A codevelopment process to advance methods for the use of patient-reported outcome measures and patient-reported experience measures with people who are homeless and experience chronic illness.

INTRODUCTION: People who experience social disadvantage including homelessness suffer from numerous ill health effects when compared to the general public. Use of patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) enables collection of information from the point of view of the person receiving care. Involvement in research and health care decision-making, a process that can be facilitated by the use of PROMs and PREMs, is one way to promote equity in care. METHODS: This article reports on a codevelopment and consultation study investigating the use of PROMs and PREMs with people who experience homelessness and chronic illness. Data were analysed according to interpretative phenomenological analysis. RESULTS: Committee members with lived experience identified three themes for the role of PROMs and PREMs in health care measurement: trust and relationship-building; health and quality of life; and equity, alongside specific recommendations for the design and administration of PROMs and PREMs. The codevelopment process is reported to demonstrate the meaningful investment in time, infrastructure and relationship-building required for successful partnership between researchers and people with lived experience of homelessness. CONCLUSION: PROMs and PREMs can be meaningful measurement tools for people who experience social disadvantage, but can be alienating or reproduce inequity if they fail to capture complexity or rely on hidden assumptions of key concepts. PATIENT OR PUBLIC CONTRIBUTION: This study was conducted in active partnership between researchers and people with experience of homelessness and chronic illness, including priority setting for study design, data construction, analysis and coauthorship on this article.

Beyond the EHR: How Digital Health Tools Foster Participatory Health and Self-Care for Patients with Diabetes.

Just as physicians managing patients with diabetes find that it is a data-driven process, for patients living with diabetes, it is even more so, as physicians see them every few months, but patients need to live with diabetes all the time. Fortunately, the advent of the web has allowed patients to connect with information, medical care, and other patients, while mobile and connected technologies such as smartphones have provided the flexibility to do this-and to manage and share their health information-from anywhere. Healthcare professionals who care for patients with diabetes should be aware of the digital health technologies that enable patients to better care for themselves, be more active participants in their healthcare, and improve the quality of their lives.

Quantifying the economic impact of communication inefficiencies in U.S. hospitals.

Care delivery is a complex enterprise that involves multiple interactions among multiple stakeholders. Effective communication between these dispersed parties is critical to ensuring quality and safety and improves operational efficiencies. Time and motion studies in hospital settings provide strong evidence that care providers-doctors and nurses-spend a significant proportion of their time obtaining or providing information (i.e., communicating). Yet, surprisingly, no studies attempt to quantify the economic waste associated with communication inefficiencies in hospital settings at a national level. Our research focuses on developing models for quantifying the economic burden on hospitals of poor communications. We developed a conceptual model of the effects of poor communications in hospitals that isolates four outcomes: (1) efficiency of resource utilization, (2) effectiveness of core operations, (3) quality of work life, and (4) service quality, identifying specific metrics for each outcome. We developed estimates of costs associated with wasted physician time, wasted nurse time, and increase in length of stay caused by communication inefficiencies across all U.S. hospitals, using primary data collected from interviews in seven hospitals and secondary data from a literature review, the Bureau of Labor Statistics (BLS), and the Agency for Healthcare Research and Quality (AHRQ). We find that U.S. hospitals waste over $12 billion annually as a result of communication inefficiency among care providers. Increase in length of stay accounts for 53 percent of the annual economic burden. A 500-bed hospital loses over $4 million annually as a result of communication inefficiencies. We note that our estimates are conservative as they do not include all dimensions of economic waste arising from poor communications. The economic burden of communication inefficiency in U.S. hospitals is substantial. Information technologies and process redesign may help alleviate some of this burden.

An MPER antibody neutralizes HIV-1 using germline features shared among donors.

The membrane-proximal external region (MPER) of HIV-1 envelope glycoprotein (Env) can be targeted by neutralizing antibodies of exceptional breadth. MPER antibodies usually have long, hydrophobic CDRH3s, lack activity as inferred germline precursors, are often from the minor IgG3 subclass, and some are polyreactive, such as 4E10. Here we describe an MPER broadly neutralizing antibody from the major IgG1 subclass, PGZL1, which shares germline V/D-region genes with 4E10, has a shorter CDRH3, and is less polyreactive. A recombinant sublineage variant pan-neutralizes a 130-isolate panel at 1.4 µg/ml (IC50). Notably, a germline revertant with mature CDR3s neutralizes 12% of viruses and still binds MPER after DJ reversion. Crystal structures of lipid-bound PGZL1 variants and cryo-EM reconstruction of an Env-PGZL1 complex reveal how these antibodies recognize MPER and viral membrane. Discovery of common genetic and structural elements among MPER antibodies from different patients suggests that such antibodies could be elicited using carefully designed immunogens.

Zika Virus Protease Cleavage of Host Protein Septin-2 Mediates Mitotic Defects in Neural Progenitors.

Zika virus (ZIKV) targets neural progenitor cells in the brain, attenuates cell proliferation, and leads to cell death. Here, we describe a role for the ZIKV protease NS2B-NS3 heterodimer in mediating neurotoxicity through cleavage of a host protein required for neurogenesis. Similar to ZIKV infection, NS2B-NS3 expression led to cytokinesis defects and cell death in a protease activity-dependent fashion. Among binding partners, NS2B-NS3 cleaved Septin-2, a cytoskeletal factor involved in cytokinesis. Cleavage of Septin-2 occurred at residue 306 and forced expression of a non-cleavable Septin-2 restored cytokinesis, suggesting a direct mechanism of ZIKV-induced neural toxicity. VIDEO ABSTRACT.

Medication safety messages for patients via the web portal: the MedCheck intervention.

OBJECTIVE: Communication failures account for many adverse drug events (ADEs) in adult primary care. Improving patient-physician communication may improve medication safety. Accordingly, the goal of this study was to learn whether electronic medication safety messages directed to patients can improve communication about medications and identify ADEs. DESIGN: We studied adult patients enrolled in a patient Internet portal at three primary care practices affiliated with a teaching hospital. MedCheck, a medication safety application, sent patients a secure electronic message 10 days after they received a new or changed prescription. MedCheck asked if the patient had filled the prescription or experienced medication-related problems, and then forwarded the patient's response to their primary care physician. MEASUREMENTS: We selected a stratified random sample of 267 subjects from 1821 patients who received and opened a MedCheck message from April 2001 to June 2002. We reviewed subjects' medical records for three months following their first MedCheck message. We analyzed patient and clinician response rates and times, examined patient-clinician communication about medications, and identified ADEs. RESULTS: Patients opened 79% of MedCheck messages and responded to 12%; 77% responded within 1 day. Patients often identified problems filling their prescriptions (48%), problems with drug effectiveness (12%), and medication symptoms (10%). Clinicians responded to 68% of patients' messages; 93% answered within 1 week. Clinicians often supplied or requested information (19%), or made multiple recommendations (15%). Patients experienced 21 total ADEs; they reported 17 electronically. CONCLUSION: Patients and physicians responded promptly to patient-directed electronic medication messages, identifying and addressing medication-related problems including ADEs.

Who uses the patient internet portal? The PatientSite experience.

OBJECTIVE: Although the patient Internet portal is a potentially transformative technology, there is little scientific information about the demographic and clinical characteristics of portal enrollees and the features that they access. DESIGN: We describe two pilot studies of a comprehensive Internet portal called PatientSite. These pilots include a prospective one-year cohort study of all patients who enrolled in April 2003 and a case-control study in 2004 of enrollees and nonenrollees at two hospital-based primary care practices. MEASUREMENTS: The cohort study tracked patient enrollment and features in PatientSite that enrollees accessed, such as laboratory and radiology results, prescription renewals, appointment requests, managed care referrals, and clinical messaging. The case-control study used medical record review to compare the demographic and clinical characteristics of 100 randomly selected PatientSite enrollees and 100 nonenrollees. RESULTS: PatientSite use grew steadily after its introduction. New enrollees logged in most frequently in the first month, but 26% to 77% of the cohort continued to access the portal at least monthly. They most often examined laboratory and radiology results and sent clinical messages to their providers. PatientSite enrollees were younger and more affluent and had fewer medical problems than nonenrollees. CONCLUSION: Expanding the use of patient portals will require an understanding of obstacles that prevent access for those who might benefit most from this technology.

Personal health records: definitions, benefits, and strategies for overcoming barriers to adoption.

Recently there has been a remarkable upsurge in activity surrounding the adoption of personal health record (PHR) systems for patients and consumers. The biomedical literature does not yet adequately describe the potential capabilities and utility of PHR systems. In addition, the lack of a proven business case for widespread deployment hinders PHR adoption. In a 2005 working symposium, the American Medical Informatics Association's College of Medical Informatics discussed the issues surrounding personal health record systems and developed recommendations for PHR-promoting activities. Personal health record systems are more than just static repositories for patient data; they combine data, knowledge, and software tools, which help patients to become active participants in their own care. When PHRs are integrated with electronic health record systems, they provide greater benefits than would stand-alone systems for consumers. This paper summarizes the College Symposium discussions on PHR systems and provides definitions, system characteristics, technical architectures, benefits, barriers to adoption, and strategies for increasing adoption.

What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents.

PURPOSE: Little is known about how well hospitalized patients can identify errors or injuries in their care. Accordingly, the purpose of this study was to elicit incident reports from hospital inpatients in order to identify and characterize adverse events and near-miss errors. SUBJECTS: We conducted a prospective cohort study of 228 adult inpatients on a medicine unit of a Boston teaching hospital. METHODS: Investigators reviewed medical records and interviewed patients during the hospitalization and by telephone 10 days after discharge about "problems,""mistakes," and "injuries" that occurred. Physician investigators classified patients' reports. We calculated event rates and used multivariable Poisson regression models to examine the factors associated with patient-reported events. RESULTS: Of 264 eligible patients, 228 (86%) agreed to participate and completed 528 interviews. Seventeen patients (8%) experienced 20 adverse events; 1 was serious. Eight patients (4%) experienced 13 near misses; 5 were serious or life threatening. Eleven (55%) of 20 adverse events and 4 (31%) of 13 near misses were documented in the medical record, but none were found in the hospital incident reporting system. Patients with 3 or more drug allergies were more likely to report errors compared with patients without drug allergies (incidence rate ratio 4.7, 95% CI 1.7, 13.4). CONCLUSION: Inpatients can identify adverse events affecting their care. Many patient-identified events are not captured by the hospital incident reporting system or recorded in the medical record. Engaging hospitalized patients as partners in identifying medical errors and injuries is a potentially promising approach for enhancing patient safety.

Physicians' decisions to override computerized drug alerts in primary care.

BACKGROUND: Although computerized physician order entry reduces medication errors among inpatients, little is known about the use of this system in primary care. METHODS: We calculated the override rate among 3481 consecutive alerts generated at 5 adult primary care practices that use a common computerized physician order entry system for prescription writing. For detailed review, we selected a random sample of 67 alerts in which physicians did not prescribe an alerted medication and 122 alerts that resulted in a written prescription. We identified factors associated with the physicians' decisions to override a medication alert, and determined whether an adverse drug event (ADE) occurred. RESULTS: Physicians overrode 91.2% of drug allergy and 89.4% of high-severity drug interaction alerts. In the multivariable analysis using the medical chart review sample (n = 189), physicians were less likely to prescribe an alerted medication if the prescriber was a house officer (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.08-0.84) and if the patient had many drug allergies (OR, 0.70; 95% CI, 0.53-0.93). They were more likely to override alerts for renewals compared with new prescriptions (OR, 17.74; 95% CI, 5.60-56.18). We found no ADEs in cases where physicians observed the alert and 3 ADEs among patients with alert overrides, a nonsignificant difference (P =.55). Physician reviewers judged that 36.5% of the alerts were inappropriate. CONCLUSIONS: Few physicians changed their prescription in response to a drug allergy or interaction alert, and there were few ADEs, suggesting that the threshold for alerting was set too low. Computerized physician order entry systems should suppress alerts for renewals of medication combinations that patients currently tolerate.

Experiences of patients who were early adopters of electronic communication with their physician: satisfaction, benefits, and concerns.

OBJECTIVE: To explore the experiences of patients who were early adopters of e-mail communication with their physicians. METHODS: Patients' experiences were assessed with an Internetbased survey of 1881 individuals and in-depth telephone follow-up interviews with 56 individuals who used e-mail to communicate with providers. Two investigators qualitatively coded interview comments independently, with differences adjudicated by group consensus. RESULTS: A total of 311 (16.5%) of the 1881 individuals reported using electronic mail to communicate with their physicians. Compared with the population-based Behavioral Risk Factor Surveillance Survey, users of e-mail with physicians were twice as likely to have a college education, were younger, were less frequently ethnic minorities, and more frequently reported fair/poor health. Among the 311 patients who used e-mail with their physicians, the most frequent topics were results of laboratory testing and prescription renewals. However, many of the 311 users (21%) also reported using asynchronous e-mail inappropriately to convey urgent or sensitive issues (suicidality, chest pain, etc). Almost all (95%) perceived that e-mail was more efficient than the telephone. Important benefits uncovered from the interviews were that some patients felt more emboldened to ask questions in e-mail compared with face-to-face communication with doctors, and liked the ability to save the e-mail messages. Users also expressed concerns about privacy. CONCLUSION: Patients that use electronic communication with their physicians find the communication efficient for disease management. Further patient education about inappropriate use of e-mail for urgent issues is needed.

Doctors who are using e-mail with their patients: a qualitative exploration.

BACKGROUND: Despite the potential for rapid, asynchronous, documentable communication, the use of e-mail for physician-patient communication has not been widely adopted. OBJECTIVE: To survey physicians currently using e-mail with their patients daily to understand their experiences. METHODS: In-depth phone interviews of 45 physicians currently using e-mail with patients were audio taped and transcribed verbatim. Two investigators independently qualitatively coded comments. Differences were adjudicated by group consensus. RESULTS: Almost all of the 642 comments from these physicians who currently use e-mail with patients daily could be grouped into 1 of 4 broad domains: (1) e-mail access and content, (2) effects of e-mail on the doctor-patient relationship, (3) managing clinical issues by e-mail, and (4) integrating e-mail into office processes. The most consistent theme was that e-mail communication enhances chronic-disease management. Many physicians also reported improved continuity of care and increased flexibility in responding to nonurgent issues. Integration of e-mail into daily workflow, such as utilization of office personnel, appears to be a significant area of concern for many of the physicians. For other issues, such as content, efficiency of e-mail, and confidentiality, there were diverging experiences and opinions. Physicians appear to be selective in choosing which patients they will communicate with via e-mail, but the criteria for selection is unclear. CONCLUSION: These physician respondents did perceive benefits to e-mail with a select group of patients. Several areas, such as identifying clinical situations where e-mail communication is effective, incorporating e-mail into office flow, and being reimbursed for online medical care/communication, need to be addressed before this mode of communication diffuses into most practices.

Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: a report of an AMIA special task force.

The current commercial health information technology (HIT) arena encompasses a number of competing firms that provide electronic health applications to hospitals, clinical practices, and other healthcare-related entities. Such applications collect, store, and analyze patient information. Some vendors incorporate contract language whereby purchasers of HIT systems, such as hospitals and clinics, must indemnify vendors for malpractice or personal injury claims, even if those events are not caused or fostered by the purchasers. Some vendors require contract clauses that force HIT system purchasers to adopt vendor-defined policies that prevent the disclosure of errors, bugs, design flaws, and other HIT-software-related hazards. To address this issue, the AMIA Board of Directors appointed a Task Force to provide an analysis and insights. Task Force findings and recommendations include: patient safety should trump all other values; corporate concerns about liability and intellectual property ownership may be valid but should not over-ride all other considerations; transparency and a commitment to patient safety should govern vendor contracts; institutions are duty-bound to provide ethics education to purchasers and users, and should commit publicly to standards of corporate conduct; and vendors, system purchasers, and users should encourage and assist in each others' efforts to adopt best practices. Finally, the HIT community should re-examine whether and how regulation of electronic health applications could foster improved care, public health, and patient safety.

Assessing the value of electronic prescribing in ambulatory care: a focus group study.

INTRODUCTION: Drug allergy and interaction alerts are a core function of most electronic prescribing (e-prescribing) systems. To characterize the value of e-prescribing and medication safety alerts, especially in small and medium-size practices, we undertook a hypothesis-generating focus group study of Massachusetts clinicians. We sought to understand the reasons for adoption and use of e-prescribing, as well as clinicians' complaints about and perceived benefits of drug allergy and interaction alerts. METHODS: We recruited 25 Massachusetts clinicians to participate in three focus groups regarding the use and value of e-prescribing and medication safety alerts. The participants included high-volume (>100 electronic scripts per month) physicians, nurse practitioners, and practice assistants in family practice, internal medicine, pediatrics, and subspecialty practices who used a common commercial e-prescribing system. RESULTS: Most clinicians were in small and medium-size group practices. Participants were, on average, 25 years post-medical school graduation (range 8-36), had used e-prescribing for 2.5 years (range 1.0-5.5), and wrote the majority (89%, range 15-100%) of prescriptions electronically. The participants' decision to adopt e-prescribing was driven largely by financial incentives offered by insurers, and was viewed as a step toward implementation of an electronic medical record. Although participants agreed that the system was easy to learn, few anticipated efficiencies were realized until clinicians configured the device to meet their needs. The participants were ambivalent about whether e-prescribing improved their own or overall office efficiency, and--in the absence of payer incentives--few were willing to pay for the systems out-of-pocket. The most valuable aspects of e-prescribing were the ease of changing doses, renewing prescriptions, ensuring legibility, and transmitting prescriptions to in- and out-of-state pharmacies. Participants were dissatisfied with the unreliability of transmitting prescriptions successfully to the pharmacy, and with their inability to merge duplicate patient entries, to create a comprehensive, allprescriber medication list, to write prescriptions for commonly ordered medications and supplies, and to enter allergy information into the system. Participants were critical of the volume of drug allergy and interaction alerts. Many alerts were of trivial clinical significance or were generated by interactions with out-of-date medications. As a result, many clinicians habitually ignored these alerts. Alerts were most helpful to clinicians who were unfamiliar with a particular drug or patient. Although alerts rarely led the clinicians to abort or alter a prescription, alerts did prompt clinicians to counsel patients about medication side effects, to educate themselves about potential interactions, to check physical examination findings, or to order laboratory tests. Despite problems, few clinicians were willing to forego receiving alerts for fear that they would miss a potentially dangerous drug interaction. CONCLUSION: Electronic prescribing is a potential boon to ambulatory medical practice, although its value may be compromised by inappropriate and irrelevant medication safety alerts and by features of the e-prescribing system that prove burdensome to frontline clinicians. While alerts infrequently result in changed or aborted prescriptions, they may trigger a variety of other provider behaviors that help to ensure safe care.

Overrides of medication alerts in ambulatory care.

BACKGROUND: Electronic prescribing systems with decision support may improve patient safety in ambulatory care by offering drug allergy and drug interaction alerts. However, preliminary studies show that clinicians override most of these alerts. METHODS: We performed a retrospective analysis of 233 537 medication safety alerts generated by 2872 clinicians in Massachusetts, New Jersey, and Pennsylvania who used a common electronic prescribing system from January 1, 2006, through September 30, 2006. We used multivariate techniques to examine factors associated with alert acceptance. RESULTS: A total of 6.6% of electronic prescription attempts generated alerts. Clinicians accepted 9.2% of drug interaction alerts and 23.0% of allergy alerts. High-severity interactions accounted for most alerts (61.6%); clinicians accepted high-severity alerts slightly more often than moderate- or low-severity interaction alerts (10.4%, 7.3%, and 7.1%, respectively; P < .001). Clinicians accepted 2.2% to 43.1% of high-severity interaction alerts, depending on the classes of interacting medications. In multivariable analyses, we found no difference in alert acceptance among clinicians of different specialties (P = .16). Clinicians were less likely to accept a drug interaction alert if the patient had previously received the alerted medication (odds ratio, 0.03; 95% confidence interval, 0.03-0.03). CONCLUSION: Clinicians override most medication alerts, suggesting that current medication safety alerts may be inadequate to protect patient safety.

Clinicians' assessments of electronic medication safety alerts in ambulatory care.

BACKGROUND: While electronic prescribing (e-prescribing) systems with drug interaction and allergy alerts promise to improve medication safety in ambulatory care, clinicians often override these safety features. We undertook a study of respondents' satisfaction with e-prescribing systems, their perceptions of alerts, and their perceptions of behavior changes resulting from alerts. METHODS: Random sample survey of 300 Massachusetts ambulatory care clinicians who used a commercial e-prescribing system. RESULTS: A total of 184 respondents completed the survey (61%). Respondents indicated that e-prescribing improved the quality of care delivered (78%), prevented medical errors (83%), and enhanced patient satisfaction (71%) and clinician efficiency (75%). In addition, 35% of prescribers said that electronic alerts caused them to modify a potentially dangerous prescription in the last 30 days. They suggested that alerts also led to other changes in clinical care: counseling patients about potential reactions (49% of respondents), looking up information in medical references (44%), and changing the way a patient was monitored (33%). Altogether, 63% of clinicians reported taking action other than discontinuing or modifying an alerted prescription in the previous month in response to alerts. Despite these benefits, fewer than half of respondents were satisfied with drug interaction and allergy alerts (47%). Problems included alerts triggered by discontinued medications (58%), alerts that failed to account for appropriate drug combinations (46%), and excessive volume of alerts (37%). CONCLUSION: Although clinicians were critical of the quality of e-prescribing alerts, alerts may lead to clinically significant modifications in patient management not readily apparent based on "acceptance" rates.

Can e-mail messages between patients and physicians be patient-centered?

This study explores the extent to which e-mail messages between patients and physicians mimic the communication dynamics of traditional medical dialogue and its fulfillment of communication functions. Eight volunteers drawn from a larger study of e-mail users agreed to supply copies of their last 5 e-mail messages with their physicians and the physician replies. Seventy-four e-mail messages (40 patient and 34 physician) were provided and coded using the Roter Interactive Analysis System. The study found that physicians' e-mails are shorter and more direct than those of patients, averaging half the number of statements (7 vs. 14; p < .02) and words (62 vs. 121; p < .02). Whereas 72% of physician and 59% of patient statements were devoted to information exchange, the remaining communication is characterized as expressing and responding to emotions and acting to build a therapeutic partnership. Comparisons between e-mail and with face-to-face communication show many similarities in the address of these tasks. The authors concluded that e-mail accomplishes informational tasks but is also a vehicle for emotional support and partnership. The patterns of e-mail exchange appear similar to those of in-person visits and can be used by physicians in a patient-centered manner. E-mail has the potential to support the doctor-patient relationship by providing a medium through which patients can express worries and concerns and physicians can be patient-centered in response.