COVID-19 outbreaks surveillance through text mining applied to electronic health records.

BACKGROUND: The COVID-19 pandemic has caused significant disruptions to everyday life and has had social, political, and financial consequences that will persist for years. Several initiatives with intensive use of technology were quickly developed in this scenario. However, technologies that enhance epidemiological surveillance in contexts with low testing capacity and healthcare resources are scarce. Therefore, this study aims to address this gap by developing a data science model that uses routinely generated healthcare encounter records to detect possible new outbreaks early in real-time. METHODS: We defined an epidemiological indicator that is a proxy for suspected cases of COVID-19 using the health records of Emergency Care Unit (ECU) patients and text mining techniques. The open-field dataset comprises 2,760,862 medical records from nine ECUs, where each record has information about the patient's age, reported symptoms, and the time and date of admission. We also used a dataset where 1,026,804 cases of COVID-19 were officially confirmed. The records range from January 2020 to May 2022. Sample cross-correlation between two finite stochastic time series was used to evaluate the models. RESULTS: For patients with age 18 years, we find time-lag () = 72 days and cross-correlation () ~ 0.82, = 25 days and ~ 0.93, and = 17 days and ~ 0.88 for the first, second, and third waves, respectively. CONCLUSIONS: In conclusion, the developed model can aid in the early detection of signs of possible new COVID-19 outbreaks, weeks before traditional surveillance systems, thereby anticipating in initiating preventive and control actions in public health with a higher likelihood of success.

Assessing the Effectiveness of Engaging Patients and Their Families in the Three-Step Fall Prevention Process Across Modalities of an Evidence-Based Fall Prevention Toolkit: An Implementation Science Study.

BACKGROUND: Patient falls are a major problem in hospitals. The development of a Patient-Centered Fall Prevention Toolkit, Fall TIPS (Tailoring Interventions for Patient Safety), reduced falls by 25% in acute care hospitals by leveraging health information technology to complete the 3-step fall prevention process-(1) conduct fall risk assessments; (2) develop tailored fall prevention plans with the evidence-based interventions; and (3) consistently implement the plan. We learned that Fall TIPS was most effective when patients and family were engaged in all 3 steps of the fall prevention process. Over the past decade, our team developed 3 Fall TIPS modalities-the original electronic health record (EHR) version, a laminated paper version that uses color to provide clinical decision support linking patient-specific risk factors to the interventions, and a bedside display version that automatically populates the bedside monitor with the patients' fall prevention plan based on the clinical documentation in the EHR. However, the relative effectiveness of each Fall TIPS modality for engaging patients and family in the 3-step fall prevention process remains unknown. OBJECTIVE: This study aims to examine if the Fall TIPS modality impacts patient engagement in the 3-step fall prevention process and thus Fall TIPS efficacy. METHODS: To assess patient engagement in the 3-step fall prevention process, we conducted random audits with the question, "Does the patient/family member know their fall prevention plan?" In addition, audits were conducted to measure adherence, defined by the presence of the Fall TIPS poster at the bedside. Champions from 3 hospitals reported data from April to June 2017 on 6 neurology and 7 medical units. Peer-to-peer feedback to reiterate the best practice for patient engagement was central to data collection. RESULTS: Overall, 1209 audits were submitted for the patient engagement measure and 1401 for the presence of the Fall TIPS poster at the bedside. All units reached 80% adherence for both measures. While some units maintained high levels of patient engagement and adherence with the poster protocol, others showed improvement over time, reaching clinically significant adherence (>80%) by the final month of data collection. CONCLUSIONS: Each Fall TIPS modality effectively facilitates patient engagement in the 3-step fall prevention process, suggesting all 3 can be used to integrate evidence-based fall prevention practices into the clinical workflow. The 3 Fall TIPS modalities may prove an effective strategy for the spread, allowing diverse institutions to choose the modality that fits with the organizational culture and health information technology infrastructure.

Resilience perspective on healthcare professionals' adaptations to changes and challenges resulting from the COVID-19 pandemic: a meta-synthesis.

OBJECTIVE: To identify, review and synthesise qualitative literature on healthcare professionals' adaptations to changes and challenges resulting from the COVID-19 pandemic. DESIGN: Systematic review with meta-synthesis. DATA SOURCES: Academic Search Elite, CINAHL, MEDLINE, PubMed, Science Direct and Scopus. ELIGIBILITY CRITERIA: Qualitative or mixed-methods studies published between 2019 and 2021 investigating healthcare professionals' adaptations to changes and challenges resulting from the COVID-19 pandemic. DATA EXTRACTION AND SYNTHESIS: Data were extracted using a predesigned data extraction form that included details about publication (eg, authors, setting, participants, adaptations and outcomes). Data were analysed using thematic analysis. RESULTS: Forty-seven studies were included. A range of adaptations crucial to maintaining healthcare delivery during the COVID-19 pandemic were found, including taking on new roles, conducting self and peer education and reorganising workspaces. Triggers for adaptations included unclear workflows, lack of guidelines, increased workload and transition to digital solutions. As challenges arose, many health professionals reported increased collaboration across wards, healthcare teams, hierarchies and healthcare services. CONCLUSION: Healthcare professionals demonstrated significant adaptive capacity when faced with challenges imposed by the COVID-19 pandemic. Several adaptations were identified as beneficial for future organisational healthcare service changes, while others exposed weaknesses in healthcare system designs and capacity, leading to dysfunctional adaptations. Healthcare professionals' experiences working during the COVID-19 pandemic present a unique opportunity to learn how healthcare systems rapidly respond to changes, and how resilient healthcare services can be built globally.

Implementation of a Scalable Online Weight Management Programme in Clinical Settings: Protocol for the PROPS 2.0 Programme (Partnerships for Reducing Overweight and Obesity with Patient-Centered Strategies 2.0).

INTRODUCTION: There is an urgent need for scalable strategies for treating overweight and obesity in clinical settings. PROPS 2.0 (Partnerships for Reducing Overweight and Obesity with Patient-Centered Strategies 2.0) aims to adapt and implement the combined intervention from the PROPS Study at scale, in a diverse cross-section of patients and providers. METHODS AND ANALYSIS: We are implementing PROPS 2.0 across a variety of clinics at Brigham and Women's Hospital, targeting enrolment of 5000 patients. Providers can refer patients or patients can self-refer. Eligible patients must be ≥20 years old and have a body mass index (BMI) of ≥30 kg/m2 or a BMI of 25-29.9 kg/m2 plus another cardiovascular risk factor or obesity-related condition. After enrolment, patients register for the RestoreHealth online programme/app (HealthFleet Inc.) and participate for 12 months. Patients can engage with the programme and receive personalized feedback from a coach. Patient navigators help to enrol patients, enter updates in the electronic health record, and refer patients to additional resources. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework is guiding the evaluation. ETHICS AND DISSEMINATION: The Mass General Brigham Human Research Committee approved this protocol. An implementation guide will be created and disseminated, to help other sites adopt the intervention in the future. TRIAL REGISTRATION NUMBER: NCT0555925.

Towards The Automated, Empirical Filtering of Drug-Drug Interaction Alerts in Clinical Decision Support Systems: Historical Cohort Study of Vitamin K Antagonists.

BACKGROUND: Drug-drug interactions (DDIs) involving vitamin K antagonists (VKAs) constitute an important cause of in-hospital morbidity and mortality. However, the list of potential DDIs is long; the implementation of all these interactions in a clinical decision support system (CDSS) results in over-alerting and alert fatigue, limiting the benefits provided by the CDSS. OBJECTIVE: To estimate the probability of occurrence of international normalized ratio (INR) changes for each DDI rule, via the reuse of electronic health records. METHODS: An 8-year, exhaustive, population-based, historical cohort study including a French community hospital, a group of Danish community hospitals, and a Bulgarian hospital. The study database included 156,893 stays. After filtering against two criteria (at least one VKA administration and at least one INR laboratory result), the final analysis covered 4047 stays. Exposure to any of the 145 drugs known to interact with VKA was tracked and analyzed if at least 3 patients were concerned. The main outcomes are VKA potentiation (defined as an INR≥5) and VKA inhibition (defined as an INR≤1.5). Groups were compared using the Fisher exact test and logistic regression, and the results were expressed as an odds ratio (95% confidence limits). RESULTS: The drugs known to interact with VKAs either did not have a statistically significant association regarding the outcome (47 drug administrations and 14 discontinuations) or were associated with significant reduction in risk of its occurrence (odds ratio<1 for 18 administrations and 21 discontinuations). CONCLUSIONS: The probabilities of outcomes obtained were not those expected on the basis of our current body of pharmacological knowledge. The results do not cast doubt on our current pharmacological knowledge per se but do challenge the commonly accepted idea whereby this knowledge alone should be used to define when a DDI alert should be displayed. Real-life probabilities should also be considered during the filtration of DDI alerts by CDSSs, as proposed in SPC-CDSS (statistically prioritized and contextualized CDSS). However, these probabilities may differ from one hospital to another and so should probably be calculated locally.

Multicomponent intervention to improve blood pressure management in chronic kidney disease: a protocol for a pragmatic clinical trial.

INTRODUCTION: The purpose of this study is to incorporate behavioural economic principles and user-centred design principles into a multicomponent intervention for the management of uncontrolled hypertension (HTN) in chronic kidney disease (CKD) in primary care. METHODS AND ANALYSIS: This is a multicentre, pragmatic, controlled trial cluster-randomised at the clinician level at The Brigham and Women's Practice -Based Research Network of 15 practices. Of 220 total clinicians, 184 were eligible to be enrolled, and the remainder were excluded (residents and clinicians who see urgent care or walk-in patients); no clinicians opted out. The intervention consists of a clinical decision support system based in behavioural economic and user-centred design principles that will: (1) synthesise existing laboratory tests, medication orders and vital sign data; (2) increase recognition of CKD, (3) increase recognition of uncontrolled HTN in CKD patients and (4) deliver evidence-based CKD and HTN management recommendations. The primary endpoint is the change in mean systolic blood pressure between baseline and 6 months compared across arms. We will use the Reach Effectiveness Adoption Implementation Maintenance framework. At the conclusion of this study, we will have: (1) validated an intervention that combines laboratory tests, medication records and clinical information collected by electronic health records to recognise uncontrolled HTN in CKD patients and recommend a course of care, (2) tested the effectiveness of said intervention and (3) collected information about the implementation of the intervention that will aid in dissemination of the intervention to other practice settings. ETHICS AND DISSEMINATION: The Human Subjects Institutional Review Board at Brigham and Women's Hospital provided an expedited review and approval for this study protocol, and a Data Safety Monitoring Board will ensure the ongoing safety of the trial. TRIAL REGISTRATION NUMBER: NCT03679247.

Assessing the International Transferability of a Machine Learning Model for Detecting Medication Error in the General Internal Medicine Clinic: Multicenter Preliminary Validation Study.

BACKGROUND: Although most current medication error prevention systems are rule-based, these systems may result in alert fatigue because of poor accuracy. Previously, we had developed a machine learning (ML) model based on Taiwan's local databases (TLD) to address this issue. However, the international transferability of this model is unclear. OBJECTIVE: This study examines the international transferability of a machine learning model for detecting medication errors and whether the federated learning approach could further improve the accuracy of the model. METHODS: The study cohort included 667,572 outpatient prescriptions from 2 large US academic medical centers. Our ML model was applied to build the original model (O model), the local model (L model), and the hybrid model (H model). The O model was built using the data of 1.34 billion outpatient prescriptions from TLD. A validation set with 8.98% (60,000/667,572) of the prescriptions was first randomly sampled, and the remaining 91.02% (607,572/667,572) of the prescriptions served as the local training set for the L model. With a federated learning approach, the H model used the association values with a higher frequency of co-occurrence among the O and L models. A testing set with 600 prescriptions was classified as substantiated and unsubstantiated by 2 independent physician reviewers and was then used to assess model performance. RESULTS: The interrater agreement was significant in terms of classifying prescriptions as substantiated and unsubstantiated (κ=0.91; 95% CI 0.88 to 0.95). With thresholds ranging from 0.5 to 1.5, the alert accuracy ranged from 75%-78% for the O model, 76%-78% for the L model, and 79%-85% for the H model. CONCLUSIONS: Our ML model has good international transferability among US hospital data. Using the federated learning approach with local hospital data could further improve the accuracy of the model.

Expert Consensus on Currently Accepted Measures of Harm.

BACKGROUND: Twenty-five years after the seminal work of the Harvard Medical Practice Study, the numbers and specific types of health care measures of harm have evolved and expanded. Using the World Café method to derive expert consensus, we sought to generate a contemporary list of triggers and adverse event measures that could be used for chart review to determine the current incidence of inpatient and outpatient adverse events. METHODS: We held a modified World Café event in March 2018, during which content experts were divided into 10 tables by clinical domain. After a focused discussion of a prepopulated list of literature-based triggers and measures relevant to that domain, they were asked to rate each measure on clinical importance and suitability for chart review and electronic extraction (very low, low, medium, high, very high). RESULTS: Seventy-one experts from 9 diverse institutions attended (primary acceptance rate, 72%). Of 525 total triggers and measures, 67% of 391 measures and 46% of 134 triggers were deemed to have high or very high clinical importance. For those triggers and measures with high or very high clinical importance, 218 overall were deemed to be highly amenable to chart review and 198 overall were deemed to be suitable for electronic surveillance. CONCLUSIONS: The World Café method effectively prioritized measures/triggers of high clinical importance including those that can be used in chart review, which is considered the gold standard. A future goal is to validate these measures using electronic surveillance mechanisms to decrease the need for chart review.

Evaluation of a Patient-Centered Fall-Prevention Tool Kit to Reduce Falls and Injuries: A Nonrandomized Controlled Trial.

Importance: Falls represent a leading cause of preventable injury in hospitals and a frequently reported serious adverse event. Hospitalization is associated with an increased risk for falls and serious injuries including hip fractures, subdural hematomas, or even death. Multifactorial strategies have been shown to reduce falls in acute care hospitals, but evidence for fall-related injury prevention in hospitals is lacking. Objective: To assess whether a fall-prevention tool kit that engages patients and families in the fall-prevention process throughout hospitalization is associated with reduced falls and injurious falls. Design, Setting, and Participants: This nonrandomized controlled trial using stepped wedge design was conducted between November 1, 2015, and October 31, 2018, in 14 medical units within 3 academic medical centers in Boston and New York City. All adult inpatients hospitalized in participating units were included in the analysis. Interventions: A nurse-led fall-prevention tool kit linking evidence-based preventive interventions to patient-specific fall risk factors and designed to integrate continuous patient and family engagement in the fall-prevention process. Main Outcomes and Measures: The primary outcome was the rate of patient falls per 1000 patient-days in targeted units during the study period. The secondary outcome was the rate of falls with injury per 1000 patient-days. Results: During the interrupted time series, 37 231 patients were evaluated, including 17 948 before the intervention (mean [SD] age, 60.56 [18.30] years; 9723 [54.17%] women) and 19 283 after the intervention (mean [SD] age, 60.92 [18.10] years; 10 325 [53.54%] women). There was an overall adjusted 15% reduction in falls after implementation of the fall-prevention tool kit compared with before implementation (2.92 vs 2.49 falls per 1000 patient-days [95% CI, 2.06-3.00 falls per 1000 patient-days]; adjusted rate ratio 0.85; 95% CI, 0.75-0.96; P = .01) and an adjusted 34% reduction in injurious falls (0.73 vs 0.48 injurious falls per 1000 patient-days [95% CI, 0.34-0.70 injurious falls per 1000 patient-days]; adjusted rate ratio, 0.66; 95% CI, 0.53-0.88; P = .003). Conclusions and Relevance: In this nonrandomized controlled trial, implementation of a fall-prevention tool kit was associated with a significant reduction in falls and related injuries. A patient-care team partnership appears to be beneficial for prevention of falls and fall-related injuries. Trial Registration: ClinicalTrials.gov Identifier: NCT02969343.

Multinational comparison of new antidepressant use in older adults: a cohort study.

OBJECTIVES: We used an international pharmacosurveillance network to estimate the rate and characteristics of antidepressant use in older adults in countries with more conservative (UK) and liberal depression guidelines (Canada, USA). SETTING: Electronic health records and population-based administrative data from six jurisdictions in four countries (UK, Taiwan, USA and Canada). PARTICIPANTS: A historical cohort of older adults (≥65 years) who had a new episode of antidepressant use between 2009 and 2014. OUTCOME MEASURES: The age and sex-standardised cumulative incidence of new episodes of antidepressant use in older adults was measured. Descriptive statistics were used to compare the proportion of new users by the antidepressant prescribed, therapeutic class, potential treatment indication and country, as well as the characteristics of the first treatment episode (standardised daily doses, duration and changes). RESULTS: The incidence of antidepressant use between 2009 and 2014 varied from 4.7% (Montreal and Quebec City) to 18.6% (Taiwan). Tricyclic antidepressants (TCAs) were the most commonly used class in the UK (48.8%) and Taiwan (52.4%) compared with selective serotonin reuptake inhibitors (SSRIs) in North American jurisdictions (42.3%-53.3%). Chronic pain was the most common potential treatment indication (41.2%-68.2%). Among users with chronic pain, TCAs were used most frequently in the UK and Taiwan (55.2%-60.4%), whereas SSRIs were used most frequently in North America (33.5%-46.4%). Treatment was longer (252-525 vs 169-437 days), standardised doses were higher (0.7-1.3 vs 0.5-1.0) and treatment was more likely to be changed (31%-46% vs 21%-34%) among patients with depression (9.1%-43%) than those with chronic pain. CONCLUSION: Antidepressant use in older adults varied 24-fold by country, with the UK, which has the most conservative treatment guidelines, being among the lowest. Chronic pain was the most common potential treatment indication. Evaluation of real-world risks of TCAs is a priority for future research, given high rates of use and the potential for increased toxicity in older adults because of potent anticholinergic effects.

Addressing postdischarge adverse events: a neglected area.

BACKGROUND: Postdischarge safety is an area that has long been neglected. Recent studies from the United States and Canada found that about one in five patients discharged home from the general internal medicine services of major teaching hospitals suffered an adverse event. METHODS: MEDLINE, Cochrane databases, and reference lists of retrieved articles were used in a literature search of articles published from 1966 through May 2007. FINDINGS: Patient safety research has focused mostly on adverse events in hospitalized patients. Although some data are available about the ambulatory setting, even fewer studies have been done focusing on adverse events following hospital discharge. Only two studies conducted in North America have examined the incidence rate of all types of postdischarge adverse events. On the basis of the available evidence, key areas of opportunity to improve postdischarge care are as follows: (1) improving transitional care, (2) improving information transfer through strategic use of electronic health records, (3) medication reconciliation, (4) improving follow-up of test results, and (5) using screening methods to identify patients with adverse events. DISCUSSION: Limited evidence suggests that about one in five internal medicine patients suffers an adverse event after discharge from a North American hospital. The risk of postdischarge adverse events should be recognized by patient safety experts as an important area of concern.

Development of the individualised Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial: a protocol summary of a national cluster-randomised trial of resident duty hour policies in internal medicine.

INTRODUCTION: Medical trainees' duty hours have received attention globally; restrictions in Europe, New Zealand and some Canadian provinces are much lower than the 80 hours per week enforced in USA. In USA, resident duty hours have been implemented without evidence simultaneously reflecting competing concerns about patient safety and physician education. The objective is to prospectively evaluate the implications of alternative resident duty hour rules for patient safety, trainee education and intern sleep and alertness. METHODS AND ANALYSIS: 63 US internal medicine training programmes were randomly assigned 1:1 to the 2011 Accreditation Council for Graduate Medical Education resident duty hour rules or to rules more flexible in intern shift length and number of hours off between shifts for academic year 2015-2016. The primary outcome is calculated for each programme as the difference in 30-day mortality rate among Medicare beneficiaries with any of several prespecified principal diagnoses in the intervention year minus 30-day mortality in the preintervention year among Medicare beneficiaries with any of several prespecified principal diagnoses. Additional safety outcomes include readmission rates, prolonged length of stay and costs. Measures derived from trainees' and faculty responses to surveys and from time-motion studies of interns compare the educational experiences of residents. Measures derived from wrist actigraphy, subjective ratings and psychomotor vigilance testing compare the sleep and alertness of interns. Differences between duty hour groups in outcomes will be assessed by intention-to-treat analyses. ETHICS AND DISSEMINATION: The University of Pennsylvania Institutional Review Board (IRB) approved the protocol and served as the IRB of record for 40 programmes that agreed to sign an Institutional Affiliation Agreement. Twenty-three programmes opted for a local review process. TRIAL REGISTRATION NUMBER: NCT02274818; Pre-results.

Exploring the Current Landscape of Intravenous Infusion Practices and Errors (ECLIPSE): protocol for a mixed-methods observational study.

INTRODUCTION: Intravenous medication is essential for many hospital inpatients. However, providing intravenous therapy is complex and errors are common. 'Smart pumps' incorporating dose error reduction software have been widely advocated to reduce error. However, little is known about their effect on patient safety, how they are used or their likely impact. This study will explore the landscape of intravenous medication infusion practices and errors in English hospitals and how smart pumps may relate to the prevalence of medication administration errors. METHODS AND ANALYSIS: This is a mixed-methods study involving an observational quantitative point prevalence study to determine the frequency and types of errors that occur in the infusion of intravenous medication, and qualitative interviews with hospital staff to better understand infusion practices and the contexts in which errors occur. The study will involve 5 clinical areas (critical care, general medicine, general surgery, paediatrics and oncology), across 14 purposively sampled acute hospitals and 2 paediatric hospitals to cover a range of intravenous infusion practices. Data collectors will compare each infusion running at the time of data collection against the patient's medication orders to identify any discrepancies. The potential clinical importance of errors will be assessed. Quantitative data will be analysed descriptively; interviews will be analysed using thematic analysis. ETHICS AND DISSEMINATION: Ethical approval has been obtained from an NHS Research Ethics Committee (14/SC/0290); local approvals will be sought from each participating organisation. Findings will be published in peer-reviewed journals and presented at conferences for academic and health professional audiences. Results will also be fed back to participating organisations to inform local policy, training and procurement. Aggregated findings will inform the debate on costs and benefits of the NHS investing in smart pump technology, and what other changes may need to be made to ensure effectiveness of such an investment.

Clinical decision support systems.

Clinical decision support (CDS) systems link patient data with an electronic knowledge base in order to improve decision-making and computerised physician order entry (CPOE) is a requirement to set up electronic CDS. The medical informatics literature suggests categorising CDS tools into medication dosing support, order facilitators, point-of-care alerts and reminders, relevant information display, expert systems and workflow support. To date, CDS has particularly been recognised for improving processes. CDS successfully fostered prevention of deep-vein thrombosis, improved adherence to guidelines, increased the use of vaccinations, and decreased the rate of serious medication errors. However, CDS may introduce errors, and therefore the term "e-iatrogenesis" has been proposed to address unintended consequences. At least two studies reported severe treatment delays due to CPOE and CDS. In addition, the phenomenon of "alert fatigue" - arising from a high number of CDS alerts of low clinical significance - may facilitate overriding of potentially critical notifications. The implementation of CDS needs to be carefully planned, CDS interventions should be thoroughly examined in pilot wards only, and then stepwise introduced. A crucial feature of CPOE in combination with CDS is speed, since time consumption has been found to be a major factor determining failure. In the near future, the specificity of alerts will be improved, notifications will be prioritised and offer detailed advice, customisation of CDS will play an increasing role, and finally, CDS is heading for patient-centred decision support. The most important research question remains whether CDS is able to improve patient outcomes beyond processes.

The impact of electronic health records on ambulatory costs among Medicaid beneficiaries.

BACKGROUND: Broad adoption of electronic health records (EHRs) is a potential strategy for curbing healthcare cost growth, which is particularly vital for Medicaid. Despite limited evidence for EHR-related cost savings, the 2009 HITECH Act included incentives for providers to become meaningful users of EHRs. We evaluated a large Massachusetts EHR pilot to obtain early insight into the potential for the national strategy to reduce short-run healthcare costs in the Medicaid population. METHODS: We calculated monthly ambulatory cost and visit measures from Medicaid claims data for beneficiaries receiving the majority of their care in the three Massachusetts eHealth Collaborative (MAeHC) pilot communities or in six matched control communities. Using a difference-in-differences of slope analysis, we assessed whether cost and visit trajectories differed in the pre-implementation period compared to the post-implementation period for intervention and control community members. RESULTS: We found evidence that EHR adoption impacted ambulatory medical cost in two of the three communities, but the effects were in opposite directions. Ambulatory medical costs increased more slowly in one intervention compared to its control communities in the pre-to-post period (difference-in-differences=-1.98%, p<0.001; PMPM savings of $41.60). In contrast, for a second pilot community, ambulatory medical cost increased more slowly in the control communities (difference-in-differences=2.56%, p=0.005; PMPM increase of $43.34). CONCLUSIONS: As a stand-alone approach, adoption of commercially-available EHRs in community practices did not consistently impact Medicaid costs in the short-run. This suggests that future meaningful use criteria may need to specifically target cost savings and coordinate with payment reform efforts.

Ability to perform registry functions among practices with and without electronic health records.

Patient care registries allow physicians to identify patients based on a subset of conditions, including medicine prescribed, laboratory results and diagnosis. The presence of EHRs and a physician's ability to query across patient medical records is unknown in Massachusetts. A survey was conducted to examine the presence of EHRs in medical practices, and the degree to which EHRs enable physicians to carry out registry functions. EHR adoption was correlated with the use of registry functions.

Do electronic health records create more errors than they prevent?

While use of electronic health records (EHRs) and electronic prescribing can prevent many medication errors, it may also create opportunities for new errors. Therefore, we conducted a study to examine providers' perception of opportunities for errors introduced by the use of EHRs.

Effectiveness of health maintenance reminders provided directly to patients.

Provider-centric Electronic Health Records (EHRs) with clinical decision support have had a modest impact on improving quality care. However, they do not directly engage patients in promoting guideline adherence. Tethered Personal Health Records (PHRs) in contrast, can deliver decision support to both patients and providers. We conducted a randomized controlled trial to determine the effectiveness of providing seven screening reminders directly to patients via a PHR. Patients receiving the intervention were significantly more likely to receive Pap smears. No difference was seen for the other reminders.

From research to daily clinical practice: what are the challenges in "translation"?

BACKGROUND: Translating research findings into sustainable improvements in clinical and patient outcomes remains a substantial obstacle to improving the quality and safety of care. The Agency for Healthcare Research and Quality funded two initiatives to assess strategies for improvements--Translating Research into Practice (TRIP). The TRIP II initiative supported 13 quality improvement projects. SURVEYING THE TRIP II STUDIES: The principal investigators (PIs) of the 13 projects were surveyed regarding encountered barriers to implementation at 6 months and 18 months (when they were also asked about solutions). RESULTS: Seven of the 13 PIs responded to the survey at both times--6 and 18 months. For each project stage--Select a TRIP focus and develop intervention strategies (Stage 1), Conduct the intervention (Stage 2), and Measure the Impact (Stage 3)--barriers were described, and field-tested solutions were provided. For example, for Stage 2, if the target audience lacked buy-in and would not participate, solutions would be to get up-front buy-in from all staff, not just leaders; address root causes of problems; use opinion leaders and incentives; plan interventions ahead and provide make-up videos; and accept that targets vary in their readiness to change. DISCUSSION: The framework and examples provided should help overcome challenges in any work in which research findings are applied to clinical practice.