Setting and EHR
Partners HealthCare System is an integrated regional health delivery network in eastern Massachusetts. The main EHR used in Partners HealthCare ambulatory clinics is the Longitudinal Medical Record, or LMR. The LMR is an internally developed, full-featured EHR including typed and dictated notes from primary care and subspecialty clinics; problem lists; medication lists; coded allergies; and laboratory test and radiographic results.
The ARI Smart Form
The ARI Smart Form is launched from the Notes page of the EHR and is designed to be used while interviewing and evaluating patients. The ARI Smart Form includes 6 components: entry of clinical information; patient data display; diagnosis selection; presentation of treatment options with integrated decision support; printing of patient handouts; and access to supporting medical literature. The ARI Smart Form imports patients’ problem lists, allergies, medications, and vital signs into the visit note; speeds workflow using drop-down lists, radio buttons, and check boxes; and provides “one-click” ordering of medicines, patient handouts, and excuse-from-work letters. The ARI Smart Form automatically generates a narrative visit note from all entered information.
The ARI Smart Form provides decision support in several ways. First, clinicians’ selection of a particular ARI diagnosis results in the generation of a diagnosis-appropriate order set. Antibiotic prescribing and antibiotic choices are based on the recommendations of the Centers for Disease Control and Prevention (CDC) and American College of Physicians (ACP).7
At a basic level, the ARI Smart Form decision support strives to make the antibiotic treatment match the diagnosis (e.g., not prescribing antibiotics for patients with acute bronchitis). Second, the ARI Smart Form provides diagnostic decision support by calculating the probability of streptococcal pharyngitis based on signs and symptoms and also how rapid streptococcal testing would change the probability of streptococcal pharyngitis ().8
Third, the ARI Smart Form has medication prescribing alerts to potential medication interactions or patient allergies. Fourth, the ARI Smart Form supports clinicians by providing easy access to diagnosis-appropriate patient handouts. The handouts contain information about the diagnosis and why or why not antibiotics may be indicated.
The ARI Smart Form should standardize documentation for several reasons. To obtain the workflow benefits of using the ARI Smart Form (i.e., facilitated orders and patient instructions), clinicians need to indicate a specific diagnosis as opposed to using non-standard or vague diagnoses like “URI.” In addition, clinicians use the ARI Smart Form to enter standard data elements that are stored and can be used in subsequent analyses.
We recruited pilot clinicians by emailing 10 clinic directors and asking them to identify 2 volunteers each. Potential pilot clinicians were then contacted via email and invited to participate. Those clinicians who accepted were instructed on how to use the ARI Smart Form through a series of emails detailing the layout, functionality, and technical issues associated with the ARI Smart Form. We encouraged clinicians to practice with the ARI Smart Form by using it with “test patients” (fictitious patients contained in the LMR) and then to start using it for all their ARI visits. On-line support for usability and technical issues was provided for the duration of the pilot via a link in the ARI Smart Form. The pilot period ran from August 29, 2005 to September 31, 2005.
Outcomes of interest for this pilot study included the proportion of all ARI visits for which the ARI Smart Form was used, the proportion of ARI visits at which antibiotics were prescribed, rates of antibiotic prescribing across different diagnoses, and the duration of ARI Smart Form use.
At the end of the pilot period, we asked pilot clinicians to complete an electronic survey. The 5-minute survey asked questions about clinicians’ satisfaction with the ARI Smart Form, focusing on areas needing improvement. In particular, the survey asked clinicians if they would recommend the ARI Smart Form to colleagues and if they felt using the ARI Smart Form saved time.
Data Capture, Extraction, and Analysis
We captured data about diagnosis and antibiotic prescribing from the ARI Smart Form. We also recorded time stamps associated with starting and ending the ARI Smart Form session, which allowed us to calculate the duration of use of the ARI Smart Form. The duration of use is only a proxy for the visit duration as clinicians could choose to use the ARI Smart Form throughout a visit or only for a portion of a visit.
After the pilot was complete, we assessed our ability to compare antibiotic prescribing between visits at which the ARI Smart Form was used to visits at which the ARI Smart Form was not used. We extracted 2 groups for comparison. The first comparison group was all contemporaneous ARI visits for which the pilot clinicians did not use the ARI Smart Form. The second comparison group was all ARI visits from the previous winter season (from October 1, 2004 to May 31, 2005) made to the pilot clinicians.
We identified comparison visits using administrative data coded as International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM). We identified visits with diagnoses of non-specific upper respiratory infections (ICD-9-CM 460, 464, and 465), otitis media (ICD-9-CM 381 and 382), sinusitis (ICD-9-CM 461 and 473), pharyngitis (ICD-9-CM 034.0, 462, and 463), acute bronchitis (ICD-9-CM 466 and 490), and pneumonia (ICD-9-CM 481–486). We considered otitis media, sinusitis, streptococcal pharyngitis, and pneumonia to be antibiotic-appropriate diagnoses. We considered non-specific upper respiratory tract infections, non-streptococcal pharyngitis, acute bronchitis, viral syndrome, and other diagnoses to be non-antibiotic-appropriate diagnoses.
We report results as simple proportions and means with standard deviations (SD). We did not perform statistical testing because of the small sample size of this pilot study.