Obstetrician/gynecologists' experiences with electronic health record systems: a narrative study.

OBJECTIVE: To explore the experiences of obstetrician/gynecologists (ob/gyns) with regard to the use of electronic health record (EHR) systems in practice. STUDY DESIGN: Surveys were mailed to 1,200 ob/gyns, with an overall response rate of 57.2%, 402 of whom currently use an EHR system. The survey included questions about the physicians' use of EHR systems as well as what features they found most or least helpful. In addition, a focus group of 6 practicing ob/gyns at a university-based hospital was conducted in which they were encouraged to give free responses about their experiences working with EHR systems. Responses from surveys and the focus group were analyzed for frequency by the investigators. RESULTS: The majority of ob/gyns who used an EHR reported being satisfied with that system (61.4%). The most commonly reported impediments to EHR use were time needed, ineffective templates, note quality, interference with patient interactions, and expense. The most commonly cited positives were electronic medication prescription (e-scribing) capabilities, efficiency, and ease of access to notes, including legibility. CONCLUSION: In spite of increased adoption of EHR systems, more work is needed to improve ob/gyn satisfaction with EHR systems.

EHR safety: the way forward to safe and effective systems.

Diverse stakeholders--clinicians, researchers, business leaders, policy makers, and the public--have good reason to believe that the effective use of electronic health care records (EHRs) is essential to meaningful advances in health care quality and patient safety. However, several reports have documented the potential of EHRs to contribute to health care system flaws and patient harm. As organizations (including small hospitals and physician practices) with limited resources for care-process transformation, human-factors engineering, software safety, and project management begin to use EHRs, the chance of EHR-associated harm may increase. The authors propose a coordinated set of steps to advance the practice and theory of safe EHR design, implementation, and continuous improvement. These include setting EHR implementation in the context of health care process improvement, building safety into the specification and design of EHRs, safety testing and reporting, and rapid communication of EHR-related safety flaws and incidents.

Implementing a personalized medicine program in a community health system.

The implementation of a de novo personalized medicine program in a rural community health system serving an underserved population is described. Focusing on the safe use of drugs impacted by genetic variations in the non-oncology setting, we first addressed drug-gene pairs designated by the US FDA in black-box warnings (codeine, clopidogrel, abacavir, carbamazepine). The program's first success was a policy change to remove codeine from the pediatric formulary, rather than a testing recommendation. Pilot studies were then conducted with primary care providers to get them familiar with pharmacogenetic testing, and a consultative outpatient clinic for patients was developed. The assessment, planning, implementation, challenges, successes and lessons learned are described.

Electronic Health Record Adoption among Obstetrician/Gynecologists in the United States: Physician Practices and Satisfaction.

Implementation of electronic health records (EHRs) has historically been lower among obstetrician-gynecologists (ob-gyns) than many physician groups. This study described ob-gyns' adoption and use of EHR systems in practice, as well as barriers and benefits to implementation. Surveys asking about the physicians' use of EHR, satisfaction with systems, and what features they found most or least helpful were mailed to 1,200 ob-gyns. An overall response rate of 57.4% was achieved, with 559 returning completed surveys. Over three-quarters of responders reported that they used an EHR system or planned to implement one. Physicians without EHR tended to be older, were more likely to be male, have a solo practice, and describe themselves as Asian/Pacific Islander. Over 63% of those physicians who use EHR reported being satisfied with their system, while 30.8% were not satisfied. Ob-gyns who reported satisfaction had a younger mean age (M = 52.98, SD = 8.87) than those not satisfied (M = 56.30, SD = 8.59; p = .002). Use of EHR systems among ob-gyns has increased in recent years and overall satisfaction with these systems is high. In spite of this, barriers to implementation are still present and increased outreach to certain groups of ob-gyns, including older practitioners and those in solo practices, is needed.

How Geisinger's advanced medical home model argues the case for rapid-cycle innovation.

The Patient Protection and Affordable Care Act of 2010 provides for a number of major payment and delivery system initiatives. These potential changes need to be tested, scaled, and adapted with an urgency not evident in previous demonstration projects of the Centers for Medicare and Medicaid Services. We discuss lessons learned from our iterative tests of care reengineering at Geisinger--specifically, through our advanced medical home model, ProvenHealth Navigator, and the way we continuously modified the model to improve quality and value. We hypothesize that the most important ingredient in our model has been the embedding of nurse case managers into our community practices and the real-time feedback of data on the use of health services by the most complex patients.

Value and the medical home: effects of transformed primary care.

BACKGROUND: The primary care medical home has been promoted to integrate and improve patient care while reducing healthcare spending, but with little formal study of the model or evidence of its efficacy. ProvenHealth Navigator (PHN), an intensive multidimensional medical home model that addresses care delivery and financing, was introduced into 11 different primary care practices. The goals were to improve the quality, efficiency, and patient experience of care. OBJECTIVE: To evaluate the ability of a medical home model to improve the efficiency of care for Medicare beneficiaries. STUDY DESIGN: Observational study using regression modeling based on preintervention and postintervention data and a propensity-selected control cohort. METHODS: Four years of claims data for Medicare patients at 11 intervention sites and 75 control groups were analyzed to compute hospital admission and readmission rates, and the total cost of care. Regression modeling was used to establish predicted rates and costs in the absence of the intervention. Actual results were compared with predicted results to compute changes attributable to the PHN model. RESULTS: ProvenHealth Navigator was associated with an 18% (P <.01) cumulative reduction in inpatient admissions and a 36% (P = .02) cumulative reduction in readmissions across the total population over the study period. CONCLUSIONS: Investing in the capabilities of primary care practices to serve as medical homes may increase healthcare value by improving the efficiency of care. This study demonstrates that the PHN model is capable of significantly reducing admissions and readmissions for Medicare Advantage members.

Continuous innovation in health care: implications of the Geisinger experience.

To achieve the diverse health care goals of the United States, health care value must increase. The capacity to create value through innovation is facilitated by an integrated delivery system focused on creating value, measuring innovation returns, and receiving market rewards. This paper describes the Geisinger Health System's innovation strategy for care model redesign. Geisinger's clinical leadership, dedicated innovation team, electronic health information systems, and financial incentive alignment each contribute to its innovation record. Although Geisinger's characteristics raise serious questions about broad applicability to nonintegrated health care organizations, its experience can provide useful insights for health system reform.

Bridging the inferential gap: the electronic health record and clinical evidence.

Most clinical decisions involve bridging the inferential gap: Clinicians are required to "fill in" where they lack knowledge or where no knowledge yet exists. In this context we consider how the inferential gap is a product, in part, of how knowledge is created, the limits to gaining access to such knowledge, and the variable ways in which knowledge is translated into decisions. We consider how electronic health records (EHRs) will help narrow this gap by accelerating the creation of evidence relevant to everyday practice needs and facilitating real-time use of knowledge in practice.

"ProvenCareSM": a provider-driven pay-for-performance program for acute episodic cardiac surgical care.

OBJECTIVE: To test whether an integrated delivery system could successfully implement an evidence-based pay-for-performance program for coronary artery bypass graft (CABG) surgery. METHODS: The program consisted of 3 components: (1) establishing implementable best practices; (2) developing risk-based pricing; (3) establishing a mechanism for patient engagement. Surgeons reviewed all class I and IIa "2004 American Heart Association/American College of Cardiology Guidelines for CABG Surgery" and translated them into 40 verifiable behaviors. These were imbedded within a new ProvenCareSM program and "hardwired" within the electronic health record system, including order sets, templates, and "time outs". Concurrently preoperative, inpatient, and postoperative care within 90 days was packaged into a fixed price. A Patient Compact was developed to highlight the importance of patient activation. All elective CABG patients treated between February 2, 2006 and February 2, 2007 were included (ProvenCareSM Group) and compared with 137 patients treated in 2005 (Conventional Care Group). RESULTS: Initially, only 59% of patients received all 40 best practice components. At 3 months, program compliance reached 100%, but fell transiently to 86% over the next 3 months. Reliability subsequently increased to 100% and was sustained for the remainder of the study period. The overall trend in reliability was significant at P=0.001. Thirty-day clinical outcomes showed improved trends () but only the likelihood of discharge to home reached statistical significance. Length of stay decreased by 16% and mean hospital charges fell 5.2%.(Table is included in full-text article.) CONCLUSION: A provider-driven pay-for-performance process for CABG, enabled by an electronic health record system, can reliably deliver evidence-based care, fundamentally alter reimbursement incentives, and may ultimately improve outcomes and reduce resource use.