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1.  The Current Capabilities of Health Information Technology to Support Care Transitions 
To determine whether HIT currently supports care transitions we interviewed clinicians from several healthcare settings. We learned about HIT tools to help nurses facilitate transitions, but discovered that there are few tools to promote high quality, safe transitions of care. We also found that HIT is rarely employed for patient-centered care coordination mechanisms. In conclusion, HIT tools are typically used within one healthcare setting to prepare for a transition, rather than across healthcare settings.
PMCID: PMC3900141  PMID: 24551404
electronic health record; meaningful use; care coordination; care transitions
2.  Design and Implementation of a Web-Based Patient Portal Linked to an Ambulatory Care Electronic Health Record: Patient Gateway for Diabetes Collaborative Care 
Diabetes technology & therapeutics  2006;8(5):10.1089/dia.2006.8.576.
Background
Despite the availability of expert guidelines and widespread diabetes quality improvement efforts, care of patients with diabetes remains suboptimal. Two key barriers to care that may be amenable to informatics-based interventions include (1) lack of patient engagement with therapeutic care plans and (2) lack of medication adjustment by physicians (“clinical inertia”) during clinical encounters.
Methods
The authors describe the conceptual framework, design, implementation, and analysis plan for a diabetes patient web-portal linked directly to the electronic health record (EHR) of a large academic medical center via secure Internet access designed to overcome barriers to effective diabetes care.
Results
Partners HealthCare System (Boston, MA), a multi-hospital health care network comprising several thousand physicians caring for over 1 million individual patients, has developed a comprehensive patient web-portal called Patient Gateway that allows patients to interact directly with their EHR via secure Internet access. Using this portal, a specific diabetes interface was designed to maximize patient engagement by importing the patient's current clinical data in an educational format, providing patient-tailored decision support, and enabling the patient to author a “Diabetes Care Plan.” The physician view of the patient's Diabetes Care Plan was designed to be concise and to fit into typical EHR clinical workflow.
Conclusions
We successfully designed and implemented a Diabetes Patient portal that allows direct interaction with our system's EHR. We are assessing the impact of this advanced informatics tool for collaborative diabetes care in a clinic-randomized controlled trial among 14 primary care practices within our integrated health care system.
doi:10.1089/dia.2006.8.576
PMCID: PMC3829634  PMID: 17037972
3.  Practice-Linked Online Personal Health Records for Type 2 Diabetes Mellitus 
Archives of internal medicine  2008;168(16):10.1001/archinte.168.16.1776.
Background
Web-based personal health records (PHRs) have been advocated as a means to improve type 2 diabetes mellitus (DM) care. However, few Web-based systems are linked directly to the electronic medical record (EMR) used by physicians.
Methods
We randomized 11 primary care practices. Intervention practices received access to a DM-specific PHR that imported clinical and medications data, provided patient-tailored decision support, and enabled the patient to author a “Diabetes Care Plan” for electronic submission to their physician prior to upcoming appointments. Active control practices received a PHR to update and submit family history and health maintenance information. All patients attending these practices were encouraged to sign up for online access.
Results
We enrolled 244 patients with DM (37% of the eligible population with registered online access, 4% of the overall population of patients with DM). Study participants were younger (mean age, 56.1 years vs 60.3 years; P< .001) and lived in higher-income neighborhoods (median income, $53 784 vs $49 713; P<.001) but had similar baseline glycemic control compared with nonparticipants. More patients in the intervention arm had their DM treatment regimens adjusted (53% vs 15%; P< .001) compared with active controls. However, there were no significant differences in risk factor control between study arms after 1 year (P=.53).
Conclusions
Previsit use of online PHR linked to the EMR increased rates of DM-related medication adjustment. Low rates of online patient account registration and good baseline control among participants limited the intervention's impact on overall risk factor control.
doi:10.1001/archinte.168.16.1776
PMCID: PMC3829635  PMID: 18779465
4.  Usability of a Novel Clinician Interface for Genetic Results 
Journal of biomedical informatics  2012;45(5):950-957.
The complexity and rapid growth of genetic data demand investment in information technology to support effective use of this information. Creating infrastructure to communicate genetic information to health care providers and enable them to manage that data can positively affect a patient’s care in many ways. However, genetic data are complex and present many challenges. We report on the usability of a novel application designed to assist providers in receiving and managing a patient’s genetic profile, including ongoing updated interpretations of the genetic variants in those patients. Because these interpretations are constantly evolving, managing them represents a challenge. We conducted usability tests with potential users of this application and reported findings to the application development team, many of which were addressed in subsequent versions. Clinicians were excited about the value this tool provides in pushing out variant updates to providers and overall gave the application high usability ratings, but had some difficulty interpreting elements of the interface. Many issues identified required relatively little development effort to fix suggesting that consistently incorporating this type of analysis in the development process can be highly beneficial. For genetic decision support applications, our findings suggest the importance of designing a system that can deliver the most current knowledge and highlight the significance of new genetic information for clinical care. Our results demonstrate that using a development and design process that is user focused helped optimize the value of this application for personalized medicine.
doi:10.1016/j.jbi.2012.03.007
PMCID: PMC3426649  PMID: 22521718
clinical decision support; electronic health records; genomics; personalized medicine
5.  Simulation Suggests That Medical Group Mergers Won’t Undermine The Potential Utility Of Health Information Exchanges 
Health affairs (Project Hope)  2012;31(3):548-559.
Substantial resources are being invested in health information exchanges (HIE), community-based 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 HIE, reducing the potential utility of community HIEs. Simulations of “care transitions” based on data from 10 Massachusetts communities suggest that mergers would have to be considerable to substantially reduce the potential utility of an HIE. Nonetheless, simulations also suggest that HIEs will need to recruit a large proportion of the medical groups in a community, as hospitals and the largest groups account for only 10 to 20% of care transitions in communities.
doi:10.1377/hlthaff.2011.0799
PMCID: PMC3759523  PMID: 22392665
6.  Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial 
Objective
To determine the effects of a personal health record (PHR)-linked medications module on medication accuracy and safety.
Design
From September 2005 to March 2007, we conducted an on-treatment sub-study within a cluster-randomized trial involving 11 primary care practices that used the same PHR. Intervention practices received access to a medications module prompting patients to review their documented medications and identify discrepancies, generating ‘eJournals’ that enabled rapid updating of medication lists during subsequent clinical visits.
Measurements
A sample of 267 patients who submitted medications eJournals was contacted by phone 3 weeks after an eligible visit and compared with a matched sample of 274 patients in control practices that received a different PHR-linked intervention. Two blinded physician adjudicators determined unexplained discrepancies between documented and patient-reported medication regimens. The primary outcome was proportion of medications per patient with unexplained discrepancies.
Results
Among 121 046 patients in eligible practices, 3979 participated in the main trial and 541 participated in the sub-study. The proportion of medications per patient with unexplained discrepancies was 42% in the intervention arm and 51% in the control arm (adjusted OR 0.71, 95% CI 0.54 to 0.94, p=0.01). The number of unexplained discrepancies per patient with potential for severe harm was 0.03 in the intervention arm and 0.08 in the control arm (adjusted RR 0.31, 95% CI 0.10 to 0.92, p=0.04).
Conclusions
When used, concordance between documented and patient-reported medication regimens and reduction in potentially harmful medication discrepancies can be improved with a PHR medication review tool linked to the provider's medical record.
Trial registration number
This study was registered at ClinicalTrials.gov (NCT00251875).
doi:10.1136/amiajnl-2011-000723
PMCID: PMC3422826  PMID: 22556186
Heath records, personal; medication errors; ambulatory care; quality improvement; patient safety; clinical decision support; hospital medicine; personal health records; diabetes; medical informatics; decision support; healthcare information technology; knowledge management; electronic health records; clinical informatics
7.  Ambulatory prescribing errors among community-based providers in two states 
Objective
Little is known about the frequency and types of prescribing errors in the ambulatory setting among community-based, primary care providers. Therefore, the rates and types of prescribing errors were assessed among community-based, primary care providers in two states.
Material and Methods
A non-randomized cross-sectional study was conducted of 48 providers in New York and 30 providers in Massachusetts, all of whom used paper prescriptions, from September 2005 to November 2006. Using standardized methodology, prescriptions and medical records were reviewed to identify errors.
Results
9385 prescriptions were analyzed from 5955 patients. The overall prescribing error rate, excluding illegibility errors, was 36.7 per 100 prescriptions (95% CI 30.7 to 44.0) and did not vary significantly between providers from each state (p=0.39). One or more non-illegibility errors were found in 28% of prescriptions. Rates of illegibility errors were very high (175.0 per 100 prescriptions, 95% CI 169.1 to 181.3). Inappropriate abbreviation and direction errors also occurred frequently (13.4 and 4.2 errors per 100 prescriptions, respectively). Reviewers determined that the vast majority of errors could have been eliminated through the use of e-prescribing with clinical decision support.
Discussion
Prescribing errors appear to occur at very high rates among community-based primary care providers, especially when compared with studies of academic-affiliated providers that have found nearly threefold lower error rates. Illegibility errors are particularly problematical.
Conclusions
Further characterizing prescribing errors of community-based providers may inform strategies to improve ambulatory medication safety, especially e-prescribing.
Trial registration number
http://www.clinicaltrials.gov, NCT00225576.
doi:10.1136/amiajnl-2011-000345
PMCID: PMC3384098  PMID: 22140209
Ambulatory; data exchange; decision support; electronic health records; health information technology; inappropriate prescribing; medication error; measuring/improving patient safety and reducing medical errors; patient safety; primary care; quality of care; veterans
8.  Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use? 
Background
Electronic health record (EHR) adoption is a national priority in the USA, and well-designed EHRs have the potential to improve quality and safety. However, physicians are reluctant to implement EHRs due to financial constraints, usability concerns, and apprehension about unintended consequences, including the introduction of medical errors related to EHR use. The goal of this study was to characterize and describe physicians' attitudes towards three consequences of EHR implementation: (1) the potential for EHRs to introduce new errors; (2) improvements in healthcare quality; and (3) changes in overall physician satisfaction.
Methods
Using data from a 2007 statewide survey of Massachusetts physicians, we conducted multivariate regression analysis to examine relationships between practice characteristics, perceptions of EHR-related errors, perceptions of healthcare quality, and overall physician satisfaction.
Results
30% of physicians agreed that EHRs create new opportunities for error, but only 2% believed their EHR has created more errors than it prevented. With respect to perceptions of quality, there was no significant association between perceptions of EHR-associated errors and perceptions of EHR-associated changes in healthcare quality. Finally, physicians who believed that EHRs created new opportunities for error were less likely be satisfied with their practice situation (adjusted OR 0.49, p=0.001).
Conclusions
Almost one third of physicians perceived that EHRs create new opportunities for error. This perception was associated with lower levels of physician satisfaction.
doi:10.1136/amiajnl-2011-000544
PMCID: PMC3384111  PMID: 22199017
Electronic medical records; medical errors; hospital information systems; unintended consequences; physician satisfaction; electronic health record; developing/using computerized provider order entry; knowledge representations; classical experimental and quasi-experimental study methods (lab and field); designing usable (responsive) resources and systems; statistical analysis of large datasets; health information technology; quality of care; electronic health records; veterans; primary care; patient safety; decision support; data exchange
9.  Factors associated with difficult electronic health record implementation in office practice 
Little is known about physicians' perception of the ease or difficulty of implementing electronic health records (EHR). This study identified factors related to the perceived difficulty of implementing EHR. 163 physicians completed surveys before and after the implementation of EHR in an externally funded pilot program in three Massachusetts communities. Ordinal hierarchical logistic regression was used to identify baseline factors that correlated with physicians' report of difficulty with EHR implementation. Compared with physicians with ownership stake in their practices, physician employees were less likely to describe EHR implementation as difficult (adjusted OR 0.5, 95% CI 0.3 to 1.0). Physicians who perceived their staff to be innovative were also less likely to view EHR implementation as difficult (adjusted OR 0.4, 95% CI 0.2 to 0.8). Physicians who own their practice may need more external support for EHR implementation than those who do not. Innovative clinical support staff may ease the EHR implementation process and contribute to its success.
doi:10.1136/amiajnl-2011-000689
PMCID: PMC3384124  PMID: 22249965
Data exchange; decision support; electronic health records; group practice; health information technology; implementation; ownership; patient safety; practice management; primary care; quality of care; veterans
10.  Randomized Controlled Trial of Health Maintenance Reminders Provided Directly to Patients Through an Electronic PHR 
BACKGROUND
Provider and patient reminders can be effective in increasing rates of preventive screenings and vaccinations. However, the effect of patient-directed electronic reminders is understudied.
OBJECTIVE
To determine whether providing reminders directly to patients via an electronic Personal Health Record (PHR) improved adherence to care recommendations.
DESIGN
We conducted a cluster randomized trial without blinding from 2005 to 2007 at 11 primary care practices in the Partners HealthCare system.
PARTICIPANTS
A total of 21,533 patients with access to a PHR were invited to the study, and 3,979 (18.5%) consented to enroll.
INTERVENTIONS
Patients in the intervention arm received health maintenance (HM) reminders via a secure PHR “eJournal,” which allowed them to review and update HM and family history information. Patients in the active control arm received access to an eJournal that allowed them to input and review information related to medications, allergies and diabetes management.
MAIN MEASURES
The primary outcome measure was adherence to guideline-based care recommendations.
KEY RESULTS
Intention-to-treat analysis showed that patients in the intervention arm were significantly more likely to receive mammography (48.6% vs 29.5%, p = 0.006) and influenza vaccinations (22.0% vs 14.0%, p = 0.018). No significant improvement was observed in rates of other screenings. Although Pap smear completion rates were higher in the intervention arm (41.0% vs 10.4%, p < 0.001), this finding was no longer significant after excluding women’s health clinics. Additional on-treatment analysis showed significant increases in mammography (p = 0.019) and influenza vaccination (p = 0.015) for intervention arm patients who opened an eJournal compared to control arm patients, but no differences for any measure among patients who did not open an eJournal.
CONCLUSIONS
Providing patients with HM reminders via a PHR may be effective in improving some elements of preventive care.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1859-6) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-011-1859-6
PMCID: PMC3250545  PMID: 21904945
health maintenance reminders; personal health record; preventive care; clinical decision support; Patient Gateway
11.  Development and preliminary evidence for the validity of an instrument assessing implementation of human-factors principles in medication-related decision-support systems—I-MeDeSA 
Background
Medication-related decision support can reduce the frequency of preventable adverse drug events. However, the design of current medication alerts often results in alert fatigue and high over-ride rates, thus reducing any potential benefits.
Methods
The authors previously reviewed human-factors principles for relevance to medication-related decision support alerts. In this study, instrument items were developed for assessing the appropriate implementation of these human-factors principles in drug–drug interaction (DDI) alerts. User feedback regarding nine electronic medical records was considered during the development process. Content validity, construct validity through correlation analysis, and inter-rater reliability were assessed.
Results
The final version of the instrument included 26 items associated with nine human-factors principles. Content validation on three systems resulted in the addition of one principle (Corrective Actions) to the instrument and the elimination of eight items. Additionally, the wording of eight items was altered. Correlation analysis suggests a direct relationship between system age and performance of DDI alerts (p=0.0016). Inter-rater reliability indicated substantial agreement between raters (κ=0.764).
Conclusion
The authors developed and gathered preliminary evidence for the validity of an instrument that measures the appropriate use of human-factors principles in the design and display of DDI alerts. Designers of DDI alerts may use the instrument to improve usability and increase user acceptance of medication alerts, and organizations selecting an electronic medical record may find the instrument helpful in meeting their clinicians' usability needs.
doi:10.1136/amiajnl-2011-000362
PMCID: PMC3241174  PMID: 21946241
Human factors; medication-related decision support; clinical decision support; medication alerts; name; visualization of data and knowledge; designing usable (responsive) resources and systems; developing/using clinical decision support (other than diagnostic) and guideline systems; human–computer interaction and human-centered computing; policy; health IT; innovation; patient safety; decision support; data exchange
12.  Physician Satisfaction Following Electronic Health Record Adoption in Three Massachusetts Communities 
Background
Despite mandates and incentives for electronic health record (EHR) adoption, little is known about factors predicting physicians’ satisfaction following EHR implementation.
Objective
To measure predictors of physician satisfaction following EHR adoption.
Methods
A total of 163 physicians completed a mailed survey before and after EHR implementation through a statewide pilot project in Massachusetts. Multivariable logistic regression identified predictors of physician satisfaction with their current practice situation in 2009 and generalized estimating equations accounted for clustering.
Results
The response rate was 77% in 2005 and 68% in 2009. In 2005, prior to EHR adoption, 28% of physicians were very satisfied with their current practice situation compared to 25% in 2009, following EHR adoption (P < .001). In multivariate analysis, physician satisfaction following EHR adoption was correlated with self-reported ease of EHR implementation (adjusted odds ratio [OR] = 5.7, 95% CI 2.1 - 16), resources for practice improvement (adjusted OR = 2.6, 95% CI 1.2 - 6.1), pre-intervention satisfaction (adjusted OR = 4.8, 95% CI 1.5 - 15), and stress (adjusted OR = 5.3, 95% CI 1.1 - 25). Male physicians reported lower satisfaction following EHR adoption (adjusted OR = 0.3, 95% CI 0.2 - 0.6).
Conclusions
Interventions to expand EHR use should consider additional support for practices with fewer resources for improvement and ensure ease of EHR implementation. EHR adoption may be a factor in alleviating physicians’ stress. Addressing physicians’ satisfaction prior to practice transformation and anticipating greater dissatisfaction among male physicians will be essential to retaining the physician workforce and ensuring the quality of care they deliver.
doi:10.2196/ijmr.2064
PMCID: PMC3626123  PMID: 23611987
electronic health record; physician satisfaction; implementation; Massachusetts eHealth collaborative
13.  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.
doi:10.1136/amiajnl-2010-000072
PMCID: PMC3197987  PMID: 21531703
Health information policy; decision support; machine learning; confidentiality; Patient Safety; decision support; data exchange; editorial Office; health data standards; vocabulary; ontology; scientific information and health data policy; consumer health/patient education information; information retrieval; NLP; public health informatics; clinical trials; health information exchange; health information technology; meaningful use; care coordination
14.  Self-reported familiarity with acute respiratory infection guidelines and antibiotic prescribing in primary care† 
Objective
Familiarity with guidelines is generally thought to be associated with guideline implementation, adherence and improved quality of care. We sought to determine if self-reported familiarity with acute respiratory infection (ARI) antibiotic treatment guidelines was associated with reduced or more appropriate antibiotic prescribing for ARIs in primary care.
Design, Setting, Participants and Main Outcome Measures
We surveyed primary care clinicians about their familiarity with ARI antibiotic treatment guidelines and linked responses to administrative diagnostic and prescribing data for non-pneumonia ARI visits.
Results
Sixty-five percent of clinicians responded to the survey question about guideline familiarity. There were 208 survey respondents who had ARI patient visits during the study period. Respondents reported being ‘not at all’ (7%), ‘somewhat’ (30%), ‘moderately’ (45%) or ‘extremely’ (18%) familiar with the guidelines. After dichotomizing responses, compared with clinicians who reported being less familiar with the guidelines, clinicians who reported being more familiar with the guidelines had higher rates of antibiotic prescribing for all ARIs combined (46% versus 38%; n = 11 164; P < 0.0001), for antibiotic-appropriate diagnoses (69% versus 59%; n = 3213; P < 0.0001) and for non-antibiotic appropriate diagnoses (38% versus 28%; n = 7951; P < 0.0001). After adjusting for potential confounders, self-reported guideline familiarity was an independent predictor of increased antibiotic prescribing (odds ratio, 1.36; 95% confidence interval, 1.25–1.48).
Conclusions
Self-reported familiarity with an ARI antibiotic treatment guideline was, seemingly paradoxically, associated with increased antibiotic prescribing. Self-reported familiarity with guidelines should not be assumed to be associated with consistent guideline adherence or higher quality of care.
doi:10.1093/intqhc/mzq052
PMCID: PMC3003551  PMID: 20935008
guideline adherence; respiratory tract infections; anti-bacterial agents; physicians’ practice patterns; primary health care
15.  Implementing practice-linked pre-visit electronic journals in primary care: patient and physician use and satisfaction 
Electronic health records (EHRs) and EHR-connected patient portals offer patient–provider collaboration tools for visit-based care. During a randomized controlled trial, primary care patients completed pre-visit electronic journals (eJournals) containing EHR-based medication, allergies, and diabetes (study arm 1) or health maintenance, personal history, and family history (study arm 2) topics to share with their provider. Assessment with surveys and usage data showed that among 2027 patients invited to complete an eJournal, 70.3% submitted one and 71.1% of submitters had one opened by their provider. Surveyed patients reported they felt more prepared for the visit (55.9%) and their provider had more accurate information about them (58.0%). More arm 1 versus arm 2 providers reported that eJournals were visit-time neutral (100% vs 53%; p<0.013), helpful to patients in visit preparation (66% vs 20%; p=0.082), and would recommend them to colleagues (78% vs 22%; p=0.0143). eJournal integration into practice warrants further study.
doi:10.1136/jamia.2009.001362
PMCID: PMC2995665  PMID: 20819852
16.  Physician attitudes toward health information exchange: results of a statewide survey 
Objective
To assess physicians' attitudes toward health information exchange (HIE) and physicians' willingness to pay to participate in HIE.
Design
We conducted a cross-sectional mail survey of 1296 licensed physicians (77% response rate) in Massachusetts in 2007.
Measurements
Perceptions of the potential effects of HIE on healthcare costs, quality of care, clinicians' time, patients' privacy concerns, and willingness to pay for HIE.
Results
After excluding 253 physicians who did not see any outpatients, we analyzed 1043 responses. Overall, 70% indicated that HIE would reduce costs, while 86% said it would improve quality and 76% believed that it would save time. On the other hand, 16% reported being very concerned about HIE's effect on privacy, while 55.0% were somewhat concerned and 29% not at all concerned. Slightly more than half of the physicians (54%) said they would be willing to pay an unspecified monthly fee to participate in HIE, but only 37% said they would be willing to pay $150 per month for it. Primary care physicians and those in larger practices tended to have more positive attitudes toward HIE.
Conclusions
Physicians perceive that HIE will have generally positive effects, though a considerable fraction harbor concerns about privacy. While physicians may be willing to participate in HIE, they are not consistently willing to pay to participate. HIE business models that require substantial physician subscription fees may face significant challenges.
doi:10.1197/jamia.M3241
PMCID: PMC2995629  PMID: 20064804
17.  Physicians' Use of Key Functions in Electronic Health Records from 2005 to 2007: A Statewide Survey 
Objective
Electronic health records (EHRs) have potential to improve quality and safety, but many physicians do not use these systems to full capacity. The objective of this study was to determine whether this usage gap is narrowing over time.
Design
Follow-up mail survey of 1,144 physicians in Massachusetts who completed a 2005 survey.
Measurements
Adoption of EHRs and availability and use of 10 EHR functions.
Results
The response rate was 79.4%. In 2007, 35% of practices had EHRs, up from 23% in 2005. Among practices with EHRs, there was little change between 2005 and 2007 in the availability of nine of ten EHR features; the notable exception was electronic prescribing, reported as available in 44.7% of practices with EHRs in 2005 and 70.8% in 2007. Use of EHR functions changed inconsequentially, with more than one out of five physicians not using each available function regularly in both 2005 and 2007. Only electronic prescribing increased substantially: in 2005, 19.9% of physicians with this function available used it most or all the time, compared with 42.6% in 2007 (p < 0.001).
Conclusions
By 2007, more than one third of practices in Massachusetts reported having EHRs; the availability and use of electronic prescribing within these systems has increased. In contrast, physicians reported little change in the availability and use of other EHR functions. System refinements, certification efforts, and health policies, including standards development, should address the gaps in both EHR adoption and the use of key functions.
doi:10.1197/jamia.M3081
PMCID: PMC2705248  PMID: 19390104
18.  The Relationship between Electronic Health Record Use and Quality of Care over Time 
Objective
Electronic health records (EHRs) have the potential to advance the quality of care, but studies have shown mixed results. The authors sought to examine the extent of EHR usage and how the quality of care delivered in ambulatory care practices varied according to duration of EHR availability.
Methods
The study linked two data sources: a statewide survey of physicians' adoption and use of EHR and claims data reflecting quality of care as indicated by physicians' performance on widely used quality measures. Using four years of measurement, we combined 18 quality measures into 6 clinical condition categories. While the survey of physicians was cross-sectional, respondents indicated the year in which they adopted EHR. In an analysis accounting for duration of EHR use, we examined the relationship between EHR adoption and quality of care.
Results
The percent of physicians reporting adoption of EHR and availability of EHR core functions more than doubled between 2000 and 2005. Among EHR users in 2005, the average duration of EHR use was 4.8 years. For all 6 clinical conditions, there was no difference in performance between EHR users and non-users. In addition, for these 6 clinical conditions, there was no consistent pattern between length of time using an EHR and physicians performance on quality measures in both bivariate and multivariate analyses.
Conclusions
In this cross-sectional study, we found no association between duration of using an EHR and performance with respect to quality of care, although power was limited. Intensifying the use of key EHR features, such as clinical decision support, may be needed to realize quality improvement from EHRs. Future studies should examine the relationship between the extent to which physicians use key EHR functions and their performance on quality measures over time.
doi:10.1197/jamia.M3128
PMCID: PMC2705247  PMID: 19390094
19.  Physician Opinions of the Importance, Accessibility, and Quality of Health Information and Their Use of the Information 
This study compared physicians’ perceptions of the importance, accessibility, and quality of different types of patient information that could potentially be available with Health Information Exchange (HIE) with how they use patient information. The results showed that while the physicians rated the majority of 11 data types as very important, accessible, and of high quality, they regularly used only a few data types before having access to a new HIE system. The three major types of information regularly used by the physicians were diagnoses, current medication lists, and allergy information. This study provides new data about how opinions on the importance of information relate to reported information use. Our findings suggest that having important, accessible, and high quality information does not necessarily lead to routine use, but that much of the early value of HIE may lie in improving access to a few data areas.
PMCID: PMC3041432  PMID: 21346938
20.  Survey Analysis of Patient Experience using a Practice-Linked PHR for Type 2 Diabetes Mellitus 
Patient experience was assessed by survey as part of a large, randomized controlled trial of a secure, practice-linked personal health record called Patient Gateway at Partners HealthCare in Boston, MA. The subjects were patients with Type 2 diabetes who prepared for their upcoming primary care visit using a previsit electronic journal. The journal generated a diabetes care plan using patient chart information and patient responses to questions in preparation for a scheduled office visit. Review of 37 surveys revealed that a diabetes care plan took 5–9 minutes (modal) to be created by the patient and helped many patients to feel more prepared for their visit (60%) and give more accurate information to their provider (53%). Study limitations included small numbers of survey participants and a bias toward white, better educated patients with better controlled diabetes. Nevertheless, the electronic journal is a promising tool for visit preparation and process improvement.
PMCID: PMC2815456  PMID: 20351940
21.  Electronic Health Records in Specialty Care: A Time-Motion Study 
Background
Electronic health records (EHRs) have great potential to improve safety, quality, and efficiency in medicine. However, adoption has been slow, and a key concern has been that clinicians will require more time to complete their work using EHRs. Most previous studies addressing this issue have been done in primary care.
Objective
To assess the impact of using an EHR on specialists’ time.
Design
Prospective, before-after trial of the impact of an EHR on attending physician time in four specialty clinics at an integrated delivery system: cardiology, dermatology, endocrine, and pain.
Measurements
We used a time-motion method to measure physician time spent in one of 85 designated activities.
Results
Attending physicians were monitored before and after the switch from paper records to a web-based ambulatory EHR. Across all specialties, 15 physicians were observed treating 157 patients while still using paper-based records, and 15 physicians were observed treating 146 patients after adoption. Following EHR implementation, the average adjusted total time spent per patient across all specialties increased slightly but not significantly (Δ = 0.94 min., p = 0.83) from 28.8 (SE = 3.6) to 29.8 (SE = 3.6) min.
Conclusion
These data suggest that implementation of an EHR had little effect on overall visit time in specialty clinics.
doi:10.1197/jamia.M2318
PMCID: PMC1975804  PMID: 17600102
22.  Correlates of Electronic Health Record Adoption in Office Practices: A Statewide Survey 
Objective
Despite emerging evidence that electronic health records (EHRs) can improve the efficiency and quality of medical care, most physicians in office practice in the United States do not currently use an EHR. We sought to measure the correlates of EHR adoption.
Design
Mailed survey to a stratified random sample of all medical practices in Massachusetts in 2005, with one physician per practice randomly selected for survey.
Measurements
EHR adoption rates.
Results
The response rate was 71% (1345/1884). Overall, while 45% of physicians were using an EHR, EHRs were present in only 23% of practices. In multivariate analysis, practice size was strongly correlated with EHR adoption; 52% of practices with 7 or more physicians had an EHR, as compared with 14% of solo practices (adjusted odds ratio, 3.66; 95% confidence interval, 2.28–5.87). Hospital-based practices (adjusted odds ratio, 2.44; 95% confidence interval, 1.53–3.91) and practices that teach medical students or residents (adjusted odds ratio, 2.30; 95% confidence interval, 1.60–3.31) were more likely to have an EHR. The most frequently cited barriers to adoption were start-up financial costs (84%), ongoing financial costs (82%), and loss of productivity (81%).
Conclusions
While almost half of physicians in Massachusetts are using an EHR, fewer than one in four practices in Massachusetts have adopted EHRs. Adoption rates are lower in smaller practices, those not affiliated with hospitals, and those that do not teach medical students or residents. Interventions to expand EHR use must address both financial and non-financial barriers, especially among smaller practices.
doi:10.1197/jamia.M2187
PMCID: PMC2215070  PMID: 17068351
23.  Clinical Decision Support to Improve Antibiotic Prescribing for Acute Respiratory Infections: Results of a Pilot Study 
Acute Respiratory Infections (ARIs) are the number one reason for antibiotic prescribing in the United States, and much antibiotic prescribing for ARIs is inappropriate. We designed an electronic health record-integrated, documentation-based clinical decision support system for the care of patients with ARIs, the ARI Smart Form. To evaluate the ARI Smart Form and assess the feasibility of performing a larger trial, we conducted a pilot study with 10 clinicians who used the ARI Smart Form with 26 patients. Clinicians prescribed antibiotics to 6 of 6 patients with antibiotic-appropriate diagnoses and to 3 of 20 (15%) patients with antibiotic-inappropriate diagnoses. The average duration of use of the ARI Smart Form was 7.5 (SD±4.5) minutes. Eight of 10 respondents reported that the ARI Smart Form was either time-neutral or timesaving. The ARI Smart Form requires further evaluation but has the potential to improve workflow and reduce inappropriate antibiotic prescribing.
PMCID: PMC2655801  PMID: 18693880

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