Delinquent Medical Records: Who Are the Stakeholders for Timely Medical Documentation?

The explosion of electronic documentation associated with Meaningful Use-certified electronic health record systems has led to a massive increase in provider workload for completion and finalization of patient encounters. Delinquency of required documentation affects multiple areas of hospital operations. We present the major stakeholders affected by delinquency of the electronic medical record and examine the differing perspectives to gain insight for successful engagement to reduce the burden of medical record delinquency.

Impact of duty hour regulations on medical students' education: views of key clinical faculty.

BACKGROUND: Teaching faculty have valuable perspectives on the impact of residency duty hour regulations on medical students. OBJECTIVE: The objective of this study was to elicit faculty views on the impact of residency duty hour regulations on medical students' educational experience on inpatient medicine rotations. DESIGN AND PARTICIPANTS: We conducted a National Survey of Key Clinical Faculty (KCF) at 40 internal medicine residency programs affiliated with U.S. medical schools using a random sample stratified by National Institutes of Health funding and program size. MEASUREMENTS: This study measures KCF opinions on the effect of duty hour regulations on students' education. RESULTS: Of 154 KCF targeted, 111 responded (72%). Fifty-two percent of KCF reported worsening in the overall quality of students' education compared to just 2.7% reporting improvement (p < 0.001). In multivariate analysis adjusted for gender, academic rank, specialty, and years of teaching experience, faculty who spent >/=15 hours per week teaching were more likely to report worsening in medical students' level of responsibility on inpatient teams [odds ratio (OR) 3.1; 95% confidence interval (CI) 1.3-7.6], ability to follow patients throughout hospitalization (OR 3.2; 95% CI 1.3-7.9), ability to develop working relationships with residents (OR 2.3; 95% CI 1.0-5.2), and the overall quality of students' education (OR 3.3; 95% CI 1.4-8.1) compared to faculty who spent less time teaching. CONCLUSION: Key clincal faculty report concerns about the impact of duty hour regulations on aspects of medical students' education in internal medicine. Medical schools and residency programs should identify ways to ensure optimal educational experiences for students within duty hour requirements.

The reported validity and reliability of methods for evaluating continuing medical education: a systematic review.

PURPOSE: To appraise the reported validity and reliability of evaluation methods used in high-quality trials of continuing medical education (CME). METHOD: The authors conducted a systematic review (1981 to February 2006) by hand-searching key journals and searching electronic databases. Eligible articles studied CME effectiveness using randomized controlled trials or historic/concurrent comparison designs, were conducted in the United States or Canada, were written in English, and involved at least 15 physicians. Sequential double review was conducted for data abstraction, using a traditional approach to validity and reliability. RESULTS: Of 136 eligible articles, 47 (34.6%) reported the validity or reliability of at least one evaluation method, for a total of 62 methods; 31 methods were drawn from previous sources. The most common targeted outcome was practice behavior (21 methods). Validity was reported for 31 evaluation methods, including content (16), concurrent criterion (8), predictive criterion (1), and construct (5) validity. Reliability was reported for 44 evaluation methods, including internal consistency (20), interrater (16), intrarater (2), equivalence (4), and test-retest (5) reliability. When reported, statistical tests yielded modest evidence of validity and reliability. Translated to the contemporary classification approach, our data indicate that reporting about internal structure validity exceeded reporting about other categories of validity evidence. CONCLUSIONS: The evidence for CME effectiveness is limited by weaknesses in the reported validity and reliability of evaluation methods. Educators should devote more attention to the development and reporting of high-quality CME evaluation methods and to emerging guidelines for establishing the validity of CME evaluation methods.

Effect of residency duty-hour limits: views of key clinical faculty.

BACKGROUND: To determine the effect of duty-hour limitations, it is important to consider the views of faculty who have the most contact with residents. METHOD: We conducted a national survey of key clinical faculty (KCF) at 39 internal medicine residency programs affiliated with US medical schools selected by random sample stratified by federal research funding and program size to elicit their views on the effect of duty-hour limitations on residents' patient care, education, professionalism, and well-being and on faculty workload and satisfaction. RESULTS: Of 154 KCF surveyed, 111 (72%) responded. The KCF reported worsening in residents' continuity of care (87%) and the physician-patient relationship (75%). Faculty believed that residents' education (66%) and professionalism, including accountability to patients (73%) and ability to place patient needs above self-interests (57%), worsened, yet 50% thought residents' well-being improved. The KCF reported spending more time providing inpatient services (47%). Faculty noted decreased satisfaction with teaching (56%), ability to develop relationships with residents (40%), and overall career satisfaction (31%). In multivariate analysis, KCF with 5 years of teaching experience or more were more likely to perceive a negative effect of duty hours on residents' education (odds ratio, 2.84; 95% confidence interval, 1.15-7.00). CONCLUSIONS: Key clinical faculty believe that duty-hour limitations have adversely affected important aspects of residents' patient care, education, and professionalism, as well as faculty workload and satisfaction. Residency programs should continue to look for ways to optimize experiences for residents and faculty within the confines of the duty-hour requirements.

Impact of Displaying Inpatient Pharmaceutical Costs at the Time of Order Entry: Lessons From a Tertiary Care Center.

BACKGROUND: A lack of cost-conscious medication use is a major contributor to excessive healthcare expenditures in the inpatient setting. Expensive medicines are often utilized when there are comparable alternatives available at a lower cost. Increasing prescriber awareness of medication cost at the time of ordering may help promote cost-conscious use of medications in the hospital. OBJECTIVE: To evaluate the impact of cost messaging on the ordering of 9 expensive medications. DESIGN: Retrospective analysis of an institutional cost-transparency initiative. SETTING: A 1145-bed, tertiary care, academic medical center. PARTICIPANTS: Prescribers who ordered medications through the computerized provider order entry system at the Johns Hopkins Hospital. METHODS: Interrupted time series and segmented regression models were used to examine prescriber ordering before and after implementation of cost messaging for 9 highcost medications. RESULTS: Following the implementation of cost messaging, no significant changes were observed in the number of orders or ordering trends for intravenous (IV) formulations of eculizumab, calcitonin, levetiracetam, linezolid, mycophenolate, ribavirin, and levothyroxine. An immediate and sustained reduction in medication utilization was seen in 2 drugs that underwent a policy change during our study, IV pantoprazole and oral voriconazole. IV pantoprazole became restricted at our facility due to a national shortage (-985 orders per 10,000 patient days; 𝑃 < 0.001), and oral voriconazole was replaced with an alternative antifungal in oncology order sets (-110 orders per 10,000 patient days; 𝑃 = 0.001). CONCLUSIONS: Prescriber cost transparency alone did not significantly influence medication utilization at our institution. Active strategies to reduce ordering resulted in dramatic reductions in ordering.

Osteoporosis in postmenopausal women. Therapy options across a wide range of risk for fracture.

Osteoporosis is a highly prevalent skeletal disorder characterized by compromised bone strength predisposing individuals to an increased risk of fractures. Fractures related to osteoporosis are frequently associated with chronic pain and decreased quality of life, as well as significant morbidity and mortality. Postmenopausal women are at higher risk for developing osteoporosis and osteoporosis-related fractures. Osteoporosis fractures are commonly asymptomatic, necessitating a need for proactive screening, diagnostic testing, and more importantly, therapeutic intervention that will rapidly reduce the risk of fractures in at-risk patients. Current pharmacologic prevention and treatment options for osteoporosis include antiresorptive therapies (alendronate, risedronate, ibandronate, raloxifene, hormone therapy, and calcitonin) and the anabolic agent teriparatide.

The Creation of a Biocontainment Unit at a Tertiary Care Hospital. The Johns Hopkins Medicine Experience.

In response to the 2014-2015 Ebola virus disease outbreak in West Africa, Johns Hopkins Medicine created a biocontainment unit to care for patients infected with Ebola virus and other high-consequence pathogens. The unit team examined published literature and guidelines, visited two existing U.S. biocontainment units, and contacted national and international experts to inform the design of the physical structure and patient care activities of the unit. The resulting four-bed unit allows for unidirectional flow of providers and materials and has ample space for donning and doffing personal protective equipment. The air-handling system allows treatment of diseases spread by contact, droplet, or airborne routes of transmission. An onsite laboratory and an autoclave waste management system minimize the transport of infectious materials out of the unit. The unit is staffed by self-selected nurses, providers, and support staff with pediatric and adult capabilities. A telecommunications system allows other providers and family members to interact with patients and staff remotely. A full-time nurse educator is responsible for staff training, including quarterly exercises and competency assessment in the donning and doffing of personal protective equipment. The creation of the Johns Hopkins Biocontainment Unit required the highest level of multidisciplinary collaboration. When not used for clinical care and training, the unit will be a site for research and innovation in highly infectious diseases. The lessons learned from the design process can inform a new research agenda focused on the care of patients in a biocontainment environment.

Disparities in osteoporosis screening between at-risk African-American and white women.

BACKGROUND: Despite a lower prevalence of osteoporosis in African-American women, they remain at risk and experience a greater mortality than white women after sustaining a hip fracture. Lack of recognition of risk factors may occur in African-American women, raising the possibility that disparities in screening practices may exist. OBJECTIVE: To determine whether there is a difference in physician screening for osteoporosis in postmenopausal, at-risk African-American and white women. METHODS: We conducted a retrospective chart review at an urban academic hospital and a suburban community hospital. Subjects included 205 African-American and white women, age > or = 65 years and weight < or = 127 pounds, who were seen in Internal Medicine clinics. The main outcome was dual-energy x-ray absorptiometry (DXA) scan referral. We investigated physician and patient factors associated with referral. Secondary outcomes included evidence of discussion of osteoporosis and prescription of medications to prevent osteoporosis. RESULTS: Significantly fewer African-American than white women were referred for a DXA scan (OR 0.39%, 95% confidence interval (CI): 0.22 to 0.68). Physicians were also less likely to mention consideration of osteoporosis in medical records (0.27, 0.15 to 0.48) and to recommend calcium and vitamin D supplementation for this population (0.21, 0.11 to 0.37). If referred, African-American women had comparable DXA completion rates when compared with white women. No physician characteristics were significantly associated with DXA referral patterns. CONCLUSIONS: Our study found a significant disparity in the recommendation for osteoporosis screening for African-American versus white women of similar risk, as well as evidence of disparate osteoporosis prevention and treatment, confirming results of other studies. Future educational and research initiatives should target this inequality.

Current evidence for the use of emerging radiologic technologies for disease screening.

Recent technologic advances in the field of radiology have resulted in the availability of several new tests with potential applications for disease screening. Presently, these tests are being marketed directly to patients as noninvasive means to provide peace of mind that they are disease free. Such assurance is appealing to many individuals, and some are willing to spend up to 1500 dollars to choose from a menu of available diagnostic options. Given that a physician's referral is unnecessary, many healthcare providers are unaware that such testing has taken place until their patients present to them with abnormal test results. In this review, we examine the evidence supporting the use of electron beam computed tomography for coronary artery disease screening, spiral computed tomography of the chest for lung cancer screening, computed tomographic colonography for colon cancer screening, and total-body computed tomography for general screening. Although some of these modalities show promise for the future, there is insufficient evidence to support the use of any of these testing methods for secondary prevention. The potential for harm associated with false-positive test results, false-negative test results, undue anxiety, and radiation exposure exists but requires further study to quantify actual risk.

The power of involving house staff in quality improvement: an interdisciplinary house staff-driven vaccination initiative.

Immunization for influenza and pneumococcal pneumonia were incorporated into The Joint Commission "global immunization" core measure January 1, 2012. The authors' hospital chose to adhere strictly to guidelines to avoid overvaccination. An immunization order set was created to aid appropriate ordering practices. In spite of this effort, compliance rates remained below the goal. The objective was to improve compliance with inpatient vaccination core measures to >96%. An educational slide set was created and distributed by the Housestaff Patient Safety and Quality Council (HPSQC). A competition was established among departments. Finally, the HPSQC partnered with quality improvement staff to improve communication and optimize concurrent review processes. The average compliance prior to the HPSQC vaccination initiative was 78% for pneumococcal pneumonia and 84% for influenza; average compliance in the months following the intervention was 96% and 97.5%, respectively. This project yielded significant improvement in compliance with vaccination core measures.

A critical evaluation of Internet marketing of products that contain ephedra.

OBJECTIVE: To evaluate information contained within Internet sites that advertise and market dietary supplements containing ephedra. MATERIAL AND METHODS: We conducted an Internet search to identify Web sites advertising weight-loss supplements that contained ephedra. Between July 7 and July 18, 2002, 4 search engines were used by entering the term herbal weight loss. Outcome measures included disclosure of potential adverse effects of or contraindications to ephedra-containing supplements, disclosure of ephedra alkaloid dosage, and presence of misleading or incorrect information. RESULTS: Thirty-two products and advertisements were identified and systematically evaluated for deviance from truth-in-advertising standards. Of the 32 Web sites analyzed, 13 (41%) failed to disclose potential adverse effects or contraindications to supplement use. Seventeen (53%) did not reveal the dosage of ephedra alkaloids that was recommended. More importantly, 11 sites (34%) contained incorrect or misleading statements, some of which could directly result in serious harm to consumers. CONCLUSION: If dietary supplements containing ephedra are to continue to be marketed freely, substantial reform in advertising regulation and enforcement is warranted.

Evaluation of an audience response system for the continuing education of health professionals.

INTRODUCTION: Continuing medical education (CME) for physicians and other health personnel is becoming increasingly important in light of recertification requirements. Interactive learning is more effective and may be useful in a continuing education setting. This study examines the use of an audience response system (ARS) as an interactive learning tool for health care providers. METHOD: We conducted a national randomized controlled trial to evaluate the utility of an ARS to enhance attention and learning. Speakers at 42 clinical round table (CRT) programs in five regions across the United States were randomized to "use" or "no use" of an ARS during their lectures. We surveyed participants to collect data regarding presentation and speaker quality, impressions of the ARS, and knowledge of the material presented. We collected information from speakers regarding ease of use and overall opinions of the ARS. RESULTS: A total of 283 surveys were completed (164 from participants using the ARS and 119 from participants not using the ARS). ARS participants rated the quality of the presentation, the quality of the speaker, and their level of attention more highly than non-ARS participants (p < .05). Knowledge scores (of material presented) were not significantly different between the two groups. Both participants and speakers felt that the ARS was easy to use and preferred to use the system in future CRTs. DISCUSSION: Participants in CRTs with the ARS rated presentation and speaker quality more favorably than those participants in CRTs without the tool. Participant knowledge scores, however, were not significantly different. ARSs may provide easy-to-use tools to enhance attention and enthusiasm in CME learners.

Nurse-pharmacist collaboration on medication reconciliation prevents potential harm.

BACKGROUND: Medication reconciliation can prevent some adverse drug events (ADEs). Our prospective study explored whether an easily replicable nurse-pharmacist led medication reconciliation process could efficiently and inexpensively prevent potential ADEs. METHODS: Nurses at a 1000 bed urban, tertiary care hospital developed the home medication list (HML) through patient interview. If a patient was not able to provide a written HML or recall medications, the nurses reviewed the electronic record along with other sources. The nurses then compared the HML to the patient's active inpatient medications and judged whether the discrepancies were intentional or potentially unintentional. This was repeated at discharge as well. If the prescriber changed the order when contacted about a potential unintentional discrepancy, it was categorized as unintentional and rated on a 1-3 potential harm scale. RESULTS: The study included 563 patients. HML information gathering averaged 29 minutes. Two hundred twenty-five patients (40%; 95% confidence interval [CI], 36%-44%) had at least 1 unintended discrepancy on admission or discharge. One hundred sixty-two of the 225 patients had an unintended discrepancy ranked 2 or 3 on the harm scale. It cost $113.64 to find 1 potentially harmful discrepancy. Based on the 2008 cost of an ADE, preventing 1 discrepancy in every 290 patient encounters would offset the intervention costs. We potentially averted 81 ADEs for every 290 patients. CONCLUSION: Potentially harmful medication discrepancies occurred frequently at both admission and discharge. A nurse-pharmacist collaboration allowed many discrepancies to be reconciled before causing harm. The collaboration was efficient and cost-effective, and the process potentially improves patient safety.

Health care utilization and the proportion of primary care physicians.

BACKGROUND: The impact of primary care physicians on health care utilization remains controversial. Some have hypothesized that primary care physicians decrease health care utilization through enhanced coordination of care and a preventive care focus. METHODS: Using data from the Area Resource File (a Health Resources and Services Administration US county-level database) for the years 1990, 1995, and 1999, we performed a retrospective cross-sectional analysis with generalized estimating equations to determine if measures of health care utilization (inpatient admissions, outpatient visits, emergency department visits, and surgeries) were associated with the proportion of primary care physicians to total physicians within metropolitan statistical areas. RESULTS: The average proportion of primary care physicians in each metropolitan statistical area was 0.34 (SD 0.46, range 0.20-0.54). Higher proportions of primary care physicians were associated with significantly decreased utilization, with each 1% increase in proportion of primary care physicians associated with decreased yearly utilization for an average-sized metropolitan statistical area of 503 admissions, 2968 emergency department visits, and 512 surgeries (all P <.03). These relationships were consistent each year studied. CONCLUSIONS: Increased proportions of primary care physicians appear to be associated with significant decreases in measures of health care utilization across the 1990s. National efforts aimed at limiting health care utilization may benefit from focusing on the proportion of primary care physicians relative to specialists in this country.

Patients' understanding of the regulation of dietary supplements.

The Dietary Supplement Health and Education Act (DSHEA) permits manufacturers to sell products without providing pre-market evidence of safety or efficacy. One fundamental reason for the passage of the DSHEA was to empower consumers to make their own choices, free from governmental restriction. Yet, little is known about the public's understanding of the supplement regulatory process. We undertook a study to assess patients' knowledge regarding governmental oversight of product marketing and advertising. A survey of 300 adult patients from the Baltimore Metropolitan area was administered after showing participants an advertisement for a dietary supplement. Patients were asked questions regarding their understanding of federal regulation of the advertised product. A total of 52% of respondents were unaware that the dietary supplement had not been approved by the government while 63% were unaware that the advertisement for that supplement had not been pre-approved. Factors associated with a lack of understanding of the product approval process included lower education level (OR 2.52; 95% CI 1.52-4.19) and non-Caucasian race (OR 1.99; 95% CI 1.17-3.36). Lower education level was also associated with confusion regarding the advertisement approval process (OR 2.60; 95% CI 1.48-4.57). Based on these results, patients seem unclear about the government's role in the regulation of dietary supplements. Educational efforts should be geared towards clarifying these issues.