Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions.

OBJECTIVE: To investigate whether using a computer-based patient record (CPR) affects the completeness of documentation and appropriateness of documented clinical decisions. DESIGN: A blinded expert panel of four experienced internists evaluated 50 progress notes of patients who had chronic diseases and whose physicians used either a CPR or a traditional paper record. MEASUREMENTS: Completeness of problem and medication lists in progress notes, allergies noted in the entire record, consideration of relevant patient factors in the progress note's diagnostic and treatment plans, and appropriateness of documented clinical decisions. RESULTS: The expert reviewers rated the problem lists and medication lists in the CPR progress notes as more complete (1.79/2.00 vs 0.93/2.00, P < 0.001, and 1.75/2.00 vs. 0.91/2.00, P < 0.001, respectively) than those in the paper record. The allergy lists in both records were similar. Providers using a CPR documented consideration of more relevant patient factors when making their decisions (1.53/2.00 vs. 1.07/2.00, P < 0.001), and documented more appropriate clinical decisions (3.63/5.00 vs. 2.50/5.00, P < 0.001), compared with providers who used traditional paper records. CONCLUSIONS: Physicians in our study who used a CPR produced more complete documentation and documented more appropriate clinical decisions, as judged by an expert review panel. Because the physicians who used the CPR in our study volunteered to do so, further study is warranted to test whether the same conclusions would apply to all CPR users and whether the improvement in documentation leads to better clinical outcomes.

Measuring the effects of reminders for outpatient influenza immunizations at the point of clinical opportunity.

OBJECTIVE: To evaluate the influence of computer-based reminders about influenza vaccination on the behavior of individual clinicians at each clinical opportunity. DESIGN: The authors conducted a prospective study of clinicians' influenza vaccination behavior over four years. Approximately one half of the clinicians in an internal medicine clinic used a computer-based patient record system (CPR users) that generated computer-based reminders. The other clinicians used traditional paper records (PR users). MEASUREMENTS: Each nonacute visit by a patient eligible for an influenza vaccination was considered an opportunity for intervention. Patients who had contraindications for vaccination were excluded. Compliance with the guideline was defined as documentation that a clinician ordered the vaccine, counseled the patient about the vaccine, offered the vaccine to a patient who declined it, or verified that the patient had received the vaccine elsewhere. The authors calculated the proportion of opportunities on which each clinician documented action in the CPR and PR user groups. RESULTS: The CPR and PR user groups had different baseline compliance rates (40.1 and 27.9 per cent, respectively; P<0.05). Both rates remained stable during a two-year baseline period (P = 0.34 and P = 0.47, respectively). The compliance rates in the CPR user group increased 78 per cent from baseline (P<0.001), whereas the rates for the PR user group did not change significantly (P = 0.18). CONCLUSIONS: Clinicians who used a CPR with reminders had higher rates of documentation of compliance with influenza-vaccination guidelines than did those who used a paper record. Measurements of individual clinician behavior at the point of each clinical opportunity can provide precise evaluation of interventions that are designed to improve compliance with guidelines.

Meeting the information needs of patients: results from a patient focus group.

Changing roles in health care call for patients to share increased responsibility for managing their health. Patients may need additional health-related information to participate more fully in health care decisions. We examined patients' information needs from the perspective of clinicians, educational software vendors, and patients. The most instructive information came directly from patients in focus groups. The participants in our focus groups clearly sought more information about their health than they had received during visits with their physicians. Patients' needs were specific to their individual clinical situation, and timing was critical. Although physicians spend a significant amount of time on patient education during an encounter, patients typically formulate their questions after the encounter. We used the results of focus groups to develop desired characteristics of patient education material that addresses patients' information needs. Providers who understand and address these needs will be in a better position to effectively engage patients' active participation in their health care.