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1.  Electronic Health Records and Ambulatory Quality of Care 
ABSTRACT
CONTEXT
The US Federal Government is investing up to $29 billion in incentives for meaningful use of electronic health records (EHRs). However, the effect of EHRs on ambulatory quality is unclear, with several large studies finding no effect.
OBJECTIVE
To determine the effect of EHRs on ambulatory quality in a community-based setting.
DESIGN
Cross-sectional study, using data from 2008.
SETTING
Ambulatory practices in the Hudson Valley of New York, with a median practice size of four physicians.
PARTICIPANTS
We included all general internists, pediatricians and family medicine physicians who: were members of the Taconic Independent Practice Association, had patients in a data set of claims aggregated across five health plans, and had at least 30 patients per measure for at least one of nine quality measures selected by the health plans.
IINTERVENTION
Adoption of an EHR.
MAIN OUTCOME MEASURES
We compared physicians using EHRs to physicians using paper on performance for each of the nine quality measures, using t-tests. We also created a composite quality score by standardizing performance against a national benchmark and averaging standardized performance across measures. We used generalized estimation equations, adjusting for nine physician characteristics.
KEY RESULTS
We included 466 physicians and 74,618 unique patients. Of the physicians, 204 (44 %) had adopted EHRs and 262 (56 %) were using paper. Electronic health record use was associated with significantly higher quality of care for four of the measures: hemoglobin A1c testing in diabetes, breast cancer screening, chlamydia screening, and colorectal cancer screening. Effect sizes ranged from 3 to 13 percentage points per measure. When all nine measures were combined into a composite, EHR use was associated with higher quality of care (sd 0.4, p = 0.008).
CONCLUSIONS
This is one of the first studies to find a positive association between EHRs and ambulatory quality in a community-based setting.
doi:10.1007/s11606-012-2237-8
PMCID: PMC3599037  PMID: 23054927
electronic health records; primary health care; quality of health care
2.  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
3.  Prevalence, persistence, and microbiology of Staphylococcus aureus nasal carriage among hemodialysis outpatients at a major New York Hospital☆,☆☆ 
The study aimed to determine the natural history of Staphylococcus aureus nasal colonization in hemodialysis outpatients. Surveillance cultures were taken from patients presenting for hemodialysis or routine care to identify S. aureus nasal carriers. A prospective cohort study was performed to identify risks for persistent colonization. Detailed microbiologic and molecular studies of colonizing isolates were performed. Only 23/145 (15.9%) dialysis patients were persistently colonized, and only HIV-positive status was associated with persistence (P = 0.05). Prior hospitalization was the only risk factor for methicillin-resistant S. aureus carriage (OR 2.5, P = 0.03). In isolates from patients with ≤42 days of vancomycin exposure, vancomycin minimum bactericidal concentrations (MBCs) increased with duration of exposure. Among dialysis patients, S. aureus colonization was limited and transient; only HIV status was associated with persistence. Nevertheless, duration of vancomycin exposure was associated with increasing vancomycin MBCs. Vancomycin exposure in S. aureus carriers may be involved in increasing resistance.
doi:10.1016/j.diagmicrobio.2010.12.005
PMCID: PMC3534839  PMID: 21334154
Staphylococcus aureus; Hemodialysis; Colonization; Vancomycin
4.  Use of an Electronic Patient Portal Among Disadvantaged Populations 
Journal of General Internal Medicine  2011;26(10):1117-1123.
BACKGROUND
Electronic patient portals give patients access to information from their electronic health record and the ability to message their providers. These tools are becoming more widely used and are expected to promote patient engagement with health care.
OBJECTIVE
To quantify portal usage and explore potential differences in adoption and use according to patients' socioeconomic and clinical characteristics in a network of federally qualified health centers serving New York City and neighboring counties.
DESIGN
Retrospective analysis of data from portal and electronic health records.
PARTICIPANTS
74,368 adult patients seen between April 2008 and April 2010.
MAIN MEASURES
Odds of receiving an access code to the portal, activating the account, and using the portal more than once
KEY RESULTS
Over the 2 years of the study, 16% of patients (n = 11,903) received an access code. Of these, 60% (n = 7138) activated the account, and 49% (n = 5791) used the account two or more times. Patients with chronic conditions were more likely to receive an access code and to become repeat users. In addition, the odds of receiving an access code were significantly higher for whites, women, younger patients, English speakers, and the insured. The odds of repeat portal use, among those with activated accounts, increased with white race, English language, and private insurance or Medicaid compared to no insurance. Racial disparities were small but persisted in models that controlled for language, insurance, and health status.
CONCLUSIONS
We found good early rates of adoption and use of an electronic patient portal during the first 2 years of its deployment among a predominantly low-income population, especially among patients with chronic diseases. Disparities in access to and usage of the portal were evident but were smaller than those reported recently in other populations. Continued efforts will be needed to ensure that portals are usable for and used by disadvantaged groups so that all patients benefit equally from these technologies.
doi:10.1007/s11606-011-1749-y
PMCID: PMC3181304  PMID: 21647748
personal health record; health information technology; health disparities; chronic illness; insurance status
5.  Healthcare Consumers’ Attitudes Towards Physician and Personal Use of Health Information Exchange 
Journal of General Internal Medicine  2011;26(9):1019-1026.
BACKGROUND
Health information exchange (HIE), the electronic transmission of patient medical information across healthcare institutions, is on the forefront of the national agenda for healthcare reform. As healthcare consumers are critical participants in HIE, understanding their attitudes toward HIE is essential.
OBJECTIVE
To determine healthcare consumers’ attitudes toward physician and personal use of HIE, and factors associated with their attitudes.
DESIGN
Cross-sectional telephone survey.
PARTICIPANTS
English-speaking residents of the Hudson Valley of New York.
MAIN MEASURE
Consumer reported attitudes towards HIE.
KEY RESULTS
Of 199 eligible residents contacted, 170 (85%) completed the survey: 67% supported physician HIE use and 58% reported interest in using HIE themselves. Multivariate analysis suggested supporters of physician HIE were more likely to be caregivers for chronically ill individuals (OR 4.6, 95% CI 1.06, 19.6), earn more than $100,000 yearly (OR 3.5, 95% CI 1.2, 10.0), and believe physician HIE would improve the privacy and security of their medical records (OR 2.9, 95% CI 1.05, 7.9). Respondents interested in using personal HIE were less likely to be female (OR 0.4, 95% CI 0.1, 0.98), and more likely to be frequent Internet-users (OR 3.3, 95% CI 1.03, 10.6), feel communication among their physicians was inadequate (OR 6.7, 95% CI 1.7, 25.3), and believe personal HIE use would improve communication with their physicians (OR 4.7, 95% CI 1.7, 12.8).
CONCLUSIONS
Consumer outreach to gain further support for ongoing personal and physician HIE efforts is needed and should address consumer security concerns and potential disparities in HIE acceptance and use.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1733-6) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-011-1733-6
PMCID: PMC3157531  PMID: 21584839
consumers; health information exchange; personal health records; medical informatics; survey research
6.  Antiretroviral Therapies Associated with Lipoatrophy in HIV-Infected Women 
AIDS patient care and STDs  2007;21(5):297-305.
We previously demonstrated that HIV infection is associated with peripheral and central lipoatrophy in women. We now describe the association of specific antiretroviral drugs (ARV) with body fat changes over a four-year period from 1999 to 2003. 775 HIV-positive and 205 HIV-negative women in the Women’s Interagency HIV Study with anthropometric measurements, weight, bioelectric impedance analysis and ARV collected semiannually were included in analysis. Exposure to ARV was defined as report of use for 3 consecutive semiannual study visits. The average 6–month change in weight, percent total body fat, and circumference measurements (i.e., hip, waist, chest, arm, and thigh) was compared between those exposed and those unexposed to the specific ARV for any of the same three consecutive visits. Weight, percent total body fat, and hip, waist, thigh, chest, and arm circumferences decreased in HIV-positive women, but increased in HIV-negative women on average for every six-month interval over the 4-year study period. Among the HIV-positive women, didanosine was the only ARV associated with decreases in circumference measures in the hip (−0.65 cm, 95% confidence interval [CI]: −1.18, −0.12), waist (−0.71 cm, 95% CI: −1.37, −0.04), chest (−0.71 cm, 95% CI: −1.17, −0.26), and arm (−0.23 cm, 95% CI: −0.48, 0.03; p = 0.08). These prospective data suggest that fat loss continues to predominate in HIV-positive women and exposure to didanosine for at least 12 months may further worsen fat loss.
doi:10.1089/apc.2006.128
PMCID: PMC3133726  PMID: 17518522
7.  Increased Circulating Interleukin-7 Levels in HIV-1–Infected Women 
Summary
Sex-based differences in CD4 T-cell (CD4) counts are well recognized, but the basis for these differences has not been identified. Conceivably, homeostatic factors may play a role in this process by regulating T-cell maintenance and repletion. Interleukin (IL)-7 is essential for normal T-cell production and homeostasis. We hypothesized that differences in IL-7 might contribute to sex-based differences in CD4 counts. Circulating IL-7 levels were analyzed in 299 HIV-1–infected women and men. Regression analysis estimated that IL-7 levels were 40% higher in women than in men (P = 0.0032) after controlling for CD4 count, age, and race. Given the important role of IL-7 in T-cell development and homeostasis, these findings suggest that higher IL-7 levels may contribute to higher CD4 counts in women.
PMCID: PMC3119025  PMID: 16284535
interleukin-7; sexual dimorphism; CD4-positive T cells; cytokines; sex differences
8.  Electronic Prescribing Improves Medication Safety in Community-Based Office Practices 
BACKGROUND
Although electronic prescribing (e-prescribing) holds promise for preventing prescription errors in the ambulatory setting, research on its effectiveness is inconclusive.
OBJECTIVE
To assess the impact of a stand-alone e-prescribing system on the rates and types of ambulatory prescribing errors.
DESIGN, PARTICIPANTS
Prospective, non-randomized study using pre-post design of 15 providers who adopted e-prescribing with concurrent controls of 15 paper-based providers from September 2005 through June 2007.
INTERVENTION
Use of a commercial, stand-alone e-prescribing system with clinical decision support including dosing recommendations and checks for drug-allergy interactions, drug-drug interactions, and duplicate therapies.
MAIN MEASURES
Prescribing errors were identified by a standardized prescription and chart review.
KEY RESULTS
We analyzed 3684 paper-based prescriptions at baseline and 3848 paper-based and electronic prescriptions at one year of follow-up. For e-prescribing adopters, error rates decreased nearly sevenfold, from 42.5 per 100 prescriptions (95% confidence interval (CI), 36.7–49.3) at baseline to 6.6 per 100 prescriptions (95% CI, 5.1–8.3) one year after adoption (p < 0.001). For non-adopters, error rates remained high at 37.3 per 100 prescriptions (95% CI, 27.6–50.2) at baseline and 38.4 per 100 prescriptions (95% CI, 27.4–53.9) at one year (p = 0.54). At one year, the error rate for e-prescribing adopters was significantly lower than for non-adopters (p < 0.001). Illegibility errors were very high at baseline and were completely eliminated by e-prescribing (87.6 per 100 prescriptions at baseline for e-prescribing adopters, 0 at one year).
CONCLUSIONS
Prescribing errors may occur much more frequently in community-based practices than previously reported. Our preliminary findings suggest that stand-alone e-prescribing with clinical decision support may significantly improve ambulatory medication safety.
TRIAL REGISTRATION
ClinicalTrials.gov, Taconic Health Information Network and Community (THINC), NCT00225563, http://clinicaltrials.gov/ct2/show/NCT00225563?term=Kaushal&rank=6.
doi:10.1007/s11606-009-1238-8
PMCID: PMC2869410  PMID: 20186499
electronic prescribing; ambulatory; medication safety
9.  Physicians’ Attitudes Towards Copy and Pasting in Electronic Note Writing 
BACKGROUND
The ability to copy and paste text within computerized physician documentation facilitates electronic note writing, but may affect the quality of physician notes and patient care. Little is known about physicians’ collective experience with the copy and paste function (CPF).
OBJECTIVES
To determine physicians’ CPF use, perceptions of its impact on notes and patient care, and opinions regarding its future use.
DESIGN
Cross-sectional survey.
PARTICIPANTS
Resident and faculty physicians within two affiliated academic medical centers currently using a computerized documentation system.
MEASUREMENTS
Responses on a self-administered survey.
RESULTS
A total of 315 (70%) of 451 eligible physicians responded to the survey. Of the 253 (80%) physicians who wrote inpatient notes electronically, 226 (90%) used CPF, and 177 (70%) used it almost always or most of the time when writing daily progress notes. While noting that inconsistencies (71%) and outdated information (71%) were more common in notes containing copy and pasted text, few physicians felt that CPF had a negative impact on patient documentation (19%) or led to mistakes in patient care (24%). The majority of physicians (80%) wanted to continue to use CPF.
CONCLUSIONS
Although recognizing deficits in notes written using CPF, the majority of physicians used CPF to write notes and did not perceive an overall negative impact on physician documentation or patient care. Further studies of the effects of electronic note writing on the quality and safety of patient care are required.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-008-0843-2) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-008-0843-2
PMCID: PMC2607489  PMID: 18998191
medical records system, computerized; documentation/mt [methods]; attitude of health personnel; medical staff, hospital; user-computer interface
10.  Electronic Result Viewing and Quality of Care in Small Group Practices 
Background
There is a paucity of data on the effectiveness of commercially available electronic systems for improving health care in office practices, where the majority of health care is delivered. In particular, the effect of electronic laboratory result viewing on quality of care, including preventive care, chronic disease management, and patient satisfaction, is unclear.
Objective
To determine whether electronic laboratory result viewing is associated with higher ambulatory care quality.
Methods
We conducted a cross-sectional study of primary care physicians (PCPs) in the Taconic IPA in New York, all of whom have the opportunity to use a free-standing electronic portal for laboratory result viewing. We analyzed 15 quality measures, reflecting preventive care, chronic disease management, and patient satisfaction, which were collected in 2005. Using generalized estimating equations, we determined associations between portal usage and quality, adjusting for adoption of electronic health records and 10 other physician characteristics, including case mix.
Main Results
One-third of physicians (54/168, 32%) used the portal at least once over a 6-month period. Use of the portal was associated with higher quality overall (adjusted odds ratio [OR] 1.25; 95% confidence interval [CI] 1.003, 1.57). In stratified analyses, portal usage was associated with higher quality on those performance measures expected to be impacted by result viewing (adjusted OR 1.34; 95% CI 1.00, 1.81; p = 0.05), but not associated with quality for measures not expected to be impacted by result viewing (adjusted OR 1.03; 95% CI 0.72, 1.48; p = 0.85).
Conclusion
Electronic laboratory result viewing was independently associated with higher ambulatory care quality. Longitudinal studies are needed to confirm this association.
doi:10.1007/s11606-007-0448-1
PMCID: PMC2359519  PMID: 18373137
health information technology; health information exchange; quality of health care; laboratory results
11.  Clinical Manifestations Associated with HTLV Type I Infection: A Cross-Sectional Study 
Human T-lymphotropic virus type I (HTLV-I) causes HTLV-I-associated myelopathy/tropical spastic paraparesis and adult T cell leukemia in a small percentage of infected individuals. HTLV-I infection is increasingly associated with clinical manifestations. To determine the prevalence of clinical manifestations in HTLV-I infected individuals, we conducted a cross-sectional study of 115 HTLV-I-infected blood donors without myelopathy and 115 age- and sex-matched seronegative controls. Subjects answered a standardized questionnaire and underwent physical examination. Compared with controls, HTLV-I-infected subjects were more likely to report arm or leg weakness (OR = 3.8, 95% CI: 1.4–10.2; OR = 4.0, 95% CI: 1.6–9.8, respectively), hand or foot numbness (OR = 2.1, 95% CI: 1.1–3.9; OR = 4.8, 95% CI: 2.0–11.7, respectively), arthralgia (OR = 3.3, 95% CI: 1.7–6.4), nocturia (OR = 2.7, 95% CI: 1.04–6.8), erectile dysfunction (OR = 4.0, 95% CI: 1.6–9.8), and to have gingivitis (OR = 3.8, 95% CI: 1.8–7.9), periodontitis (OR = 10.0, 95% CI: 2.3–42.8), and dry oral mucosa (OR = 7.5, 95% CI: 1.7–32.8). HTLV-I infection is associated with a variety of clinical manifestations, which may occur in patients who have not developed myelopathy.
doi:10.1089/aid.2006.0140
PMCID: PMC2593454  PMID: 17411369

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