Electronic medical record reminders and panel management to improve primary care of elderly patients.

BACKGROUND: Most elderly patients do not receive recommended preventive care, acute care, and care for chronic conditions. METHODS: We conducted a controlled trial to assess the effectiveness of electronic medical record (EMR) reminders, with or without panel management, on health care proxy designation, osteoporosis screening, and influenza and pneumococcal vaccinations in patients older than 65 years. Physicians were assigned to 1 of the following 3 arms: EMR reminder, EMR reminder plus panel manager, or control. We assessed completion of recommended practices during a 1-year period. RESULTS: Among patients who had not already received the recommended care, health care proxy was designated in 6.5% of patients in the control arm, 8.8% of the EMR reminder arm, and 19.7% of the EMR reminder plus panel manager arm (P=.002). Bone density screening was completed in 17.7% of patients in the control arm, 19.7% of the EMR reminder arm, and 30.5% of the EMR reminder plus panel manager arm (P=.02). Pneumococcal vaccine was given to 13.1% of patients in the control arm, 19.5% of the EMR reminder arm, and 25.6% of the EMR reminder plus panel manager arm (P=.02). Influenza vaccine was given to 46.8% of patients in the control arm, 56.5% of the EMR reminder arm, and 59.7% of the EMR reminder plus panel manager arm (P=.002). Results were similar when adjusted for individual physician performance in the preceding year, patient age, patient sex, years cared for by the practice, and number of visits. CONCLUSIONS: Electronic medical record reminders alone facilitated improvement in vaccination rates and, when augmented by panel management, facilitated further improvement in vaccination rates and boosted the rates of health care proxy designation and bone density screening. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01313169.

The revolving door of resident continuity practice: identifying gaps in transitions of care.

BACKGROUND: It is well documented that transitions of care pose a risk to patient safety. Every year, graduating residents transfer their patient panels to incoming interns, yet in our practice we consistently find that approximately 50% of patients do not return for follow-up care within a year of their resident leaving. OBJECTIVE: To examine the implications of this lapse of care with respect to chronic disease management, follow-up of abnormal test results, and adherence with routine health care maintenance. DESIGN: Retrospective chart review SUBJECTS: We studied a subset of patients cared for by 46 senior internal medicine residents who graduated in the spring of 2008. 300 patients had been identified as high priority requiring follow-up within a year. We examined the records of the 130 of these patients who did not return for care. MAIN MEASURES: We tabulated unaddressed abnormal test results, missed health care screening opportunities and unmonitored chronic medical conditions. We also attempted to call these patients to identify barriers to follow-up. KEY RESULTS: These patients had a total of 185 chronic medical conditions. They missed a total of 106 screening opportunities including mammogram (24), Pap smear (60) and colon cancer screening (22). Thirty-two abnormal pathology, imaging and laboratory test results were not followed-up as the graduating senior intended. Among a small sample of patients who were reached by phone, barriers to follow-up included a lack of knowledge about the need to see a physician, distance between home and our office, difficulties with insurance, and transportation. CONCLUSIONS: This study demonstrates the high-risk nature of patient handoffs in the ambulatory setting when residents graduate. We discuss changes that might improve the panel transfer process.

The challenging pelvic examination.

While there is a large body of evidence on the effectiveness of Pap smears for cervical cancer screening and on screening for cervical gonorrhea and Chlamydia, there is sparse evidence to support other portions of the pelvic examination and little guidance on examination logistics. Maximizing comfort should be the goal; lubrication use and careful speculum selection and insertion can ease this intrusive procedure. This is particularly important in adolescent and menopausal women, sexual minorities, obese women, women with disabilities, and women with a history of trauma or prior instrumentation affecting the genitalia. We review the evidence and provide guidance to minimize physical and psychological discomfort with pelvic examination.