Who Opens Alerts to Physicians? (And Who Doesn’t?)

Background: Electronic medical records (EMR) provide opportunities to implement systems of information flow, such as alerts to providers. Methods: Within a group practice with an EMR, we conducted a trial of automated alerts to the in-baskets of primary care physicians and staff when patients were discharged from hospital to home. We generated alerts for new medications or monitoring needs. Staff received alerts to schedule office visits. Using EMR “digital crumbs”, we tracked when alerts were viewed. We analyzed the impact of physician age, gender, department, and employment status (full-time, part-time) as well as patient conditions (age, gender, comorbidity, and number of office visits in the previous year) on timely opening. Results: Of 763 alerts to physicians, 616 (81%) were opened within one day. Characteristics associated with timely opening were age \u3c 50 (OR 1.7, 95% CI 1.1, 2.6) and full-time employment (OR 2.9, 95% CI 1.6, 5.2). Of 1928 alerts to staff, 1173 (61%) were opened within one day. Staff of male physicians were more likely to open the alerts within one day (OR 1.8, 95% CI 1.4, 2.4) as were working for the Family Medicine department (OR 1.9, 95% CI 1.3, 2.6) or a sub-specialty department (OR 16.6, 95% CI 2.3, 122.3). Staff of full-time physicians were less likely to open alerts (OR 0.64, 95% CI 0.47, 0.87). Adjusting for patient characteristics had no impact on results. Conclusion: Special efforts may be required to reach physicians working part-time and older physicians. Characteristics related to staff opening of alerts are specific to this group practice, but the high level of variability across physician types and departments is likely to be an issue in many settings. Design of a system directed at reaching staff quickly may require in-depth assessment of work flow and communication patterns in clinical department

Patient Adherence to Laboratory Tests to Monitor Medication Therapy: A Mixed-Methods Study

Background Little is known about the contribution of patient behavior to incomplete laboratory monitoring and the reasons for patient non-completion of ordered laboratory tests remain unclear. Objective To describe factors, including patient-reported reasons, associated with non-completion of ordered laboratory tests. Design Mixed-methods study including a quantitative assessment of the frequency of patient adherence to ordered monitoring tests combined with qualitative, semi-structured, patient interviews. Participants Quantitative assessment included patients 18 years or older from a large multispecialty group practice prescribed a medication requiring monitoring. Qualitative interviews included a subset of adherent and non-adherent patients prescribed a cardiovascular, anti-convulsant, or thyroid replacement medication. Main Measures Proportion of recommended monitoring tests for each medication not completed, factors associated with patient non-adherence, and patient-reported reasons for non-adherence. Results Of 27,802 patients who were prescribed one of 34 medications, patient non-completion of ordered tests varied (range: 0% to 29%, by drug-test pair). Factors associated with higher odds of test non-completion included younger patient age (\u3c 40 years vs. ≥80 years, adjusted odds ratio [AOR] 1.52, 95% confidence interval [95% CI] 1.27-1.83), lower medication burden (1 medication vs. more than 1 drug, AOR for non-completion 1.26, 95% CI 1.15-1.37), and lower visit frequency (0-5 visits/year vs. ≥19 visits/year, AOR 1.41, 95% CI 1.25 to 1.59). Drug-test pairs with black box warning status were associated with greater odds of non-completion compared to drugs included only in the PDR (AOR 1.91, 95% CI 1.66-2.19). Qualitative interviews, with 16 non-adherent and 7 adherent patients, identified forgetting as the main cause of non-adherence. Conclusions Patient non-adherence contributed to missed opportunities to monitor medications and was associated with younger patient age and lower medication burden and black box warning status. Interventions to improve laboratory monitoring should target patients as well as physicians

Technological Resources and Personnel Costs Required to Implement an Automated Alert System for Primary Care Physicians When Patients Transition from Hospitals to Home

Background With the adoption of electronic medical records by medical group practices, there are opportunities to improve the quality of care for patients discharged from hospitals. However, there is little guidance for medical groups outside of integrated hospital systems to automate the flow of patient information during transitions in care. Objective To describe the technological resources, expertise and time needed to develop an automated system providing information to primary care physicians when their patients transition from hospitals to home. Development Within a medical group practice, we developed an automated alert system that provides notification of discharges, reminders of the need for follow-up visits, drugs added during in-patient stays, and recommendations for laboratory monitoring of high risk drugs. We tracked components of the information system required and the time spent by team members. We used US national averages of hourly wages to estimate personnel costs. Application Critical components of the information system are notifications of hospital discharges through an admission, discharge and transfer registration (ADT) interface, linkage to the practice’s scheduling system, access to information on pharmacy dispensing and lab tests, and an interface engine. Total personnel cost was $76,314. Nearly half (47%) was for 614 hours by physicians who developed content, provided overall project management, and reviewed alerts to ensure that only “actionable” alerts would be sent. Conclusion Implementing a system to provide information about patient transitions requires strong internal informatics expertise, cooperation between facilities and ambulatory providers, development of electronic linkages, and extensive commitment of physician time

Intervention to Reduce Adverse Outcomes among Older Adults Discharged from Skilled Nursing Facilities to Home

Background: Older adults may be at risk for adverse outcomes after discharge from skilled nursing facilities (SNF), but little research has focused on this transition. Objective: To assess the impact of an alert system on the rates of adverse outcomes among older adults discharged from SNFs to home. Methods: Within a multispecialty group practice, we tracked 30-day re-hospitalizations after SNF discharges during an intervention that provided discharge alerts to primary care physicians. We compared them to discharges from the pre-intervention period matched on age, gender and SNF. For the first 100 intervention discharges and their matches, we performed chart reviews to identify adverse drug events (ADEs). Multivariate analyses controlled for age, gender and intervention status. Results: We matched 313 intervention SNF discharges to 313 previous discharges. There was a slight reduction in the rate of 30-day re-hospitalization (30% vs. 31%) adjusted. Within the ADE study, 30% of the discharges during the intervention period and 30% of matched discharges had ADEs within 45 days. Among the 83 ADEs identified, 28% were deemed preventable; 69% resulted in symptom duration more than one day; 69% occurred within the first 14 days after discharge. This was a highly vulnerable population: mean age 82.5 (standard deviation (SD) 6.7); mean number of prescribed medications 11.9 (SD 8); 17% had Charlson Comorbidity Scores of ≥4. Common clinical conditions included myocardial infarction (24%), heart failure (22%), COPD (23%), and major depression (28%). Patients with scores of ≥4 were more likely to experience an ADE than those with lower scores (adjusted OR 2.5 (CI 1.2, 5.5), RD 0.21). Conclusion: Simply providing alerts when these vulnerable patients are discharged from SNFs is not sufficient to lower rates of adverse outcomes. Further research is required to track trajectories and identify additional points for interventions

Reducing Rehospitalizations through Automated Alerts to Primary Care Providers and Staff When Older Patients are Discharged from the Hospital: A Randomized Trial

Background: Inadequate continuity of care places older patients at very high risk during transitions from the hospital to ambulatory setting. Methods: We conducted a randomized controlled trial of an HIT-based transitional care intervention in patients aged 65 and older discharged from hospital to home. All patients were senior plan members of a Massachusetts-based health plan, and cared for by a multispecialty medical group using the EpicCare Ambulatory Medical Record. In addition to notifying providers about the patient’s recent transition, the system provided information about new drugs added during the inpatient stay, warnings about drug-drug interactions, recommendations for dose changes and laboratory monitoring of high-risk medications, and reminded the primary care provider’s support staff to schedule a post-hospitalization office visit. Randomization occurred at the time of hospital discharge during a one-year intervention period beginning in August 2010. Alerts were automatically delivered to the provider and staff in-basket within the EMR. The primary outcomes were: 1) having an outpatient office visit with the primary care provider within 30 days following discharge; and 2) having a rehospitalization within 30 days following discharge. Results: The study included 3667 discharges of which 1877 discharges were randomly assigned to the intervention arm. Forty-nine percent of discharges in the intervention arm were followed by office visits with the primary care provider within 30 days, compared to 51% in the comparison arm (RR 0.96, 95% CI 0.90, 1.03). Eighteen percent of discharges in the intervention arm were followed by a rehospitalization within 30 days compared to 20% in the comparison arm (RR 0.92, 95% CI 0.80, 1.05). Conclusions: This HIT-based intervention was not effective in increasing the percentage of hospital discharges of older patients that were followed by timely office visits to primary care providers or reducing the percentage with rehospitalization

Adverse Drug Events Post-Hospital Discharge in Older Patients: Types, Severity, and Involvement of Beers Criteria Medications

Objective: To characterize adverse drug events (ADEs) occurring within the high-risk 45-day period post-hospitalization in older adults. Design: Clinical pharmacists reviewed the ambulatory records of 1000 consecutive discharges. Setting: A large multispecialty group practice closely aligned with a Massachusetts-based health plan. Participants: Hospitalized patients aged 65 years and older who were discharged to home. Measurements: Possible drug-related incidents occurring during the 45-day period post-hospitalization were identified and presented to a pair of physician-reviewers who classified incidents as to whether an ADE was present, whether the event was preventable, and the severity of the event. Medications implicated in ADEs were further characterized according to their inclusion in the 2012 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Results: At least one ADE was identified during the 45-day period in 18.7% (187) of the 1000 discharges. Of the 242 ADEs identified, 35% (n=84) were deemed preventable, of which 32% (n=27) were characterized as serious, and 5% (n=4) as life threatening. Over half of all ADEs occurred within the first 14 days post-hospitalization. The percentage of ADEs in which Beers Criteria medications were implicated was 16.5% (n=40). Beers Criteria medications with both a high quality of evidence and strong strength of recommendation were implicated in 6.6% (n=16) of the ADEs. Conclusion: ADEs are common and often preventable among older adults following hospital discharge, underscoring the need to address medication safety during this high-risk period in this vulnerable population. Beers Criteria medications played a small role in these events suggesting that efforts to improve the quality and safety of medication use during this critical transition period must extend beyond a singular focus on Beers criteria medications

Technological resources and personnel costs required to implement an automated alert system for ambulatory physicians when patients are discharged from hospitals to home

Background With the adoption of electronic medical records by medical group practices, there are opportunities to improve the quality of care for patients discharged from hospitals. However, there is little guidance for medical groups outside integrated hospital systems to automate the flow of patient information during transitions in care.Objective To describe the technological resources, expertise and time needed to develop an automated system providing information to ambulatory physicians when their patients are discharged from hospitals to home.Development Within a medical group practice, we developed an automated alert system that provides notification of discharges, reminders of the need for follow-up visits, drugs added during inpatient stays, and recommendations for laboratory monitoring of high-risk drugs. We tracked components of the information system required and the time spent by team members. We used USA national averages of hourly wages to estimate personnel costs.Application Critical components of the information system are notifications of hospital discharges through an admission, discharge and transfer registration (ADT) interface, linkage to the group’s scheduling system, access to information on pharmacy dispensing and lab tests, and an interface engine. Total personnel cost was $76,314. Nearly half (47%) was for 614 hours by physicians who developed content, provided overall project management, and reviewed alerts to ensure that only ‘actionable’ alerts would be sent.Conclusion Implementing a system to provide information about hospital discharges requires strong internal informatics expertise, cooperation between facilities and ambulatory providers, development of electronic linkages, and extensive commitment of physician time

Vaccine counseling: a content analysis of patient-physician discussions regarding human papilloma virus vaccine

OBJECTIVES: (1) Describe content and character of patient-physician human papilloma virus (HPV) vaccine discussions; (2) explore the relationship between selected characteristics and vaccine uptake. METHODS: Content analyses were conducted on 184 transcripts of audio-taped patient encounters with 11-26 year old female patients that occurred from August 2008 to March 2009 and contained mention of the HPV vaccine. Directed qualitative content analysis sought to identify key themes with a focus on elements related to communication. Quantitative content analysis included determination of associations between selected factors (e.g., physician specialty, communication variables, patient age) and vaccination rates. RESULTS: Communication themes identified though qualitative content analysis demonstrated potential opportunities for improvement in vaccine communication were identified. Quantitative content analysis showed twenty-eight percent of eligible patients received HPV vaccine and on average these patients were younger (17.0 vs. 19.6 years). The youngest and oldest patients were vaccinated less frequently. CONCLUSIONS: Targeting age groups with lower vaccination rates may increase overall vaccine uptake. Additional quantitative analyses of patient-physician discussions about vaccine may generate further recommendations regarding optimal communication strategies for HPV vaccine counseling

Identification of olivetolic acid cyclase from Cannabis sativa reveals a unique catalytic route to plant polyketides

\u3949-Tetrahydrocannabinol (THC) and other cannabinoids are responsible for the psychoactive and medicinal properties of Cannabis sativa L. (marijuana). The first intermediate in the cannabinoid biosynthetic pathway is proposed to be olivetolic acid (OA), an alkylresorcinolic acid that forms the polyketide nucleus of the cannabinoids. OA has been postulated to be synthesized by a type III polyketide synthase (PKS) enzyme, but so far type III PKSs from cannabis have been shown to produce catalytic byproducts instead of OA. We analyzed the transcriptome of glandular trichomes from female cannabis flowers, which are the primary site of cannabinoid biosynthesis, and searched for polyketide cyclase-like enzymes that could assist in OA cyclization. Here, we show that a type III PKS (tetraketide synthase) from cannabis trichomes requires the presence of a polyketide cyclase enzyme, olivetolic acid cyclase (OAC), which catalyzes a C2\u2013C7 intramolecular aldol condensation with carboxylate retention to form OA. OAC is a dimeric \u3b1+\u3b2 barrel (DABB) protein that is structurally similar to polyketide cyclases from Streptomyces species. OAC transcript is present at high levels in glandular trichomes, an expression profile that parallels other cannabinoid pathway enzymes. Our identification of OAC both clarifies the cannabinoid pathway and demonstrates unexpected evolutionary parallels between polyketide biosynthesis in plants and bacteria. In addition, the widespread occurrence of DABB proteins in plants suggests that polyketide cyclases may play an overlooked role in generating plant chemical diversity.Peer reviewed: YesNRC publication: Ye

Quality measurement of medication monitoring in the meaningful use era

Objectives: While the 2011 implementation of meaningful use legislation for certified electronic health records (EHRs) promises to change quality reporting by overcoming data capture issues affecting quality measurement, the magnitude of this effect is unclear. We compared the measured quality of laboratory monitoring of Healthcare Effectiveness Data and Information Set (HEDIS) medications based on specifications that (1) include and exclude patients hospitalized in the measurement year and (2) use physician test orders and patient test completion. Study Design: Cross-sectional study. Methods: Among patients 18 years and older in a large multispecialty group practice utilizing a fully implemented EHR between January 1, 2008, and July 31, 2008, we measured the prevalence of ordering and completion of laboratory tests monitoring HEDIS medications (cardiovascular drugs [angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, digoxin, and diuretics] and anticonvulsants [carbamazepine, phenobarbital, phenytoin, and valproic acid]). Results: Measures excluding hospitalized patients were not statistically significantly different from measures including hospitalized patients, except for digoxin, but this difference was not clinically significant. The prevalence of appropriate monitoring based on test orders typically captured in the EHR was statistically significantly higher than the prevalence based on claims-based test completions for cardiovascular drugs. Conclusions: HEDIS quality metrics based on data typically collected from claims undermeasured quality of medication monitoring compared to EHR data. The HEDIS optional specification excluding hospitalized patients from the monitoring measure does not have a significant impact on reported quality. Integration of EHR data into quality measurement may significantly change some organizations\u27 reported quality of care