Prevalence and factors affecting home blood pressure documentation in routine clinical care: a retrospective study.

BACKGROUND: Home blood pressure (BP) is closely linked to patient outcomes. However, the prevalence of its documentation has not been examined. The objective of this study was to analyze the prevalence and factors affecting documentation of home BP in routine clinical care. METHODS: A retrospective study of 142,973 encounters of 9,840 hypertensive patients with diabetes from 2000 to 2005 was performed. The prevalence of recorded home BP and the factors associated with its documentation were analyzed. We assessed validity of home BP information by comparing the difference between home and office BP to previously published prospective studies. RESULTS: Home BP was documented in narrative notes for 2.08% of encounters where any blood pressure was recorded and negligibly in structured data (EMR flowsheets). Systolic and diastolic home BP in narrative notes were lower than office BP readings by 9.6 and 2.5 mm Hg, respectively (p < 0.0001 for both), consistent with prospective data. Probability of home BP documentation increased by 23.0% for each 10 mm Hg of office systolic BP (p < 0.0001), by 6.2% for each $10,000 in median income of zip code (p = 0.0055), and by 17.7% for each decade in the patient's age (p < 0.0001). CONCLUSIONS: Home BP readings provide a valid representation of the patient's condition, yet are seldom documented despite their potential utility in both patient care and research. Strong association between higher patient income and home BP documentation suggests that the cost of the monitors may be a limiting factor; reimbursement of home BP monitoring expenses should be pursued.

Comparison of information content of structured and narrative text data sources on the example of medication intensification.

OBJECTIVE To compare information obtained from narrative and structured electronic sources using anti-hypertensive medication intensification as an example clinical issue of interest. DESIGN A retrospective cohort study of 5,634 hypertensive patients with diabetes from 2000 to 2005. MEASUREMENTS The authors determined the fraction of medication intensification events documented in both narrative and structured data in the electronic medical record. The authors analyzed the relationship between provider characteristics and concordance between intensifications in narrative and structured data. As there is no gold standard data source for medication information, the authors clinically validated medication intensification information by assessing the relationship between documented medication intensification and the patients' blood pressure in univariate and multivariate models. RESULTS Overall, 5,627 (30.9%) of 18,185 medication intensification events were documented in both sources. For a medication intensification event documented in narrative notes the probability of a concordant entry in structured records increased by 11% for each study year (p < 0.0001) and decreased by 19% for each decade of provider age (p = 0.035). In a multivariate model that adjusted for patient demographics and intraphysician correlations, an increase of one medication intensification per month documented in either narrative or structured data were associated with a 5-8 mm Hg monthly decrease in systolic and 1.5-4 mm Hg decrease in diastolic blood pressure (p < 0.0001 for all). CONCLUSION Narrative and structured electronic data sources provide complementary information on anti-hypertensive medication intensification. Clinical validity of information in both sources was demonstrated by correlation with changes in blood pressure.

An online spaced-education game among clinicians improves their patients' time to blood pressure control: a randomized controlled trial.

BACKGROUND: Many patients with high blood pressure (BP) do not have antihypertensive medications appropriately intensified at clinician visits. We investigated whether an online spaced-education (SE) game among primary care clinicians can decrease time to BP target among their hypertensive patients. METHODS AND RESULTS: A 2-arm randomized trial was conducted over 52 weeks among primary care clinicians at 8 hospitals. Educational content consisted of 32 validated multiple-choice questions with explanations on hypertension management. Providers were randomized into 2 groups: SE clinicians were enrolled in the game, whereas control clinicians received identical educational content in an online posting. SE game clinicians were e-mailed 1 question every 3 days. Adaptive game mechanics resent questions in 12 or 24 days if answered incorrectly or correctly, respectively. Clinicians retired questions by answering each correctly twice consecutively. Posting of relative performance among peers fostered competition. Primary outcome measure was time to BP target (<140/90 mm Hg). One hundred eleven clinicians enrolled. The SE game was completed by 87% of clinicians (48/55), whereas 84% of control clinicians (47/56) read the online posting. In multivariable analysis of 17 866 hypertensive periods among 14 336 patients, the hazard ratio for time to BP target in the SE game cohort was 1.043 (95% confidence interval, 1.007-1.081; P=0.018). The number of hypertensive episodes needed to treat to normalize one additional patient's BP was 67.8. The number of clinicians needed to teach to achieve this was 0.43. CONCLUSIONS: An online SE game among clinicians generated a modest but significant reduction in the time to BP target among their hypertensive patients. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00904007.

Lexical concept distribution reflects clinical practice.

It is not known whether narrative medical text directly reflects clinical reality. We have tested the hypothesis that the pattern of distribution of lexical concept of medication intensification in narrative provider notes correlates with clinical practice as reflected in electronic medication records. Over 29,000 medication intensifications identified in narrative provider notes and 444,000 electronic medication records for 82 anti-hypertensive, anti-hyperlipidemic and anti-hyperglycemic medications were analyzed. Pearson correlation coefficient between the fraction of dose increases among all medication intensifications and therapeutic range calculated from EMR medication records was 0.39 (p = 0.0003). Correlations with therapeutic ranges obtained from two medication dictionaries, used as a negative control, were not significant. These findings provide evidence that narrative medical documents directly reflect clinical practice and constitute a valid source of medical data.

An electronic patient risk communication board.

Communication failures have been identified as the root cause of the majority of medical malpractice claims and patient safety violations. We believe it is essential to share key patient risk information with healthcare team members at the patient's bedside. In this study, we developed an electronic Patient Risk Communication Board (ePRCB) to assist in bridging the communication gap between all health care team members. The goal of the ePRCB is to effectively communicate the patient's key risk factors, such as a fall risk or risk of aspiration, to the healthcare team and to reduce adverse events caused by communication failures. The ePRCB will transmit patient risk information and tailored interventions with easy-to-understand icons on an LCD screen at the point of care. A set of patient risk reminder icons was developed and validated by focus groups. We used the results of the evaluation to refine the icons for the ePRCB.

Identification of inactive medications in narrative medical text.

Discontinued medications are frequently not removed from EMR medication lists - a patient safety risk. We developed an algorithm to identify inactive medications using in the text of narrative notes in the EMR. The algorithm was evaluated against manual review of 297 randomly selected notes. One in five notes documented inactive medications. Sensitivity and precision of 87.7% and 80.7%, respectively, on per-note basis and 66.3% and 80.0%, respectively, on per-medication basis. When medication names missing from the dictionary were excluded, the algorithm achieved sensitivity of 91.4%. Using real clinical data, the algorithm identified inactive medications documented in the note but still listed as active on the patients medication list in more than one in ten notes. Documentation of inactive medications is common in narrative provider notes and can be computationally extracted. This technology could be employed in real-time patient care as well as for research and quality of care monitoring.

Identification of inactive medications in narrative physician notes.

Information about inactive medications is important for patient safety but is frequently missing from the electronic medical record. We investigated the feasibility of extracting this information from narrative physician notes. Our analysis of 298 physician notes showed that 1 in 3 notes contains documentation of medication discontinuation. This documentation can be described by one of six semantic fields. Documentation of inactive medications is common in narrative documents and could potentially be extracted using semantic analysis.