Annotated Bibliography: Understanding Ambulatory Care Practices in the Context of Patient Safety and Quality Improvement.

The ambulatory care setting is an increasingly important component of the patient safety conversation. Inpatient safety is the primary focus of the vast majority of safety research and interventions, but the ambulatory setting is actually where most medical care is administered. Recent attention has shifted toward examining ambulatory care in order to implement better health care quality and safety practices. This annotated bibliography was created to analyze and augment the current literature on ambulatory care practices with regard to patient safety and quality improvement. By providing a thorough examination of current practices, potential improvement strategies in ambulatory care health care settings can be suggested. A better understanding of the myriad factors that influence delivery of patient care will catalyze future health care system development and implementation in the ambulatory setting

Performance Measures Using Electronic Health Records: Five Case Studies

Presents the experiences of five provider organizations in developing, testing, and implementing four types of electronic quality-of-care indicators based on EHR data. Discusses challenges, and compares results with those from traditional indicators

Advancing Pharmacist Collaborative Care within Academic Health Systems.

INTRODUCTION:The scope of pharmacy practice has evolved over the last few decades to focus on the optimization of medication therapy. Despite this positive impact, the lack of reimbursement remains a significant barrier to the implementation of innovative pharmacist practice models. SUMMARY:We describe the successful development, implementation and outcomes of three types of pharmacist collaborative care models: (1) a pharmacist with physician oversight, (2) pharmacist-interprofessional teams and (3) physician-pharmacist teams. The outcome measurement of these pharmacist care models varied from the design phase to patient volume measurement and to comprehensive quality dashboards. All of these practice models have been successfully funded by affiliated health systems or grants. CONCLUSIONS:The expansion of pharmacist services delivered by clinical faculty has several benefits to affiliated health systems: (1) significant improvements in patient care quality, (2) access to experts in specialty areas, and (3) the dissemination of outcomes with national and international recognition, increasing the visibility of the health system

The New York City Health and Hospitals Corporation: Transforming a Public Safety Net Delivery System to Achieve Higher Performance

Describes the results of the public benefit corporation's improvement initiatives -- a common clinical information system for continuity, coordination on chronic disease management, teamwork and continuous innovation, and access to appropriate care

Impact of an Electronic Medical Record Implementation on Drug Allergy Overrides in a Large Southeastern HMO Setting

Renny Varghese Impact of an Electronic Medical Record Implementation on Drug Allergy Overrides in a Large Southeastern HMO Setting (Under the direction of Russell Toal, Associate Professor) Electronic medical records (EMRs) have become recognized as an important tool for improving patient safety and quality of care. Decision support tools such as alerting functions for patient medication allergies are a key part of reducing the frequency of serious medication problems. Kaiser Permanente Georgia (KPGA) implemented its EMR system in the primary care departments at Kaiser\u27s twelve facilities in the greater metro Atlanta area over a six month period beginning in June 2005 and ending December 2005. The aim of this study is to analyze the impact of the EMR implementation on the number of drug allergy overrides within this large HMO outpatient setting. Research was conducted by comparing the rate of drug allergy overrides during pre and post EMR implementation. The timeline will be six months pre and post implementation. Observing the impact of the incidence rate of drug allergy alerts after the implementation provided insight into the effectiveness of EMRs in reducing contraindicated drug allergies. Results show that the incidence rate of drug allergy overrides per 1,000 filled prescriptions rose by a statistically significant 5.9% (ñ \u3e 0.0002; 95% CI [-1.531, -0.767]) following the implementation. Although results were unexpected, several factors are discussed as to the reason for the increase. Further research is recommended to explore trends in provider behavior, KPGA specific facilities and departments, and in other KP regions and non-KP healthcare settings. INDEX WORDS: electronic medical records, drug allergy overrides, patient safety, medication errors, decision support tools, outpatient setting, primary care, computerized provider order entr

Factors Associated with Ordering and Completion of Laboratory Monitoring Tests for High-Risk Medications in the Ambulatory Setting: A Dissertation

Since the Institute of Medicine highlighted the devastating impact of medical errors in their seminal report, “To Err is Human” (2000), efforts have been underway to improve patient safety. A portion of medical errors are due to medication errors, and a large portion of these can be attributed to inadequate laboratory monitoring. In this thesis, I attempt to address this small but important corner of this patient safety endeavor. Why are patients not getting their laboratory monitoring tests? Do they fail to complete them or do doctors not order the tests in the first place? Which prescribers and which patients are least likely to do what is needed for testing to happen and what interventions would be most promising? To address these questions, I conducted a systematic review of existing interventions. I then proceeded with three aims: 1) To identify reasons that patients give for missing monitoring tests; 2) To identify patient and provider factors associated with monitoring test ordering; and 3) To identify patient and provider factors associated with completion of ordered testing. To achieve these aims, I worked with patients and data at the Fallon Clinic. For aim 1, I conducted a qualitative analysis of their reasons for missing tests as well as reporting completion and ordering rates. For aims 2 and 3, I used electronic medical record data and conducted a regression with patient and provider characteristics as covariates to identify factors contributing to test ordering and completion. Interviews revealed that patients had few barriers to completion, with forgetting being the most common reason for missing a test. The quantitative studies showed that: older patients with more interactions with the health care system were more likely to have tests ordered and were more likely to complete them; providers who more frequently prescribe a drug were more likely to order testing for it; and drug-test combinations that were particularly dangerous, indicated by a black box warning, were more likely to have appropriate ordering, though for these combinations, primary care providers were less likely to order tests appropriately, and patients were less likely to complete tests. Taken together, my work can inform future interventions in laboratory monitoring and patient safety

Predictive Relationships Between Electronic Health Records Attributes and Meaningful Use Objectives

The use of electronic health records (EHR) has the potential to improve relationships between physicians and patients and significantly improve care delivery. The purpose of this study was to analyze the relationships between hospital attributes and EHR implementation. The research design for this study was the cross-sectional approach. Secondary data from the Health Information and Management Systems Society (HIMSS) Analytics Database was utilized (n = 169) in a correlational crosssectional research design. Normalization Process Theory (NPT) and implementation theory were the theoretical underpinnings used in this study. Multiple linear regressions results showed statistically significant relationships between the 4 independent variables (region, ownership status, number of staffed beds [size], and organizational control) and the outcomes for the dependent variables of EHR software application attributes (Clinical Decision Support Systems (CDSS) components), EHR software application attributes (major systems), and successful implementation of Meaningful Use (MU) (p = .001). A statistically significant relationship (p = .001) was also found between the 2 independent variables (EHR software application attributes [CDSS components] and EHR software application attributes [major systems]) and the outcome of successful implementation of MU when combined. This evidence should provide policy makers and health practitioners support for their attempts to implement EHR systems to result in positive Meaningful Use which has been shown to be more cost effective and result in better quality of care for patients.The potential social change is improved medication prescribing and administration for hospitals and, lower cost and better quality of care for patients

Linking Health Information Technology to Patient Safety and Quality Outcomes: A Bibliometric Analysis and Review

Informatics for Health and Social Care is published by Informa Healthcare. Publisher's version can be found at: http://informahealthcare.com/doi/abs/10.3109/17538157.2012.678451OBJECTIVE: To assess the scholarly output of grants funded by the Agency for Healthcare Research and Quality (AHRQ) that published knowledge relevant to the impact of health information technologies on patient safety and quality of care outcomes. STUDY DESIGN: We performed a bibliometric analysis of the identified scholarly articles, their journals, and citations. In addition, we performed a qualitative review of the full-text articles and grant documents. DATA COLLECTION/EXTRACTION METHODS: Papers published by AHRQ-funded investigators were retrieved from MEDLINE, journal impact factors were extracted from the 2010 Thompson Reuters Journal Citation Report, citations were retrieved from ISI's Web of Knowledge and Google Scholar. PRINCIPAL FINDINGS: Seventy-two articles met the criteria for review. Most articles addressed one or more of AHRQ's outcome goals and focus priorities. The average impact factor for the journals was 4.005 (range: 0.654-28.899). The articles, and their respective grants, represented a broad range of health information technologies. CONCLUSIONS: This set of AHRQ-funded research projects addressed the goals and priorities of AHRQ, indicating notable contributions to the scientific knowledge base on the impact of information system use in healthcare.This work was supported, in part, by the National Resource Center of the Agency for Healthcare Research and Quality, contract number 290-04-0016

The use of administrative health care databases to identify patients with Rheumatoid Arthritis

Objective: To validate and compare the decision rules to identify rheumatoid arthritis (RA) in administrative databases. Methods: A study was performed using administrative health care data from a population of 1 million people who had access to universal health care. Information was available on hospital discharge abstracts and physician billings. RA cases in health administrative databases were matched 1:4 by age and sex to randomly selected controls without inflammatory arthritis. Seven case definitions were applied to identify RA cases in the health administrative data, and their performance was compared with the diagnosis by a rheumatologist. The validation study was conducted on a sample of individuals with administrative data who received a rheumatologist consultation at the Arthritis Center of Nova Scotia. Results: We identified 535 RA cases and 2,140 non-RA, noninflammatory arthritis controls. Using the rheumatologist's diagnosis as the gold standard, the overall accuracy of the case definitions for RA cases varied between 68.9% and 82.9% with a kappa statistic between 0.26 and 0.53. The sensitivity and specificity varied from 20.7% to 94.8% and 62.5% to 98.5%, respectively. In a reference population of 1 million, the estimated annual number of incident cases of RA was between 176 and 1,610 and the annual number of prevalent cases was between 1,384 and 5,722. Conclusion: The accuracy of case definitions for the identification of RA cases from rheumatology clinics using administrative health care databases is variable when compared to a rheumatologist's assessment. This should be considered when comparing results across studies. This variability may also be used as an advantage in different study designs, depending on the relative importance of sensitivity and specificity for identifying the population of interest to the research question