Electronic Health Record Functionality Needed to Better Support Primary Care

Electronic health records (EHRs) must support primary care clinicians and patients, yet many clinicians remain dissatisfied with their system. This manuscript presents a consensus statement about gaps in current EHR functionality and needed enhancements to support primary care. The Institute of Medicine primary care attributes were used to define needs and Meaningful Use (MU) objectives to define EHR functionality. Current objectives remain disease- rather than whole-person focused, ignoring factors like personal risks, behaviors, family structure, and occupational and environmental influences. Primary care needs EHRs to move beyond documentation to interpreting and tracking information over time as well as patient partnering activities, support for team based care, population management tools that deliver care, and reduced documentation burden. While Stage 3 MU’s focus on outcomes is laudable, enhanced functionality is still needed including EHR modifications, expanded use of patient portals, seamless integration with external applications, and advancement of national infrastructure and policies

Roles and practices of general practitioners and psychiatrists in management of depression in the community

BACKGROUND: Little is known about depressed patients' profiles and how they are managed. The aim of the study is to compare GPs and psychiatrists for 1°) sociodemographic and clinical profile of their patients considered as depressed 2°) patterns of care provision. METHODS: The study design is an observational cross-sectional study on a random sample of GPs and psychiatrists working in France. Consecutive inclusion of patients seen in consultation considered as depressed by the physician. GPs enrolled 6,104 and psychiatrists 1,433 patients. Data collected: sociodemographics, psychiatric profile, environmental risk factors of depression and treatment. All clinical data were collected by participating physicians; there was no direct independent clinical assessment of patients to check the diagnosis of depressive disorder. RESULTS: Compared to patients identified as depressed by GPs, those identified by psychiatrists were younger, more often urban (10.5% v 5.4% – OR = 2.4), educated (42.4% v 25.4% – OR = 3.9), met DSM-IV criteria for depression (94.6% v 85.6% – OR = 2.9), had been hospitalized for depression (26.1% v 15.6% – OR = 2.0) and were younger at onset of depressive problems (all adjusted p < .001). No difference was found for psychiatric and somatic comorbidity, suicide attempt and severity of current depression. Compared to GPs, psychiatrists more often prescribed tricyclics and very novel antidepressants (7.8% v 2.3% OR = 5.0 and 6.8% v 3.0% OR = 3.8) with longer duration of antidepressant treatment. GPs' patients received more "non-conventional" treatment (8.8% v 2.4% OR = 0.3) and less psychotherapy (72.2% v 89.1% OR = 3.1) (all adjusted p < .001). CONCLUSION: Differences between patients mainly concerned educational level and area of residence with few differences regarding clinical profile. Differences between practices of GPs and psychiatrists appear to reflect more the organization of the French care system than the competence of providers

The Economics of Integrated Depression Care: The University of Michigan Study

A goal of the Robert Wood Johnson Depression and Primary Care Initiative at the University of Michigan is to create and implement the clinical care and financial systems necessary to enable links between primary care and mental health specialty depression care. This paper describes the economic issues related to resources required, the mechanisms to distribute those resources, and the support that must be garnered from stakeholders. By systematic measurement and application, we assess the cost, price and selected consequences of these efforts. The study illustrates the need for both centralized and distributed capacity and support for innovative models of care.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/44096/1/10488_2005_Article_4231.pd

The Role of Clinical Information Technology in Depression Care Management

We examine the literature on the growing application of clinical information technology in managing depression care and highlight lessons learned from Robert Wood Johnson Foundation’s national program “Depression in Primary Care-Incentives Demonstrations.” Several program sites are implementing depression care registries. Key issues discussed about implementing registries include using a simple yet functional format, designing registries to track multiple conditions versus depression alone (i.e., patient-centric versus disease-centric registries) and avoiding violations of patient privacy with the advent of more advanced information technologies (e.g., web-based formats). Finally, we discuss some implications of clinical information technology for healthcare practices and policy makers.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/44097/1/10488_2005_Article_4236.pd

The Process of Choice of Health Care Plan and Provider: Development of an Integrated Analytic Framework

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/68543/2/10.1177_002570879104800304.pd

Partnering with Hospice - Setting Expectations: How to Avoid the \u27Over-promise\u27

Adam Herman, MD, Executive Medical Director Palliative Medicine and Hospice Care Service Line, RRH; Erin Klinkman, MD, Hospice Medical Director RRH Hospice; Michael DiSalle, MD, Interim Chief, Division of Palliative Medicine, Unity Hospital Objectives: Define and recognize criteria for hospice enrollment Understand the differences between the different levels of care for hospice Define the criteria for Acute inpatient hospic

Partnering with Hospice - Setting Expectations: How to Avoid the \u27Over-promise\u27

Partnering with Hospice - Setting Expectations: How to Avoid the \u27Over-promise\u27, Adam Herman, MD, Executive Medical Director Palliative Medicine and Hospice Care Service Line, RRH; Erin Klinkman, MD, Hospice Medical Director RRH Hospice; Michael DiSalle, MD, Interim Chief, Division of Palliative Medicine, Unity Hospital Discussion: Brief review of the relationship between palliative care and hospice How to engage patients and families when making a hospice referral Define hospice services What attending for hospice means Explain hospice level of care (LOC) determination Understand how the Hildebrandt serves our communit

The Effects of Insurance Coverage on the Quality of Prenatal Care

Objective: To compare the quality of prenatal care provided to patients with traditional fee-for-service, health maintenance organization, and Medicaid insurance using an evidence-based, community-derived prenatal care guideline. Design: Retrospective cohort study. Setting: Seven private and hospital-based prenatal care sites in a suburban county in southeast Michigan. Patients: A stratified random sample of 267 patients (93 with Medicaid, 92 with health maintenance organization, and 82 with fee-for-service insurance) receiving prenatal care from community physicians (obstetriciansgynecologists and family practitioners) between January 1, 1991, and December 31, 1992. Main Outcome Measure: Adherence to explicit prenatal care criteria as measured by an evidence-based prenatal care guideline developed by a community panel. Quality scores were compared across groups in 4 areas: performance of prenatal screening procedures or tests, visit-based screening, substance use screening, and clinician management of abnormal clinical findings. Results: Patients with Medicaid insurance presented for prenatal care significantly later in pregnancy (14.5 vs 10.5 weeks, P\u3c.01). No significant differences were seen between groups in quality scores for screening tests, clinician management of abnormal clinical findings, visit-based screening, or substance use screening. The overall similarity in quality scores did obscure some significant differences in adherence to individual criteria, particularly in the area of screening tests. Significantly more patients with Medicaid were screened for genital infection (P\u3c.001) and fewer for gestational diabetes (P\u3c.001) or anemia (P\u3c.001) than patients in the other 2 groups. Conclusions: Although patients with Medicaid presented for prenatal care later in pregnancy and received a different package of screening tests than the other 2 groups, there was no overall measurable difference in the quality of prenatal care provided to patients with Medicaid, health maintenance organization, and fee-for-service insurance. Clinicians may have altered screening protocols based on preexisting perceptions of patient risk. Although summary quality measures are a promising tool for comparative research, they provide an incomplete picture of the quality of the prenatal care process and must be interpreted with caution

The Effects of Insurance Coverage on the Quality of Prenatal Care

Objective: To compare the quality of prenatal care provided to patients with traditional fee-for-service, health maintenance organization, and Medicaid insurance using an evidence-based, community-derived prenatal care guideline. Design: Retrospective cohort study. Setting: Seven private and hospital-based prenatal care sites in a suburban county in southeast Michigan. Patients: A stratified random sample of 267 patients (93 with Medicaid, 92 with health maintenance organization, and 82 with fee-for-service insurance) receiving prenatal care from community physicians (obstetriciansgynecologists and family practitioners) between January 1, 1991, and December 31, 1992. Main Outcome Measure: Adherence to explicit prenatal care criteria as measured by an evidence-based prenatal care guideline developed by a community panel. Quality scores were compared across groups in 4 areas: performance of prenatal screening procedures or tests, visit-based screening, substance use screening, and clinician management of abnormal clinical findings. Results: Patients with Medicaid insurance presented for prenatal care significantly later in pregnancy (14.5 vs 10.5 weeks, P\u3c.01). No significant differences were seen between groups in quality scores for screening tests, clinician management of abnormal clinical findings, visit-based screening, or substance use screening. The overall similarity in quality scores did obscure some significant differences in adherence to individual criteria, particularly in the area of screening tests. Significantly more patients with Medicaid were screened for genital infection (P\u3c.001) and fewer for gestational diabetes (P\u3c.001) or anemia (P\u3c.001) than patients in the other 2 groups. Conclusions: Although patients with Medicaid presented for prenatal care later in pregnancy and received a different package of screening tests than the other 2 groups, there was no overall measurable difference in the quality of prenatal care provided to patients with Medicaid, health maintenance organization, and fee-for-service insurance. Clinicians may have altered screening protocols based on preexisting perceptions of patient risk. Although summary quality measures are a promising tool for comparative research, they provide an incomplete picture of the quality of the prenatal care process and must be interpreted with caution