The Impact of Alternative Payment in Chronically Ill and Older Patients in the Patient-centered Medical Home.

BACKGROUND: Patient-centered medical home (PCMH) has gained prominence as a promising model to encourage improved primary care delivery. There is a paucity of studies that evaluate the impact of payment models in the PCMH. OBJECTIVES: We sought to examine whether coupling coordinated, team-based care transformation plan with a novel reimbursement model affects outcomes related to expenditures and utilization. RESEARCH DESIGN: Interrupted time-series model with a difference-in-differences approach to assess differences between intervention and control groups, across time periods attributable to PCMH transformation and/or payment change. RESULTS: Although results were modest and mixed overall, PCMH with payment reform is associated with a reduction of $1.04 (P=0.0347) per member per month (PMPM) in pharmacy expenditures. Patients with hypertension, hyperlipidemia, diabetes, and coronary atherosclerosis enrolled in PCMH without payment reform experienced reductions in emergency department visits of 2.16 (P<0.0001), 2.42 (P<0.0001), 3.98 (P<0.0001), and 3.61 (P<0.0001) per 1000 per month. Modest increases in inpatient admission were seen among these patients in PCMH either with or without payment reform. Patients 65 and older enrolled in PMCH without payment reform experienced reductions in pharmacy expenditures $2.35 (P=0.0077) PMPM with a parallel reduction in pharmacy standardized cost of $2.81 (P=0.0174) PMPM indicative of a reduction in the intensity of drug utilization. CONCLUSIONS: We conclude that PCMH implementation coupled with an innovative payment arrangement generated mixed results with modest improvements with respect to pharmacy expenditures, but no overall financial improvement. However, we did see improvement within specific groups, especially older patients and those with chronic conditions.

High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? A Population-Based Comparison of Demographics, Health Care Use, and Expenditures.

Issue: Finding ways to improve outcomes and reduce spending for patients with complex and costly care needs requires an understanding of their unique needs and characteristics. Goal: Examine demographics and health care spending and use of services among adults with high needs, defined as people who have three or more chronic diseases and a functional limitation in their ability to care for themselves or perform routine daily tasks. Methods: Analysis of data from the 2009­2011 Medical Expenditure Panel Survey. Key findings: High-need adults differed notably from adults with multiple chronic diseases but no functional limitations. They had average annual health care expenditures that were nearly three times higher­and which were more likely to remain high over two years of observation­and out-of-pocket expenses that were more than a third higher, despite their lower incomes. Rates of hospital use for high-need adults were more than twice those for adults with multiple chronic conditions only; high-need adults also visited the doctor more frequently and used more home health care. Costs and use of services also varied widely within the high-need group. Conclusion: These findings suggest that interventions should be targeted and tailored to high-need individuals most likely to benefit.

Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences.

Issue: Achieving a high-performing health system will require improving outcomes and reducing costs for high-need, high-cost patients--those who use the most health care services and account for a disproportionately large share of health care spending. Goal: To compare the health care experiences of adults with high needs--those with three or more chronic diseases and a functional limitation in the ability to care for themselves or perform routine daily tasks--to all adults and to those with multiple chronic diseases but no functional limitations. Methods: Analysis of data from the 2009--2011 Medical Expenditure Panel Survey. Key findings: High-need adults were more likely to report having an unmet medical need and less likely to report having good patient-provider communication. High-need adults reported roughly similar ease of obtaining specialist referrals as other adults and greater likelihood of having a medical home. While adults with private health insurance reported the fewest unmet needs overall, privately insured high-need adults reported the greatest difficulties having their needs met. Conclusion: The health care system needs to work better for the highest-need, most-complex patients. This study's findings highlight the importance of tailoring interventions to address their needs.

Nurses' Perspectives on Patient Satisfaction and Expectations: An International Cross-Sectional Multicenter Study With Implications for Evidence-Based Practice.

BACKGROUND: Addressing patient expectations is necessary to achieve high satisfaction. However, few data are available on nurses' perceptions and performance with respect to patient expectations and satisfaction. OBJECTIVES: This international multicenter study aimed to: (a) evaluate nurses' attitudes and performance with respect to patient satisfaction and expectations, and (b) identify predictors of nurses' inquiry of patients' satisfaction at the point of discharge. METHODS: A questionnaire examining attitudes and performance toward patient satisfaction and expectations was developed and validated. Nurses at four academic hospitals in the United States, the United Kingdom, Israel, and Denmark were surveyed. RESULTS: A total of 536 nurses participated in the study (response rate 85.3%). Nurses expressed positive attitudes toward activities related to patient satisfaction and expectations, endorsing the importance of talking with patients about their satisfaction status (91.6%) and their expectations (93.2%). More than half of the responders (51.8%) claimed to have responded to the status of patient satisfaction or dissatisfaction (Israel: 25%; United States: 54.9%; United Kingdom: 61.7%; Denmark: 69.9%; p < .001). However, only 12.1% stated that they routinely ask patients about their level of satisfaction, with nurses in the United States (18.3%) and Denmark (17.5%) more likely to ask compared to nurses in the United Kingdom (7.4%) and Israel (6.3%; p = .001). Adjusted logistic regression identified four significant predictors (p < .05) of nurses' inquiry about patients' satisfaction: "Responding to patient's satisfaction status" (OR: 3.1; 95% CI: 1.7-5.8); "Documenting patient's satisfaction status" (OR: 2.8; 95% CI: 1.6-5.1); "Asking routinely about expectations" (OR: 5.4; 95% CI: 3-9.7); and "Responded to expectations during the past month" (OR: 4.3; 95% CI: 1.9-9.4). LINKING EVIDENCE TO ACTION: These findings warrant further investigation, potentially into the nurses' work environments or educational programs, to better understand why nurses' positive attitudes toward patient satisfaction and expectations do not result in actively asking patients about their satisfaction level and what should be done to improve nurses' performance. Healthcare organizations and policy makers should develop and support structured programs to address patient expectations and improve patient satisfaction during hospitalization.

Systematic Review of Programs Treating High-Need and High-Cost People With Multiple Chronic Diseases or Disabilities in the United States, 2008-2014.

INTRODUCTION: Finding ways to provide better and less expensive health care for people with multiple chronic conditions or disability is a pressing concern. The purpose of this systematic review was to evaluate different approaches for caring for this high-need and high-cost population. METHODS: We searched Medline for articles published from May 31, 2008, through June 10, 2014, for relevant studies. Articles were considered eligible for this review if they met the following criteria: included people with multiple chronic conditions (behavioral or mental health) or disabilities (2 or more); addressed 1 or more of clinical outcomes, health care use and spending, or patient satisfaction; and compared results from an intervention group with a comparison group or baseline measurements. We extracted information on program characteristics, participant characteristics, and significant (positive and negative) clinical findings, patient satisfaction, and health care use outcomes. For each outcome, the number of significant and positive results was tabulated. RESULTS: Twenty-seven studies were included across 5 models of care. Of the 3 studies reporting patient satisfaction outcomes, 2 reported significant improvements; both were randomized controlled trials (RCTs). Of the 14 studies reporting clinical outcomes, 12 reported improvements (8 were RCTs). Of the 13 studies reporting health care use and spending outcomes, 12 reported significant improvements (2 were RCTs). Two models of care - care and case management and disease management - reported improvements in all 3 outcomes. For care and case management models, most improvements were related to health care use. For the disease management models, most improvements were related to clinical outcomes. CONCLUSIONS: Care and case management as well as disease management may be promising models of care for people with multiple chronic conditions or disabilities. More research and consistent methods are needed to understand the most appropriate care for these high-need and high-cost patients.

Effect of electronic health records on health care costs: longitudinal comparative evidence from community practices.

BACKGROUND: The United States is aiming to achieve nationwide adoption of electronic health records (EHRs) but lacks robust empirical evidence to anticipate the effect on health care costs. OBJECTIVE: To assess short-term cost savings from community-wide adoption of ambulatory EHRs. DESIGN: Longitudinal trial with parallel control group. SETTING: Natural experiment in which 806 ambulatory clinicians across 3 Massachusetts communities adopted subsidized EHRs. Six matched control communities applied but were not selected to participate. PATIENTS: 47,979 intervention patients and 130,603 control patients. MEASUREMENTS: Monthly standardized health care costs from commercial claims data from January 2005 to June 2009, including total cost, inpatient cost, and ambulatory cost and its subtypes (pharmacy, laboratory, and radiology). Projected savings per member per month (PMPM), excluding EHR adoption costs. RESULTS: Ambulatory EHR adoption did not impact total cost (pre- to postimplementation difference in monthly trend change, -0.30 percentage point; P = 0.135), but the results favored savings (95% CI, $21.95 PMPM in savings to $1.53 PMPM in higher costs). It slowed ambulatory cost growth (difference in monthly trend change, -0.35 percentage point; P = 0.012); projected ambulatory savings were $4.69 PMPM (CI, $8.45 to $1.09 PMPM) (3.10% of total PMPM cost). Ambulatory radiology costs decreased (difference in monthly trend change, -1.61 percentage points; P < 0.001), with projected savings of $1.61 PMPM (1.07% of total PMPM cost). LIMITATIONS: Intervention communities were not randomly selected and received implementation support, suggesting that results may represent a best-case scenario. Confounding is possible. CONCLUSION: Using commercially available EHRs in community practices seems to modestly slow ambulatory cost growth. Broader changes in the organization and payment of care may prompt clinicians to use EHRs in ways that result in more substantial savings.

Advancing the future of equitable access to health care: recommendations from international health care leaders.

Disparities in access to health care are persistent and contribute to poor health outcomes for many populations around the world. Barriers to access are often similar across countries, despite differences in how health systems are structured. Health care leaders can work to address these barriers through bold, evidence-based actions. The Future of Health (FOH), an international community of senior health leaders, collaborated with the Duke-Margolis Institute for Health Policy to identify priority organizational and policy actions needed to improve equitable access to health care through a consensus-building exercise, a targeted literature review, and an expert discussion group. This paper describes four key action areas for health care leaders that FOH members identified as critical to enabling the future of equitable access to health care: ensuring prioritization of and accountability for equitable access to care; establishing comprehensive, organization-wide strategies to address barriers to access; clearly defining and incentivizing improvement on key measures related to reducing disparities in access; and establishing cross-sector partnerships to improve equitable access.

The potential for artificial intelligence to transform healthcare: perspectives from international health leaders.

Artificial intelligence (AI) has the potential to transform care delivery by improving health outcomes, patient safety, and the affordability and accessibility of high-quality care. AI will be critical to building an infrastructure capable of caring for an increasingly aging population, utilizing an ever-increasing knowledge of disease and options for precision treatments, and combatting workforce shortages and burnout of medical professionals. However, we are not currently on track to create this future. This is in part because the health data needed to train, test, use, and surveil these tools are generally neither standardized nor accessible. There is also universal concern about the ability to monitor health AI tools for changes in performance as they are implemented in new places, used with diverse populations, and over time as health data may change. The Future of Health (FOH), an international community of senior health care leaders, collaborated with the Duke-Margolis Institute for Health Policy to conduct a literature review, expert convening, and consensus-building exercise around this topic. This commentary summarizes the four priority action areas and recommendations for health care organizations and policymakers across the globe that FOH members identified as important for fully realizing AI's potential in health care: improving data quality to power AI, building infrastructure to encourage efficient and trustworthy development and evaluations, sharing data for better AI, and providing incentives to accelerate the progress and impact of AI.

A qualitative study of Canada's experience with the implementation of electronic health information technology.

BACKGROUND: In 2001, Canada Health Infoway unveiled a plan to implement a national system of interoperable electronic health records. This government-funded corporation introduced a novel model for interprovincial/territorial collaboration to establish core aspects of a national framework. Despite this $1.6 billion initiative, Canada continues to lag behind other Western countries in adopting electronic health records. We conducted a study to identify the success of different aspects of the Canadian plan and ways to improve the adoption of electronic health records. METHODS: We used a case study approach to assess the 10-year history of Canada's e-health plan. National reports and documents were reviewed, and structured interviews were conducted with 29 key stakeholders representing national and provincial organizations responsible for establishing policy and strategic direction for health information technology. Using grounded theory, we analyzed transcripts of the interviews to identify themes and their relationships. RESULTS: Key stakeholders identified funding, national standards, patient registries and digital imaging as important achievements of the e-health plan. Lack of an e-health policy, inadequate involvement of clinicians, failure to establish a business case for using electronic health records, a focus on national rather than regional interoperability, and inflexibility in approach were seen as barriers to adoption of the plan. INTERPRETATION: To accelerate adoption of electronic health records and timely return on investment, an e-health policy needs to be tightly aligned with the major strategic directions of health care reform. Adoption needs to be actively fostered through a bottom-up, clinical-needs-first approach, a national policy for investment in electronic health records, and financial incentives based on patient outcomes that can be achieved with electronic health records.

Medication errors recovered by emergency department pharmacists.

STUDY OBJECTIVE: We assess the impact of emergency department (ED) pharmacists on reducing potentially harmful medication errors. METHODS: We conducted this observational study in 4 academic EDs. Trained pharmacy residents observed a convenience sample of ED pharmacists' activities. The primary outcome was medication errors recovered by pharmacists, including errors intercepted before reaching the patient (near miss or potential adverse drug event), caught after reaching the patient but before causing harm (mitigated adverse drug event), or caught after some harm but before further or worsening harm (ameliorated adverse drug event). Pairs of physician and pharmacist reviewers confirmed recovered medication errors and assessed their potential for harm. Observers were unblinded and clinical outcomes were not evaluated. RESULTS: We conducted 226 observation sessions spanning 787 hours and observed pharmacists reviewing 17,320 medications ordered or administered to 6,471 patients. We identified 504 recovered medication errors, or 7.8 per 100 patients and 2.9 per 100 medications. Most of the recovered medication errors were intercepted potential adverse drug events (90.3%), with fewer mitigated adverse drug events (3.9%) and ameliorated adverse drug events (0.2%). The potential severities of the recovered errors were most often serious (47.8%) or significant (36.2%). The most common medication classes associated with recovered medication errors were antimicrobial agents (32.1%), central nervous system agents (16.2%), and anticoagulant and thrombolytic agents (14.1%). The most common error types were dosing errors, drug omission, and wrong frequency errors. CONCLUSION: ED pharmacists can identify and prevent potentially harmful medication errors. Controlled trials are necessary to determine the net costs and benefits of ED pharmacist staffing on safety, quality, and costs, especially important considerations for smaller EDs and pharmacy departments.

Risks of complications by attending physicians after performing nighttime procedures.

CONTEXT: Few data exist on the relationships between experienced physicians' work hours and sleep, and patient safety. OBJECTIVE: To determine if sleep opportunities for attending surgeons and obstetricians/gynecologists are associated with the risk of complications. DESIGN, SETTING, AND PATIENTS: Matched retrospective cohort study of procedures performed from January 1999 through June 2008 by attending physicians (86 surgeons and 134 obstetricians/gynecologists) who had been in the hospital performing another procedure involving adult patients for at least part of the preceding night (12 am-6 am, postnighttime procedures). Sleep opportunity was calculated as the time between end of the overnight procedure and start of the first procedure the following day. Matched control procedures included as many as 5 procedures of the same type performed by the same physician on days without preceding overnight procedures. Complications were identified and classified by a blinded 3-step process that included administrative screening, medical record reviews, and clinician ratings. MAIN OUTCOME MEASURES: Rates of complications in postnighttime procedures as compared with controls; rates of complications in postnighttime procedures among physicians with more than 6-hour sleep opportunities vs those with sleep opportunities of 6 hours or less. RESULTS: A total of 919 surgical and 957 obstetrical postnighttime procedures were matched with 3552 and 3945 control procedures, respectively. Complications occurred in 101 postnighttime procedures (5.4%) and 365 control procedures (4.9%) (odds ratio, 1.09; 95% confidence interval [CI], 0.84-1.41). Complications occurred in 82 of 1317 postnighttime procedures with sleep opportunities of 6 hours or less (6.2%) vs 19 of 559 postnighttime procedures with sleep opportunities of more than 6 hours (3.4%) (odds ratio, 1.72; 95% CI, 1.02-2.89). Postnighttime procedures completed after working more than 12 hours (n = 958) compared with 12 hours or less (n = 918) had nonsignificantly higher complication rates (6.5% vs 4.3%; odds ratio, 1.47; 95% CI, 0.96-2.27). CONCLUSION: Overall, procedures performed the day after attending physicians worked overnight were not associated with significantly increased complication rates, although there was an increased rate of complications among postnighttime surgical procedures performed by physicians with sleep opportunities of less than 6 hours.

Sustainable health information exchanges: the role of institutional factors.

The transfer of patient information between the domains of community and hospital influences the quality, continuity and cost of health care. To supply the need for information flow between community and hospital, computerized Health Information Exchange (HIE) systems have evolved. This paper examines the institutional forces that shape HIE development in Israel and in the United States.In Israel, the vertically integrated Clalit health services developed a different solution for HIE than was developed in the non-vertically integrated Maccabi and Meuhedet health funds. In the United States the fragmented nature of providers - outside of specific networks such as parts of the Kaiser Permanente and Veterans Administration system - have dictated a very different evolution of information flow between community and hospital. More broadly, we consider how institutional factors shape (and will shape) the development of HIEs in different contexts.This paper applies institutional analysis to explain the emergence of different patterns of development of HIE systems in each of the environments. The institutional analysis in this paper can be used to anticipate the future success or failure of incentives to promote digital information sharing at transition of care.

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.

The patient satisfaction chasm: the gap between hospital management and frontline clinicians.

BACKGROUND: Achieving high levels of patient satisfaction requires hospital management to be proactive in patient-centred care improvement initiatives and to engage frontline clinicians in this process. METHOD: We developed a survey to assess the attitudes of clinicians towards hospital management activities with respect to improving patient satisfaction and surveyed clinicians in four academic hospitals located in Denmark, Israel, the UK and the USA. RESULTS: We collected 1004 questionnaires (79.9% response rate) from four hospitals in four countries on three continents. Overall, 90.4% of clinicians believed that improving patient satisfaction during hospitalisation was achievable, but only 9.2% of clinicians thought their department had a structured plan to do so, with significant differences between the countries (p<0.0001). Among responders, only 38% remembered targeted actions to improve patient satisfaction and just 34% stated having received feedback from hospital management regarding patient satisfaction status in their department during the past year. In multivariate analyses, clinicians who received feedback from hospital management and remembered targeted actions to improve patient satisfaction were more likely to state that their department had a structured plan to improve patient satisfaction. CONCLUSIONS: This portrait of clinicians' attitudes highlights a chasm between hospital management and frontline clinicians with respect to improving patient satisfaction. It appears that while hospital management asserts that patient-centred care is important and invests in patient satisfaction and patient experience surveys, our findings suggest that the majority do not have a structured plan for promoting improvement of patient satisfaction and engaging clinicians in the process.

Policy initiatives for health information technology: a qualitative study of U.S. expectations and Canada's experience.

OBJECTIVE: To investigate lessons learned from national policy initiatives in Canada and U.S. with respect to health information technical infrastructure, data standards, and interoperability; and to identify the implications of these lessons for other policy makers, as they guide the future of their own healthcare information technology initiatives. MATERIALS AND METHODS: We performed semi-structured interviews with key opinion leaders including health care professionals, chief information officers, and vendors - 29 in Canada and 31 in the U.S., regarding Health Information Technology policy. The informant sample was chosen to provide views from different stakeholder groups, and included both national and regional representation - three Canadian provinces and three U.S. states. A grounded theory approach was used to analyze the data gathered through the interviews. RESULTS: The informants identified the following key components of successful health IT policy: (1) enables an iterative-incremental management approach to both technology and data standards, (2) addresses the issues around meaningful use and investment already made in existing legacy health IT systems; and (3) capitalizes on the value of data for use in performance and quality measures, public health and research. CONCLUSIONS: Our study has found that successful health information exchange depends on policies that set clear goals and outline intended effects of HIT implementation without being overly prescriptive, and defines frameworks for guiding policy improvement in a continual and systematic manner. The success of health information exchange also depends on the ability to manage an iterative-incremental approach to technology and data standards, starting from small data sets with high impact on specific care and then gradually expanding toward more comprehensive data sets with an increased emphasis on secondary uses of data.

Lessons from the Canadian national health information technology plan for the United States: opinions of key Canadian experts.

OBJECTIVE: To summarize the Canadian health information technology (HIT) policy experience and impart lessons learned to the US as it determines its policy in this area. DESIGN: Qualitative analysis of interviews with identified key stakeholders followed by an electronic survey. MEASUREMENTS: We conducted semi-structured interviews with 29 key Canadian HIT policy and opinion leaders and used a grounded theory approach to analyze the results. The informant sample was chosen to provide views from different stakeholder groups including national representatives and regional representatives from three Canadian provinces. RESULTS: Canadian informants believed that much of the current US direction is positive, especially regarding incentives and meaningful use, but that there are key opportunities for the US to emphasize direct engagement with providers, define a clear business case for them, sponsor large scale evaluations to assess HIT impact in a broad array of settings, determine standards but also enable access to resources needed for mid-course corrections of standards when issues are identified, and, finally, leverage implementation of digital imaging systems. LIMITATIONS: Not all stakeholder groups were included, such as providers or patients. In addition, as in all qualitative research, a selection bias could be present due to the relatively small sample size. CONCLUSIONS: Based on Canadian experience with HIT policy, stakeholders identified as lessons for the US the need to increase direct engagement with providers and the importance of defining the business case for HIT, which can be achieved through large scale evaluations, and of recognizing and leveraging successes as they emerge.

Simulation Suggests that medical group mergers won't undermine the potential utility of health information exchanges.

Federal and state agencies are investing substantial resources in the creation of community health information exchanges, which are consortia that enable independent health care organizations to exchange clinical data. However, under pressure to form accountable care organizations, medical groups may merge and support private health information exchanges. Such activity could reduce the potential utility of community exchanges-that is, the exchanges' capacity to share patient data across hospitals and physician practices that are independent. Simulations of care transitions based on data from ten Massachusetts communities suggest that there would have to be many such mergers to undermine the potential utility of health information exchanges. At the same time, because hospitals and the largest medical groups account for only 10-20 percent of care transitions in a community, information exchanges will still need to recruit a large proportion of the medical groups in a given community for the exchanges to maintain their usefulness in fostering information exchange across independent providers.

Care transitions as opportunities for clinicians to use data exchange services: how often do they occur?

BACKGROUND: The electronic exchange of health information among healthcare providers has the potential to produce enormous clinical benefits and financial savings, although realizing that potential will be challenging. The American Recovery and Reinvestment Act of 2009 will reward providers for 'meaningful use' of electronic health records, including participation in clinical data exchange, but the best ways to do so remain uncertain. METHODS: We analyzed patient visits in one community in which a high proportion of providers were using an electronic health record and participating in data exchange. Using claims data from one large private payer for individuals under age 65 years, we computed the number of visits to a provider which involved transitions in care from other providers as a percentage of total visits. We calculated this 'transition percentage' for individual providers and medical groups. RESULTS: On average, excluding radiology and pathology, approximately 51% of visits involved care transitions between individual providers in the community and 36%-41% involved transitions between medical groups. There was substantial variation in transition percentage across medical specialties, within specialties and across medical groups. Specialists tended to have higher transition percentages and smaller ranges within specialty than primary care physicians, who ranged from 32% to 95% (including transitions involving radiology and pathology). The transition percentages of pediatric practices were similar to those of adult primary care, except that many transitions occurred among pediatric physicians within a single medical group. CONCLUSIONS: Care transition patterns differed substantially by type of practice and should be considered in designing incentives to foster providers' meaningful use of health data exchange services.

Uncovering the blind spot of patient satisfaction: an international survey.

BACKGROUND: To achieve a high level of patient satisfaction, providers need to identify and address patients' expectations. However, providers' beliefs and attitudes regarding expectations, as well as how to manage them, are not well understood. METHODS: The authors developed a survey to assess clinicians' awareness, attitudes, competence and performance with respect to patient expectations. The authors surveyed clinicians in four academic hospitals located in Denmark, Israel, the UK and the USA. RESULTS: The authors collected 1004 questionnaires (79.9% response rate) from four hospitals in four countries spanning three continents. Overall, 88.8% of respondents stated that clinician awareness regarding patient expectations was moderate to low, with significant differences between countries (p<0.001). Although 89.4% of clinicians believed it was important to ask patients about expectations, only 16.1% reported actually asking (p<0.0001). Nurses were more likely than physicians to ask patients about expectations (20.1% vs 11.5%, p<0.001). Only 19.6% of respondents felt they had adequate training to handle patients' expectations. In multivariate analyses, clinicians with greater awareness and adequate training were more likely to ask patients about their expectations. CONCLUSION: While clinicians think it is important to ask patients about their expectations, they often fail to do so and consequently may not respond adequately. These results identify a 'blind spot' in clinicians' approach when attempting to address patient expectations and improve patient satisfaction, suggesting that healthcare organisations should take a more active role in increasing clinicians' awareness and initiating structured training programmes to cope with patient expectations.

Errors associated with outpatient computerized prescribing systems.

OBJECTIVE: To report the frequency, types, and causes of errors associated with outpatient computer-generated prescriptions, and to develop a framework to classify these errors to determine which strategies have greatest potential for preventing them. MATERIALS AND METHODS: This is a retrospective cohort study of 3850 computer-generated prescriptions received by a commercial outpatient pharmacy chain across three states over 4 weeks in 2008. A clinician panel reviewed the prescriptions using a previously described method to identify and classify medication errors. Primary outcomes were the incidence of medication errors; potential adverse drug events, defined as errors with potential for harm; and rate of prescribing errors by error type and by prescribing system. RESULTS: Of 3850 prescriptions, 452 (11.7%) contained 466 total errors, of which 163 (35.0%) were considered potential adverse drug events. Error rates varied by computerized prescribing system, from 5.1% to 37.5%. The most common error was omitted information (60.7% of all errors). DISCUSSION: About one in 10 computer-generated prescriptions included at least one error, of which a third had potential for harm. This is consistent with the literature on manual handwritten prescription error rates. The number, type, and severity of errors varied by computerized prescribing system, suggesting that some systems may be better at preventing errors than others. CONCLUSIONS: Implementing a computerized prescribing system without comprehensive functionality and processes in place to ensure meaningful system use does not decrease medication errors. The authors offer targeted recommendations on improving computerized prescribing systems to prevent errors.