Evidence that electronic health records can promote physician counseling for healthy behaviors.

BACKGROUND: Health behavior counseling services may help patients manage chronic conditions effectively and slow disease progression. Studies show, however, that many providers fail to provide these services because of time constraints and inability to tailor counseling to individual patient needs. Electronic health records (EHRs) have the potential to increase appropriate counseling by providing pertinent patient information at the point of care and clinical decision support. PURPOSE: This study estimates the impact of select EHR functionalities on the rate of health behavior counseling provided during primary care visits. METHODOLOGY: Multivariable regression analyses of the 2007-2010 National Ambulatory Medical Care Survey were conducted to examine whether eight EHR components representing four core functionalities of EHR systems were correlated with the rate of health behavior counseling services. Propensity score matching was used to control for confounding factors given the use of observational data. To address concerns that EHR may only lead to improved documentation of counseling services and not necessarily improved care, the association of EHR functionalities with prescriptions for smoking cessation medications was also estimated. FINDINGS: The use of an EHR system with health information and data, order entry and management, result management, decision support, and a notification system for abnormal test results was associated with an approximately 25% increase in the probability of health behavior counseling delivered. Clinical reminders were associated with more health behavior counseling services when available in combination with patient problem lists. The laboratory results viewer was also associated with more counseling services when implemented with a notification system for abnormal results. PRACTICE IMPLICATION: An EHR system with key supportive functionalities can enhance delivery of preventive health behavior counseling services in primary care settings. Meaningful use criteria should be evaluated to ensure that they encourage the adoption of EHR systems with those functionalities shown to improve clinical care.

Cardiovascular disease documentation and counseling in electronic medical records.

The purpose of this paper is to explore the relationship between clinical reminders generated by electronic medical record (EMR) systems and providers giving prevention counseling to patients at-risk for cardiovascular disease (CVD). Data were extracted from the 2012 National Ambulatory Medical Care Survey (NAMCS). Results indicate that the providers routinely using clinical reminders are significantly more likely to document height and weight data to determine risk and provide the recommended counseling to patients that merit the intervention. The findings are important for policymakers and managers that have been promoting the adoption of more sophisticated EMR decision support functionalities across the care delivery spectrum. In particular, the ability to intervene prior to negative health events is an important feature of the movement to improve care quality and reduce costs.

The Electronic Medical Record's Role in Support of Smoking Cessation Activities.

INTRODUCTION: Electronic medical records (EMRs) have been touted as a tool for improving physicians' performance in the effort to reduce smoking harm. The purpose of this research is to assess EMR sophistication and functionality in relationship to smoking status documentation, cessation counseling, and medication use in ambulatory care settings. METHODS: Regression analyses of the 2007-2010 National Ambulatory Medical Care Survey were conducted to measure the association between EMR sophistication and smoking status recorded, smoking cessation counseling, and medication prescribing during visits. In general, EMR sophistication is measured by the presence of interactive EMR capabilities where "advanced" systems include functionalities for clinical decision support and management of orders and tests compared to "basic" systems. RESULTS: Physicians using advanced EMR systems were significantly more likely to record smoking status, counsel patients on smoking cessation, and document prescribing medications to support cessation efforts than doctors using less sophisticated technologies. CONCLUSIONS: Generally, the use of more sophisticated EMRs were associated with improved smoking cessation support by physicians in the ambulatory environment. Physicians purchasing or upgrading an EMR system should include the smoking cessation support features as part of their requirements. Future stages in the federal government's EMR Meaningful Use incentives and rewards program should include explicit metrics related to smoking cessation activities. IMPLICATIONS: The findings of this article contribute to current literature on EMR and smoking cessation by providing empirical evidence that advanced EMR systems with features like clinical reminders serve to influence the structure of the clinical encounter such that clinicians are significantly more likely to document smoking, engage in counseling, and prescribe medications. Physicians purchasing or upgrading an EMR system should include the smoking cessation support features as part of their requirements. Future stages in the federal government's EMR Meaningful Use incentives and rewards program should include explicit metrics related to smoking cessation activities.

National estimates of the impact of electronic health records on the workload of primary care physicians.

BACKGROUND: Eighty-four thousand primary care physicians have received $1.3 billion in HITECH payments for EHR adoption. However, little is known about how this will impact primary care workload efficiency and the national primary care shortage. This study examines whether EHR is associated with increases in face time with the patient per visit and increases in the physician's patient volume per week. METHODS: We used a nationally representative sample of 37,962 patient visits to 1470 primary care physicians during the pre-HITECH years 2006-2009 from the restricted-access version of the National Ambulatory Medical Care Survey. Quantile regressions were used to estimate the effects of EHR use on patient face time per visit and physician's patient volume per week at different points of the time and volume distributions. RESULTS: Primary care physicians with EHR spend an extra 1.3 face time minutes per visit, or 1.5 extra hours per week. This is 34,000 extra hours of face time per week in the U.S. However, physician age matters. Among young physicians, EHR use is associated with a decline in weekly patient volume, while EHR use among older physicians is associated with an increase in volume, regardless of initial practice size. If younger physicians behaved like older physicians when adopting EHR, there would be 37,600 additional patient visits per week in the U.S., the equivalent of adding 500 more primary care physicians to the U.S. workforce. CONCLUSION: EHR can enhance productivity/efficiency in primary care physician workloads.

The complete mitochondrial genome of the sand bubbler crab Scopimera longidactyla Shen 1932 (Decapoda: Dotillidae) and its phylogenetic analysis.

The sand bubbler crab, Scopimera longidactyla Shen, 1932 (Arthropoda: Malacostraca: Decapoda: Thoracotremata: Dotillidae), is commonly found along tropical and subtropical sandy shores of China, Korea, and Taiwan. Ecologically, it plays an important role in the productivity of sandy shores through their feeding and burrowing activities. In this study, the first complete mitochondrial genome (mitogenome) of S. longidactyla was analyzed using next-generation sequencer. Its mitogenome, circular in structure, spans 15,965 bp with a GC content of 29.97%, consisting of 13 protein-coding genes, two ribosomal RNA genes, 22 transfer RNA genes, and one putative control region. Its mitogenome arrangement and composition are identical to its two congeners, S. globosa and S. intermedia. Phylogenetic analysis fully supports for the monophyly of the genus Scopimera and the sister relationship between S. longidactyla and S. globosa. The complete mitogenome of S. longidactyla and its phylogenetic implications will provide valuable insights for further studies in phylogenetic and evolutionary biology.

Petroleum and health care: evaluating and managing health care's vulnerability to petroleum supply shifts.

Petroleum is used widely in health care-primarily as a transport fuel and feedstock for pharmaceuticals, plastics, and medical supplies-and few substitutes for it are available. This dependence theoretically makes health care vulnerable to petroleum supply shifts, but this vulnerability has not been empirically assessed. We quantify key aspects of petroleum use in health care and explore historical associations between petroleum supply shocks and health care prices. These analyses confirm that petroleum products are intrinsic to modern health care and that petroleum supply shifts can affect health care prices. In anticipation of future supply contractions lasting longer than previous shifts and potentially disrupting health care delivery, we propose an adaptive management approach and outline its application to the example of emergency medical services.

Health information technology and its effects on hospital costs, outcomes, and patient safety.

Underlying many reforms in the Patient Protection and Affordable Care Act (ACA) is the use of electronic medical records (EMRs) to help contain costs. We use MarketScan claims data and American Hospital Association information technology (IT) data to examine whether EMRs can contain costs in the ACA's reforms to reduce patient safety events. We find EMRs do not reduce the rate of patient safety events. However, once an event occurs, EMRs reduce death by 34%, readmissions by 39%, and spending by $4,850 (16%), a cost offset of $1.75 per $1 spent on IT capital. Thus, EMRs contain costs by better coordinating care to rescue patients from medical errors once they occur.

Healthcare Utilization in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Analysis of US Ambulatory Healthcare Data, 2000-2009.

Background: ME/CFS is a complex and disabling illness with substantial economic burden and functional impairment comparable to heart disease and multiple sclerosis. Many patients with ME/CFS do not receive appropriate healthcare, partially due to lack of diagnostic tests, and knowledge/attitudes/beliefs about ME/CFS. This study was to assess the utility of US ambulatory healthcare data in profiling demographics, co-morbidities, and healthcare in ME/CFS. Methods: Data came from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) in the U.S. Weighted analysis was performed. We examined 9.06 billion adult visits from 2000 to 2009 NAMCS/NHAMCS data. ME/CFS-related visits were identified by ICD-9-CM code, 780.71, up to tertiary diagnosis. Results: We estimated 2.9 million (95% CI: 1.8-3.9 million) ME/CFS-related visits during 2000-2009, with no statistical evidence (p-trend = 0.31) for a decline or increase in ME/CFS-related visits. Internists, general and family practitioners combined provided 52.12% of these visits. Patients with ME/CFS-related visits were mostly in their 40 and 50 s (47.76%), female (66.07%), white (86.95%), metropolitan/urban residents (92.05%), and insured (87.26%). About 71% of ME/CFS patients had co-morbidities, including depression (35.79%), hypertension (31.14%), diabetes (20.30%), and arthritis (14.11%). As one quality indicator, physicians spent more time on ME/CFS-related visits than non-ME/CFS visits (23.62 vs. 19.38 min, p = 0.065). As additional quality indicators, the top three preventive counseling services provided to patients with ME/CFS-related visits were diet/nutrition (8.33%), exercise (8.21%), and smoking cessation (7.24%). Compared to non-ME/CFS visits, fewer ME/CFS-related visits included counseling for stress management (0.75 vs. 3.14%, p = 0.010), weight reduction (0.88 vs. 4.02%, p = 0.002), injury prevention (0.04 vs. 1.64%, p < 0.001), and family planning/contraception (0.17 vs. 1.45%, p = 0.037). Conclusions: Visits coded with ME/CFS did not increase from 2000 to 2009. Almost three quarters of ME/CFS-related visits were made by ME/CFS patients with other co-morbid conditions, further adding to complexity in ME/CFS healthcare. While physicians spent more time with ME/CFS patients, a lower proportion of ME/CFS patients received preventive counseling for weight reduction, stress management, and injury prevention than other patients despite the complexity of ME/CFS. NAMCS/NHAMCS data are useful in evaluating co-morbidities, healthcare utilization, and quality indicators for healthcare in ME/CFS.

Electronic clinical reminder and quality of primary diabetes care.

AIMS: To study the association of EMR's clinical reminder use on a comprehensive set of diabetes quality metrics in U.S. office-based physicians and within solo- versus multi-physician practices. We conducted a retrospective cohort study on visits made by adults with diabetes identified from the National Ambulatory Medical Care Survey (2012-2014). METHODS: Multiple logistic regression is used to test for associations between clinical reminder use and recommended services by the American Diabetes Association. RESULTS: Of 5508 visits, nationally representing 112,978,791 visits, 31% received HbA1c tests, 13% received urinalysis test, and <10% received retinal or foot exams. Main effects of practice size and clinical reminder use were found for HbA1c, urinalysis, and foot exams. We find no statistically significant relationship to suggest that clinical reminder use improve diabetes process guidelines for solo practices. CONCLUSIONS: Resource efforts, beyond clinical reminders, are needed to reduce gaps in primary diabetes care between solo and non-solo practices.

The Impact of Electronic Medical Records on Hospital-Acquired Adverse Safety Events: Differential Effects Between Single-Source and Multiple-Source Systems.

The objective was to examine differential impacts between single-source and multiple-source electronic medical record (EMR) systems, as measured by number of vendor products, on hospital-acquired patient safety events. The data source was the 2009-2010 State Inpatient Databases of the Healthcare Cost and Utilization Project for California, New York, and Florida, and the Information Technology Supplement to the American Hospital Association's Annual Survey. Multivariable regression analyses were conducted to estimate the differential impacts of EMRs between single-source and multiple-source EMR systems on hospital-acquired patient safety events. In all, 1.98% of adult surgery hospitalizations had at least 1 hospital-acquired patient safety event. Basic EMRs with a single vendor or self-developed EMR systems were associated with a significant decrease in patient safety events by 0.38 percentage point, or 19.2%, whereas basic EMRs with multiple vendors had an insignificant association. A single-source EMR system enhances the impact of EMRs on reducing patient safety events.

Electronic medical record reminders and smoking cessation activities in primary care.

PURPOSE: The purpose of this paper is to assess electronic medical record (EMR) automatic reminder use in relation to smoking cessation activities among primary-care providers. BACKGROUND: Primary-care physicians are in the frontline of efforts to promote smoking cessation. Moreover, doctors' prescribing privileges give them additional tools to help patients successfully quit smoking. New EMR functions can provide automated reminders for physicians to counsel smokers and provide prescriptions to support quit attempts. SAMPLE AND METHODS: Logit regression is used to analyze the 2012 National Ambulatory Medical Care Survey (NAMCS). Variables related to the EMR's clinical reminder capability, patient's smoking status, the provision of cessation counseling and the prescribing of drugs that support quitting are analyzed. RESULTS: For primary care visit documents, smoking status was recorded 77.7% of the time. Smoking cessation counseling was ordered/provided 16.4% of the time in physicians' offices using electronic reminders routinely compared to 9.1% in those lacking the functionality. Smoking cessation medication was ordered/prescribed for 3.7% of current smokers when reminders were routinely used versus 2.1% when no reminder was used. All the differences were statistically significant. CONCLUSIONS: The presence of an EMR equipped with automated clinical reminders is a valuable resource in efforts to promote smoking cessation. Insurers, regulators, and organizations promulgating clinical guidelines should include the use of EMR technology as part of their programs.

Electronic reminder's role in promoting human papillomavirus vaccine use.

OBJECTIVES: To study the association of using an electronic health record (EHR)'s clinical reminder functionality with increased human papillomavirus (HPV) vaccine administration among US office-based physicians. STUDY DESIGN: National Ambulatory Medical Care Survey data from 2007-2012 were pooled together to determine if EHR systems that employ clinical reminders are associated with increased immunization rates in different populations. METHODS: The administration of HPV vaccine served as the dependent variable, with the EHR reminder being the primary independent variable of interest. Logit regression was used to assess the relationship between using EHR reminders and HPV vaccine administration. RESULTS: Analyses indicated that compared with physicians without clinical reminder functions, physicians with clinical reminder functions were more likely to order HPV vaccines. Clinical reminder functions were particularly effective at increasing HPV vaccine use among adolescent males. CONCLUSIONS: Overall, physicians who report using clinical reminders were more likely to order HPV immunizations. However, the association of clinical reminders with HPV immunizations was not significant in the younger adolescent subpopulation. Further, given that HPV incidence decreases significantly even with small gains in vaccination rates, the increase in HPV immunizations found in the male population aged 11 to 21 years is promising. Therefore, targeting males to receive HPV vaccination immunizations through clinical reminders provides a positively disproportionate return on vaccination rates and disease burden.

Addressing Medicaid Expansion from the Perspective of Patient Experience in Hospitals.

BACKGROUND: More Medicaid holders are entering the healthcare system consequential to Medicaid expansion. Their experience has financial consequences for hospitals and crucial implications for the provision of patient-centered care. This study examined how the hospital characteristics, especially the rates of Medicaid coverage and racial/ethnic minorities, impact the quality of inpatient care. METHODS: Using data for years 2009-2011 for 870 observations of California hospitals, and data collected from patients via the Hospital Consumer Assessment of Healthcare Providers and Systems survey coupled with data from the Healthcare Cost and Utilization Project and American Hospital Association Annual Survey, we used a generalized estimating equation approach to evaluate patients' experience with hospital care. Our multivariate model includes a comprehensive set of characteristics capturing market, structural, process, and patient demographics associated with the patient's hospital stay. RESULTS: The findings indicate that high concentrations of Medicaid patients in the hospital negatively impact the perceived patient experience. In addition, all things being equal, hospitals with higher concentrations of Hispanic, Black, and Asian patients received lower patient satisfaction results on 28 of the 30 regression coefficients capturing patient satisfaction, with 22 of the 30 negative coefficients statistically significant. CONCLUSIONS: Hospitals serving higher concentrations of Medicaid patients and more racial/ethnic diverse patients experienced a less satisfactory patient experience than patients utilizing other payers or patients who were White. Our research magnifies the challenge for addressing the disparities that exist in healthcare. Further research is called for clarifying the underlying reasons for these disparities and the optimal strategies for addressing these problems.

Meaningful Use IT reduces hospital-caused adverse drug events even at challenged hospitals.

BACKGROUND: many Meaningful Use (MU) requirements involve medication management. Little is known about what impact these will have on adverse drug events (ADEs) at challenged hospitals. METHODS: we use the Florida State Inpatient Database (HCUP, AHRQ), the AHA IT Supplement, and Hospital Compare. Controlling for non-response selection bias, we use multi-level GLLAMM regression analysis to examine the impact of the 5 core MU medication elements on hospital-caused ADEs. RESULTS: adopting all 5 core MU elements was associated with a reduction in ADEs. Hospitals reporting costs as the main barrier to MU reduced their ADE rates by 35%; low quality hospitals reduced ADEs by 29%, compared to 27% at high quality hospitals. Among hospitals reporting these medication elements among their top MU challenges, ADEs were reduced by 69%, compared to 45% for hospitals with no drug functions as their top MU challenges. However, ADEs increased by 14% at hospitals with physician resistance to MU, compared to a 52% ADE reduction without physician resistance. CONCLUSIONS: the bundling all five medication functions in MU is associated with large reductions in ADEs. IMPLICATIONS: without physician buy-in at the hospital, MU will have no impact on ADEs.

Will meaningful use electronic medical records reduce hospital costs?

BACKGROUND: More than one-third of the Centers for Medicare and Medicaid Services core meaningful use (MU) requirements deal with medication management. OBJECTIVES: To examine what impact the 5 core medication MU criteria have on hospital-acquired adverse drug events (ADEs) and their costs in 2010, as a baseline for the start of MU implementation in 2011. DATA SOURCES: 2010 Florida State Inpatient Database (Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality), American Hospital Association (AHA) Healthcare IT Database Supplement to the AHA 2010 Annual Survey of Hospitals, and Hospital Compare. METHODS: We developed one of the first quality indicators to track in-hospital ADEs in administrative data. Controlling for nonresponse selection bias, we used multivariate logit regression analysis to examine the impact of the 5 MU medication elements on the probability of an ADE and on its costs. RESULTS: A hospital-acquired ADE was noted in 1.7% of hospitalizations. Odds of an ADE were 63% less in hospitals that adopted all 5 core medication MU elements (10% of hospitals in 2010) compared with hospitals that adopted no core elements. This effect was found even among lowperforming hospitals with below-average Hospital Compare quality. Estimated hospital cost savings per averted ADE were $4790. If all hospitals in Florida had adopted all 5 functions, 55,700 ADEs would have been averted and $267 million per year would have been saved. CONCLUSIONS: Adoption of core medication MU elements will cut ADE rates, with cost savings that recoup 22% of information technology costs.