, K. O., & Chuang, C. H. (2011). Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization. Journal of General Internal Medicine, 26(7), 718–723. http://doi.org/10.1007/s11606-011-1712-y<br />
<br />
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3138594/?tool=pmcentrez</ref> <references/></div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Effect_of_Standardized_Electronic_Discharge_Instructions_on_Post-Discharge_Hospital_UtilizationEffect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization2015-10-06T01:46:42Z<p>Arshad Ghauri: /* My thoughts */</p>
<hr />
<div>''A review of the article by Showalter, "Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization". ''<br />
<br />
=== Introduction ===<br />
Readmissions to the hospital or the visits to the emergency department within 30 days of discharge are considered failed discharges. Jenck and colleagues, according to this article, estimated that these readmissions in 2004 alone cost the health care system $17.4 billion.[[ Centers for Medicare and Medicaid Services (CMS)|Centers of Medicare and Medicaid Services (CMS)]] estimates that some of these readmissions can be prevented by clear and concise discharge instruction given to the patients at the time of discharge. [[EMR|Electronic Health Records (EHRs)]] has the [[EMR Benefits and Return on Investment Categories | potential benefit]] to reduce readmission and ED use post hospital discharge by standardizing and producing comprehensive discharge instructions. Though studies have shown that comprehensive post discharge interventions have beneficial effects but the effect of standardized discharge instructions created electronically is not clear.<br />
<br />
=== Methods ===<br />
<br />
== Settings and Interventions ==<br />
This study was conducted in [http://www.pennstatehershey.org/web/guest/welcome Penn State Hershey Medical Center], which is a large academic medical center. Discharge instructions were typed in a word document template prior to the implementation of the study, however there were no mandatory fields that were required to be filled. Also medication reconciliation was done by hand. An electronic standardized discharge template was created that the CMS regulatory requirements. In this new form some data like admission and discharge date, medications were auto populated and other fields were typed but now were mandatory.<br />
<br />
== Participants ==<br />
A pre-implementation cohort of patients aged 18 and over was compared with compared with a post-implementation cohort. Post implementation cohort was selected 3 months after the new discharge template was implemented.<br />
<br />
== Outcome ==<br />
Primary outcome of the study was either a readmission or an ED visit within 30 days of the index discharge.<br />
<br />
== Covariates ==<br />
In order to account for already known risk factors for readmissions, data was analyzed with multiple covariates. These variables were, age, sex, race, severity of illness, diagnoses, disposition home versus others. Also included were patients on dialysis.<br />
<br />
== Data Management and Statistical Analysis ==<br />
Pre-implementation and post–implementation cohorts were compared for primary and secondary outcomes through multivariable logistic regression analysis done through SAS, Version 9.1 (SAS Institute, Cary, NC). Study had the power to estimate a difference of 1% in readmissions or ED use.<br />
<br />
<br />
=== Results ===<br />
A total of about 34,000 patients were studied with slightly over half of these were in post-implementation group. The groups had small but statistically difference in race, discharge destination and severity of illness. Pre-implementation group had more whites and were sent home or to an acute rehabilitation place. <br />
In unadjusted analyses, small but statistically significant difference in readmission rates was seen in the post-implementation cohort for secondary outcomes. Age, severity of illness, and discharge diagnoses of COPD, CHF, Pneumonia and ESRD were associated with higher odds of readmissions.<br />
<br />
=== Discussion ===<br />
Other studies have shown that discharge instructions with medication reconciliation alone may not be sufficient to reduce readmissions or use of the ED post-discharge. However the authors were unable to find a good explanation to why an electronic discharge instruction would be associated with a small but statistically increase in the readmission rate. This increase could be due to slight differences between the two cohorts with regard to age and having more patients with diagnoses with higher than average readmission rates. A more comprehensive study analyzing the factors leading to readmission or ED use may be needed.<br />
<br />
=== My thoughts ===<br />
This study fails to show any decreased utilization of hospital resources post implementation of standardized electronic discharge instructions. In my opinion this means that a more comprehensive approach is needed to reduce failed discharges, that includes a standard method of communication information to the patient and other healthcare workers like it was done in this study and improving the environment to which the patient is discharged to. We need to provide better mechanisms of getting the patients followed up with their physicians and also work on developing a better primary care system. It may be the case that the hypothesis that CMS maintains may be fundamentally incorrect, and there is no achievable benefit in regard to the quality of passive written discharge instructions. In this case efforts would be better spent on maximizing post-discharge patient engagement through more active methods. In a study [[Readability of patient discharge instructions with and without the use of electronically available disease-specific templates |use of templates to improve readability of discharge instructions]] authors Mueller et. al <ref name="Discharge Template"></ref> showed that a well thought pre-developed discharge instructions templates help user readability of discharge instructions.<br />
<br />
[[ Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[ Category:EHR ]]<br />
[[Category: Electronic discharge]]<br />
<br />
==References ==<br />
<ref name="Electronic Discharge instructions"> Showalter, J. W., Rafferty, C. M., Swallow, N. A., DaSilva, K. O., & Chuang, C. H. (2011). Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization. Journal of General Internal Medicine, 26(7), 718–723. http://doi.org/10.1007/s11606-011-1712-y<br />
<br />
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3138594/?tool=pmcentrez</ref> <references/></div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Effect_of_Standardized_Electronic_Discharge_Instructions_on_Post-Discharge_Hospital_UtilizationEffect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization2015-10-06T01:44:51Z<p>Arshad Ghauri: /* My thoughts */</p>
<hr />
<div>''A review of the article by Showalter, "Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization". ''<br />
<br />
=== Introduction ===<br />
Readmissions to the hospital or the visits to the emergency department within 30 days of discharge are considered failed discharges. Jenck and colleagues, according to this article, estimated that these readmissions in 2004 alone cost the health care system $17.4 billion.[[ Centers for Medicare and Medicaid Services (CMS)|Centers of Medicare and Medicaid Services (CMS)]] estimates that some of these readmissions can be prevented by clear and concise discharge instruction given to the patients at the time of discharge. [[EMR|Electronic Health Records (EHRs)]] has the [[EMR Benefits and Return on Investment Categories | potential benefit]] to reduce readmission and ED use post hospital discharge by standardizing and producing comprehensive discharge instructions. Though studies have shown that comprehensive post discharge interventions have beneficial effects but the effect of standardized discharge instructions created electronically is not clear.<br />
<br />
=== Methods ===<br />
<br />
== Settings and Interventions ==<br />
This study was conducted in [http://www.pennstatehershey.org/web/guest/welcome Penn State Hershey Medical Center], which is a large academic medical center. Discharge instructions were typed in a word document template prior to the implementation of the study, however there were no mandatory fields that were required to be filled. Also medication reconciliation was done by hand. An electronic standardized discharge template was created that the CMS regulatory requirements. In this new form some data like admission and discharge date, medications were auto populated and other fields were typed but now were mandatory.<br />
<br />
== Participants ==<br />
A pre-implementation cohort of patients aged 18 and over was compared with compared with a post-implementation cohort. Post implementation cohort was selected 3 months after the new discharge template was implemented.<br />
<br />
== Outcome ==<br />
Primary outcome of the study was either a readmission or an ED visit within 30 days of the index discharge.<br />
<br />
== Covariates ==<br />
In order to account for already known risk factors for readmissions, data was analyzed with multiple covariates. These variables were, age, sex, race, severity of illness, diagnoses, disposition home versus others. Also included were patients on dialysis.<br />
<br />
== Data Management and Statistical Analysis ==<br />
Pre-implementation and post–implementation cohorts were compared for primary and secondary outcomes through multivariable logistic regression analysis done through SAS, Version 9.1 (SAS Institute, Cary, NC). Study had the power to estimate a difference of 1% in readmissions or ED use.<br />
<br />
<br />
=== Results ===<br />
A total of about 34,000 patients were studied with slightly over half of these were in post-implementation group. The groups had small but statistically difference in race, discharge destination and severity of illness. Pre-implementation group had more whites and were sent home or to an acute rehabilitation place. <br />
In unadjusted analyses, small but statistically significant difference in readmission rates was seen in the post-implementation cohort for secondary outcomes. Age, severity of illness, and discharge diagnoses of COPD, CHF, Pneumonia and ESRD were associated with higher odds of readmissions.<br />
<br />
=== Discussion ===<br />
Other studies have shown that discharge instructions with medication reconciliation alone may not be sufficient to reduce readmissions or use of the ED post-discharge. However the authors were unable to find a good explanation to why an electronic discharge instruction would be associated with a small but statistically increase in the readmission rate. This increase could be due to slight differences between the two cohorts with regard to age and having more patients with diagnoses with higher than average readmission rates. A more comprehensive study analyzing the factors leading to readmission or ED use may be needed.<br />
<br />
=== My thoughts ===<br />
This study fails to show any decreased utilization of hospital resources post implementation of standardized electronic discharge instructions. In my opinion this means that a more comprehensive approach is needed to reduce failed discharges, that includes a standard method of communication information to the patient and other healthcare workers like it was done in this study and improving the environment to which the patient is discharged to. We need to provide better mechanisms of getting the patients followed up with their physicians and also work on developing a better primary care system. It may be the case that the hypothesis that CMS maintains may be fundamentally incorrect, and there is no achievable benefit in regard to the quality of passive written discharge instructions. In this case efforts would be better spent on maximizing post-discharge patient engagement through more active methods. In a study [[Readability of patient discharge instructions with and without the use of electronically available disease-specific templates |use of templates to improve readability of discharge instructions]] authors Mueller et. al showed that a well thought pre-developed discharge instructions templates help user readability of discharge instructions.<br />
<br />
[[ Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[ Category:EHR ]]<br />
[[Category: Electronic discharge]]<br />
<br />
==References ==<br />
<ref name="Electronic Discharge instructions"> Showalter, J. W., Rafferty, C. M., Swallow, N. A., DaSilva, K. O., & Chuang, C. H. (2011). Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization. Journal of General Internal Medicine, 26(7), 718–723. http://doi.org/10.1007/s11606-011-1712-y<br />
<br />
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3138594/?tool=pmcentrez</ref> <references/></div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Readability_of_patient_discharge_instructions_with_and_without_the_use_of_electronically_available_disease-specific_templatesReadability of patient discharge instructions with and without the use of electronically available disease-specific templates2015-10-06T01:40:43Z<p>Arshad Ghauri: /* Background and Significance */</p>
<hr />
<div>This is a review of the article "Readability of patient discharge instructions with and without the use of electronically available disease-specific templates". <br />
<br />
== Background and Significance ==<br />
At the time of discharge patients have many concerns and may not recall verbal instructions. Typically in US hospitals discharge instructions are given in the written format. Due to low health literacy, many US adults may not understand these written discharge instructions. In this article authors have retrospective reviewed the discharge instructions given to the patients for their readability through the use of templates in [[EMR|Electronic Health Records (EHRs)]].<br />
<br />
=== Materials and Methods ===<br />
A retrospective cohort analysis was done in this study. The study was conducted at Brigham and Women’s Hospital (BWH) a large tertiary care center in Boston, Massachusetts. The subjects were randomly chosen from an adult, 18 and over population who were discharged home and received discharge instructions. <br />
<br />
BWH implemented a web based “discharge module” in 2011. For this module, discharge instruction templates were created for specific diagnoses and obtaining the feedback from the appropriate specialties. At the time of discharge physicians were free to write their own discharge instructions even if a specific template was available, use these templates as such, modify these templates.<br />
<br />
245 random subjects were chosen for this study. Out of this sample 233 were eligible. Data was analyzed for readability by using the Microsoft Office word 2007 for Flesch Reading Ease Level (FREL) scale and the Flesch-Kincaid Grade Level (FKGL) scale. <br />
<br />
The subjects were divided into two groups, one group consisted of clinician initiated discharge instructions. This group was divided into two subgroups, diagnosis specific discharge instruction template was available but not used and no diagnosis specific template was available. The other group consisted of subjects who received pre-developed diagnosis specific discharge instructions with or without modifications.<br />
<br />
=== Results ===<br />
Data analysis revealed that the pre-developed templates scored better in readability analysis. This pattern persisted even when the subjects, who received clinician initiated discharge instructions were removed from the final analysis, in which there was no diagnosis specific template was available. It was done to remove a potential bias that the lack of diagnosis specific template may mean that the illness was complex.<br />
<br />
=== Discussion ===<br />
In this study, authors found that pre-developed diagnosis specific discharge instructions even if modified resulted in better readability. This effect persisted even when after removing the subgroup from analysis for whom no diagnosis specific discharge template was available.<br />
<br />
=== My comments ===<br />
This study shows that it is possible to develop diagnosis specific discharge instructions that can be customized to meet the needs of a specific patient. However, it required a group of clinicians with the help of subject experts to develop such templates. It is not clear from this study whether this resulted in better outcomes. However, it makes sense to provide written helpful discharge instructions that can be easily understood by patients with inadequate literacy.<br />
<br />
[[ Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[ Category:EHR ]]<br />
[[Category: Electronic discharge]]<br />
<br />
<br />
Reference:<br />
<ref name="Discharge Template"> Mueller, S. K., Giannelli, K., Boxer, R., & Schnipper, J. L. (07/01/2015). Journal of the american medical informatics association : JAMIA: Readability of patient discharge instructions with and without the use of electronically available disease-specific templates BMJ. doi:10.1093/jamia/ocv005 <br />
http://dx.doi.org.ezproxyhost.library.tmc.edu/10.1093/jamia/ocv005</ref> <references/></div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Readability_of_patient_discharge_instructions_with_and_without_the_use_of_electronically_available_disease-specific_templatesReadability of patient discharge instructions with and without the use of electronically available disease-specific templates2015-10-06T01:38:42Z<p>Arshad Ghauri: /* Materials and Methods */</p>
<hr />
<div>This is a review of the article "Readability of patient discharge instructions with and without the use of electronically available disease-specific templates". <br />
<br />
== Background and Significance ==<br />
At the time of discharge patients have many concerns and may not recall verbal instructions. Typically in US hospitals discharge instructions are given in the written format. Due to low health literacy, many US adults may not understand these written discharge instructions. In this article authors have retrospective reviewed the discharge instructions given to the patients for their readability.<br />
<br />
=== Materials and Methods ===<br />
A retrospective cohort analysis was done in this study. The study was conducted at Brigham and Women’s Hospital (BWH) a large tertiary care center in Boston, Massachusetts. The subjects were randomly chosen from an adult, 18 and over population who were discharged home and received discharge instructions. <br />
<br />
BWH implemented a web based “discharge module” in 2011. For this module, discharge instruction templates were created for specific diagnoses and obtaining the feedback from the appropriate specialties. At the time of discharge physicians were free to write their own discharge instructions even if a specific template was available, use these templates as such, modify these templates.<br />
<br />
245 random subjects were chosen for this study. Out of this sample 233 were eligible. Data was analyzed for readability by using the Microsoft Office word 2007 for Flesch Reading Ease Level (FREL) scale and the Flesch-Kincaid Grade Level (FKGL) scale. <br />
<br />
The subjects were divided into two groups, one group consisted of clinician initiated discharge instructions. This group was divided into two subgroups, diagnosis specific discharge instruction template was available but not used and no diagnosis specific template was available. The other group consisted of subjects who received pre-developed diagnosis specific discharge instructions with or without modifications.<br />
<br />
=== Results ===<br />
Data analysis revealed that the pre-developed templates scored better in readability analysis. This pattern persisted even when the subjects, who received clinician initiated discharge instructions were removed from the final analysis, in which there was no diagnosis specific template was available. It was done to remove a potential bias that the lack of diagnosis specific template may mean that the illness was complex.<br />
<br />
=== Discussion ===<br />
In this study, authors found that pre-developed diagnosis specific discharge instructions even if modified resulted in better readability. This effect persisted even when after removing the subgroup from analysis for whom no diagnosis specific discharge template was available.<br />
<br />
=== My comments ===<br />
This study shows that it is possible to develop diagnosis specific discharge instructions that can be customized to meet the needs of a specific patient. However, it required a group of clinicians with the help of subject experts to develop such templates. It is not clear from this study whether this resulted in better outcomes. However, it makes sense to provide written helpful discharge instructions that can be easily understood by patients with inadequate literacy.<br />
<br />
[[ Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[ Category:EHR ]]<br />
[[Category: Electronic discharge]]<br />
<br />
<br />
Reference:<br />
<ref name="Discharge Template"> Mueller, S. K., Giannelli, K., Boxer, R., & Schnipper, J. L. (07/01/2015). Journal of the american medical informatics association : JAMIA: Readability of patient discharge instructions with and without the use of electronically available disease-specific templates BMJ. doi:10.1093/jamia/ocv005 <br />
http://dx.doi.org.ezproxyhost.library.tmc.edu/10.1093/jamia/ocv005</ref> <references/></div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Readability_of_patient_discharge_instructions_with_and_without_the_use_of_electronically_available_disease-specific_templatesReadability of patient discharge instructions with and without the use of electronically available disease-specific templates2015-10-06T01:07:23Z<p>Arshad Ghauri: /* My comments */</p>
<hr />
<div>This is a review of the article "Readability of patient discharge instructions with and without the use of electronically available disease-specific templates". <br />
<br />
== Background and Significance ==<br />
At the time of discharge patients have many concerns and may not recall verbal instructions. Typically in US hospitals discharge instructions are given in the written format. Due to low health literacy, many US adults may not understand these written discharge instructions. In this article authors have retrospective reviewed the discharge instructions given to the patients for their readability.<br />
<br />
=== Materials and Methods ===<br />
A retrospective cohort analysis was used. The study was conducted at Brigham and Women’s Hospital (BWH) a large tertiary care center in Boston, Massachusetts. The subjects were randomly chosen from an adult, 18 and over population who were discharged home and received discharge instructions. <br />
<br />
BWH implemented a web based “discharge module” in 2011. For this module, discharge instruction templates were created for specific diagnoses and obtaining the feedback from the appropriate specialties. At the time of discharge physicians were free to write their own discharge instructions even if a specific template was available, use these templates as such, modify these templates.<br />
<br />
245 random subjects were chosen for this study. Out of this sample 233 were eligible. Data was analyzed for readability by using the Microsoft Office word 2007 for Flesch Reading Ease Level (FREL) scale and the Flesch-Kincaid Grade Level (FKGL) scale. <br />
<br />
The subjects were divided into two groups, one group consisted of clinician initiated discharge instructions. This group was divided into two subgroups, diagnosis specific discharge instruction template was available but not used and no diagnosis specific template was available. The other group consisted of subjects who received pre-developed diagnosis specific discharge instructions with or without modifications.<br />
<br />
=== Results ===<br />
Data analysis revealed that the pre-developed templates scored better in readability analysis. This pattern persisted even when the subjects, who received clinician initiated discharge instructions were removed from the final analysis, in which there was no diagnosis specific template was available. It was done to remove a potential bias that the lack of diagnosis specific template may mean that the illness was complex.<br />
<br />
=== Discussion ===<br />
In this study, authors found that pre-developed diagnosis specific discharge instructions even if modified resulted in better readability. This effect persisted even when after removing the subgroup from analysis for whom no diagnosis specific discharge template was available.<br />
<br />
=== My comments ===<br />
This study shows that it is possible to develop diagnosis specific discharge instructions that can be customized to meet the needs of a specific patient. However, it required a group of clinicians with the help of subject experts to develop such templates. It is not clear from this study whether this resulted in better outcomes. However, it makes sense to provide written helpful discharge instructions that can be easily understood by patients with inadequate literacy.<br />
<br />
[[ Category:Reviews]]<br />
[[Category:HI5313-2015-FALL]]<br />
[[ Category:EHR ]]<br />
[[Category: Electronic discharge]]<br />
<br />
<br />
Reference:<br />
<ref name="Discharge Template"> Mueller, S. K., Giannelli, K., Boxer, R., & Schnipper, J. L. (07/01/2015). Journal of the american medical informatics association : JAMIA: Readability of patient discharge instructions with and without the use of electronically available disease-specific templates BMJ. doi:10.1093/jamia/ocv005 <br />
http://dx.doi.org.ezproxyhost.library.tmc.edu/10.1093/jamia/ocv005</ref> <references/></div>Arshad Ghaurihttp://www.clinfowiki.org/wiki/index.php/Readability_of_patient_discharge_instructions_with_and_without_the_use_of_electronically_available_disease-specific_templatesReadability of patient discharge instructions with and without the use of electronically available disease-specific templates2015-10-06T01:03:17Z<p>Arshad Ghauri: Created page with "This is a review of the article "Readability of patient discharge instructions with and without the use of electronically available disease-specific templates". == Backgroun..."</p>
<hr />
<div>This is a review of the article "Readability of patient discharge instructions with and without the use of electronically available disease-specific templates". <br />
<br />
== Background and Significance ==<br />
At the time of discharge patients have many concerns and may not recall verbal instructions. Typically in US hospitals discharge instructions are given in the written format. Due to low health literacy, many US adults may not understand these written discharge instructions. In this article authors have retrospective reviewed the discharge instructions given to the patients for their readability.<br />
<br />
=== Materials and Methods ===<br />
A retrospective cohort analysis was used. The study was conducted at Brigham and Women’s Hospital (BWH) a large tertiary care center in Boston, Massachusetts. The subjects were randomly chosen from an adult, 18 and over population who were discharged home and received discharge instructions. <br />
<br />
BWH implemented a web based “discharge module” in 2011. For this module, discharge instruction templates were created for specific diagnoses and obtaining the feedback from the appropriate specialties. At the time of discharge physicians were free to write their own discharge instructions even if a specific template was available, use these templates as such, modify these templates.<br />
<br />
245 random subjects were chosen for this study. Out of this sample 233 were eligible. Data was analyzed for readability by using the Microsoft Office word 2007 for Flesch Reading Ease Level (FREL) scale and the Flesch-Kincaid Grade Level (FKGL) scale. <br />
<br />
The subjects were divided into two groups, one group consisted of clinician initiated discharge instructions. This group was divided into two subgroups, diagnosis specific discharge instruction template was available but not used and no diagnosis specific template was available. The other group consisted of subjects who received pre-developed diagnosis specific discharge instructions with or without modifications.<br />
<br />
=== Results ===<br />
Data analysis revealed that the pre-developed templates scored better in readability analysis. This pattern persisted even when the subjects, who received clinician initiated discharge instructions were removed from the final analysis, in which there was no diagnosis specific template was available. It was done to remove a potential bias that the lack of diagnosis specific template may mean that the illness was complex.<br />
<br />
=== Discussion ===<br />
In this study, authors found that pre-developed diagnosis specific discharge instructions even if modified resulted in better readability. This effect persisted even when after removing the subgroup from analysis for whom no diagnosis specific discharge template was available.<br />
<br />
=== My comments ===<br />
This study shows that it is possible to develop diagnosis specific discharge instructions that can be customized to meet the needs of a specific patient. However, it required a group of clinicians with the help of subject experts to develop such templates. It is not clear from this study whether this resulted in better outcomes. However, it makes sense to provide written helpful discharge instructions that can be easily understood by patients with inadequate literacy.<br />
<br />
Reference:<br />
<ref name="Discharge Template"> Mueller, S. K., Giannelli, K., Boxer, R., & Schnipper, J. L. (07/01/2015). Journal of the american medical informatics association : JAMIA: Readability of patient discharge instructions with and without the use of electronically available disease-specific templates BMJ. doi:10.1093/jamia/ocv005 <br />
http://dx.doi.org.ezproxyhost.library.tmc.edu/10.1093/jamia/ocv005</ref> <references/></div>Arshad Ghauri