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1.  Improving the Effectiveness of Electronic Health Record-Based Referral Processes 
Electronic health records are increasingly being used to facilitate referral communication in the outpatient setting. However, despite support by technology, referral communication between primary care providers and specialists is often unsatisfactory and is unable to eliminate care delays. This may be in part due to lack of attention to how information and communication technology fits within the social environment of health care. Making electronic referral communication effective requires a multifaceted “socio-technical” approach. Using an 8-dimensional socio-technical model for health information technology as a framework, we describe ten recommendations that represent good clinical practices to design, develop, implement, improve, and monitor electronic referral communication in the outpatient setting. These recommendations were developed on the basis of our previous work, current literature, sound clinical practice, and a systems-based approach to understanding and implementing health information technology solutions. Recommendations are relevant to system designers, practicing clinicians, and other stakeholders considering use of electronic health records to support referral communication.
doi:10.1186/1472-6947-12-107
PMCID: PMC3492108  PMID: 22973874
2.  Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study 
Background
The purpose of this study was to identify recommended practices for computerized clinical decision support (CDS) development and implementation and for knowledge management (KM) processes in ambulatory clinics and community hospitals using commercial or locally developed systems in the U.S.
Methods
Guided by the Multiple Perspectives Framework, the authors conducted ethnographic field studies at two community hospitals and five ambulatory clinic organizations across the U.S. Using a Rapid Assessment Process, a multidisciplinary research team: gathered preliminary assessment data; conducted on-site interviews, observations, and field surveys; analyzed data using both template and grounded methods; and developed universal themes. A panel of experts produced recommended practices.
Results
The team identified ten themes related to CDS and KM. These include: 1) workflow; 2) knowledge management; 3) data as a foundation for CDS; 4) user computer interaction; 5) measurement and metrics; 6) governance; 7) translation for collaboration; 8) the meaning of CDS; 9) roles of special, essential people; and 10) communication, training, and support. Experts developed recommendations about each theme. The original Multiple Perspectives framework was modified to make explicit a new theoretical construct, that of Translational Interaction.
Conclusions
These ten themes represent areas that need attention if a clinic or community hospital plans to implement and successfully utilize CDS. In addition, they have implications for workforce education, research, and national-level policy development. The Translational Interaction construct could guide future applied informatics research endeavors.
doi:10.1186/1472-6947-12-6
PMCID: PMC3334687  PMID: 22333210
3.  Prescriber and staff perceptions of an electronic prescribing system in primary care: a qualitative assessment 
Background
The United States (US) Health Information Technology for Economic and Clinical Health Act of 2009 has spurred adoption of electronic health records. The corresponding meaningful use criteria proposed by the Centers for Medicare and Medicaid Services mandates use of computerized provider order entry (CPOE) systems. Yet, adoption in the US and other Western countries is low and descriptions of successful implementations are primarily from the inpatient setting; less frequently the ambulatory setting. We describe prescriber and staff perceptions of implementation of a CPOE system for medications (electronic- or e-prescribing system) in the ambulatory setting.
Methods
Using a cross-sectional study design, we conducted eight focus groups at three primary care sites in an independent medical group. Each site represented a unique stage of e-prescribing implementation - pre/transition/post. We used a theoretically based, semi-structured questionnaire to elicit physician (n = 17) and staff (n = 53) perceptions of implementation of the e-prescribing system. We conducted a thematic analysis of focus group discussions using formal qualitative analytic techniques (i.e. deductive framework and grounded theory). Two coders independently coded to theoretical saturation and resolved discrepancies through discussions.
Results
Ten themes emerged that describe perceptions of e-prescribing implementation: 1) improved availability of clinical information resulted in prescribing efficiencies and more coordinated care; 2) improved documentation resulted in safer care; 3) efficiencies were gained by using fewer paper charts; 4) organizational support facilitated adoption; 5) transition required time; resulted in workload shift to staff; 6) hardware configurations and network stability were important in facilitating workflow; 7) e-prescribing was time-neutral or time-saving; 8) changes in patient interactions enhanced patient care but required education; 9) pharmacy communications were enhanced but required education; 10) positive attitudes facilitated adoption.
Conclusions
Prescribers and staff worked through the transition to successfully adopt e-prescribing, and noted the benefits. Overall impressions were favorable. No one wished to return to paper-based prescribing.
doi:10.1186/1472-6947-10-72
PMCID: PMC2996338  PMID: 21087524
4.  Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication 
Background
Early detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positive FOBT results eligible for colonoscopy had no documented response by a treating clinician at two weeks despite procedures for electronic result notification. We determined if technical and/or workflow-related aspects of automated communication in the electronic health record could lead to the lack of response.
Methods
Using both qualitative and quantitative methods, we evaluated positive FOBT communication in the electronic health record of a large, urban facility between May 2008 and March 2009. We identified the source of test result communication breakdown, and developed an intervention to fix the problem. Explicit medical record reviews measured timely follow-up (defined as response within 30 days of positive FOBT) pre- and post-intervention.
Results
Data from 11 interviews and tracking information from 490 FOBT alerts revealed that the software intended to alert primary care practitioners (PCPs) of positive FOBT results was not configured correctly and over a third of positive FOBTs were not transmitted to PCPs. Upon correction of the technical problem, lack of timely follow-up decreased immediately from 29.9% to 5.4% (p < 0.01) and was sustained at month 4 following the intervention.
Conclusion
Electronic communication of positive FOBT results should be monitored to avoid limiting colorectal cancer screening benefits. Robust quality assurance and oversight systems are needed to achieve this. Our methods may be useful for others seeking to improve follow-up of FOBTs in their systems.
doi:10.1186/1472-6947-9-49
PMCID: PMC2797509  PMID: 20003236
5.  A survey of factors affecting clinician acceptance of clinical decision support 
Background
Real-time clinical decision support (CDS) integrated into clinicians' workflow has the potential to profoundly affect the cost, quality, and safety of health care delivery. Recent reports have identified a surprisingly low acceptance rate for different types of CDS. We hypothesized that factors affecting CDS system acceptance could be categorized as relating to differences in patients, physicians, CDS-type, or environmental characteristics.
Methods
We conducted a survey of all adult primary care physicians (PCPs, n = 225) within our group model Health Maintenance Organization (HMO) to identify factors that affect their acceptance of CDS. We defined clinical decision support broadly as "clinical information" that is either provided to you or accessible by you, from the clinical workstation (e.g., enhanced flow sheet displays, health maintenance reminders, alternative medication suggestions, order sets, alerts, and access to any internet-based information resources).
Results
110 surveys were returned (49%). There were no differences in the age, gender, or years of service between those who returned the survey and the entire adult PCP population. Overall, clinicians stated that the CDS provided "helps them take better care of their patients" (3.6 on scale of 1:Never – 5:Always), "is worth the time it takes" (3.5), and "reminds them of something they've forgotten" (3.2). There was no difference in the perceived acceptance rate of alerts based on their type (i.e., cost, safety, health maintenance). When asked about specific patient characteristics that would make the clinicians "more", "equally" or "less" likely to accept alerts: 41% stated that they were more (8% stated "less") likely to accept alerts on elderly patients (> 65 yrs); 38% were more (14% stated less) likely to accept alerts on patients with more than 5 current medications; and 38% were more (20% stated less) likely to accept alerts on patients with more than 5 chronic clinical conditions. Interestingly, 80% said they were less likely to accept alerts when they were behind schedule and 84% of clinicians admitted to being at least 20 minutes behind schedule "some", "most", or "all of the time".
Conclusion
Even though a majority of our clinical decision support suggestions are not explicitly followed, clinicians feel they are of benefit and would be even more beneficial if they had more time available to address them.
doi:10.1186/1472-6947-6-6
PMCID: PMC1403751  PMID: 16451720
6.  A draft framework for measuring progress towards the development of a national health information infrastructure 
Background
American public policy makers recently established the goal of providing the majority of Americans with electronic health records by 2014. This will require a National Health Information Infrastructure (NHII) that is far more complete than the one that is currently in its formative stage of development. We describe a conceptual framework to help measure progress toward that goal.
Discussion
The NHII comprises a set of clusters, such as Regional Health Information Organizations (RHIOs), which, in turn, are composed of smaller clusters and nodes such as private physician practices, individual hospitals, and large academic medical centers. We assess progress in terms of the availability and use of information and communications technology and the resulting effectiveness of these implementations. These three attributes can be studied in a phased approach because the system must be available before it can be used, and it must be used to have an effect. As the NHII expands, it can become a tool for evaluating itself.
Summary
The NHII has the potential to transform health care in America – improving health care quality, reducing health care costs, preventing medical errors, improving administrative efficiencies, reducing paperwork, and increasing access to affordable health care. While the President has set an ambitious goal of assuring that most Americans have electronic health records within the next 10 years, a significant question remains "How will we know if we are making progress toward that goal?" Using the definitions for "nodes" and "clusters" developed in this article along with the resulting measurement framework, we believe that we can begin a discussion that will enable us to define and then begin making the kinds of measurements necessary to answer this important question.
doi:10.1186/1472-6947-5-14
PMCID: PMC1177954  PMID: 15953388
7.  Results of a content analysis of electronic messages (email) sent between patients and their physicians 
Background
Email is the most important mechanism introduced since the telephone for developing interpersonal relationships. This study was designed to provide insight into how patients are using email to request information or services from their healthcare providers.
Methods
Following IRB approval, we reviewed all electronic mail (e-mail) messages sent between five study clinicians and their patients over a one-month period. We used a previously described taxonomy of patient requests to categorize all patient requests contained in the messages. We measured message volume, frequency, length and response time for all messages sent to and received by these clinicians.
Results
On average the 5 physicians involved in this study received 40 messages per month, each containing approximately 139 words. Replies sent by the physicians contained 39 words on average and 59.4% of them were sent within 24 hours. Patients averaged 1 request per message. Requests for information on medications or treatments, specific symptoms or diseases, and requests for actions regarding medications or treatments accounted for 75% of all requests. Physicians fulfilled 80.2% of all these requests. Upon comparison of these data to that obtained from traditional office visits, it appears that the potential exists for email encounters to substitute for some percentage of office visits.
Conclusion
Electronic messaging is an important method for physicians and patients to communicate and further develop their relationship. While many physicians worry that either the number or length of messages from their patients will overwhelm them, there is no evidence to support this. In fact, the evidence suggests that many patient requests, formerly made over the telephone or during office visits, can be addressed via email thus potentially saving both patients and physicians time.
doi:10.1186/1472-6947-3-11
PMCID: PMC270029  PMID: 14519206

Results 1-7 (7)