Person: Bates, David
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Bates, David
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Publication Readiness for electronic health records: comparison of characteristics of practices in a collaborative with the remainder of Massachusetts(BCS Learning and Development Limited, 2008-07-01) Simon, Steven; Bates, David; Kaushal, Rainu; Jenter, Chelsea; Volk, Lynn; Burdick, Elisabeth; Poon, Eric; Tumolo, Alexis; Tripathi, MickyObjective The Massachusetts e-Health Collabora- tive (MAeHC) is implementing electronic health records (EHRs) in physicians’ offices throughout three diverse communities. This study’s objective was to assess the degree to which these practices are representative of physicians’ practices statewide. Design We surveyed all MAeHC physicians (n=464) and compared their responses to those of a contemporaneously surveyed statewide random sample (n=1884). Measurements The survey questionnaire assessed practice characteristics related to EHR adoption, prevailing office culture related to quality and safety, attitudes toward health information tech- nology (HIT) and perceptions of medical practice. Results A total of 355 MAeHC physicians (77%) and 1345 physicians from the statewide sample (71%) completed the survey. MAeHC practices resembled practices throughout Massachusetts in terms of practice size, physician age and gender, prevailing financial incentives for quality performance and HIT adoption and available resources for practice expansion. MAeHC practices were more likely to be located in rural areas (9.5% vs 4.4%, P=0.004). Physicians in both samples responded similarly to six of seven self-assessments of the office practice environment for quality and safety. Internet connec- tions were more prevalent among MAeHC practices than across the state (96% vs 83%, P<0.001), but similar proportions of MAeHC physicians (83%) and statewide physicians (86%) used the internet daily (P=0.19). Conclusion MAeHC is implementing EHRs and health information exchange among communities with physicians and practices that appear generally Keywords: health information technology, quality representative of Massachusetts. The lessons of care, regional health information organisations learned from this pilot project should be applicable statewide and to other states with large numbers of physicians in small office practices.Publication Effect of Reducing Interns' Work Hours on Serious Medical Errors in Intensive Care Units(Massachusetts Medical Society, 2004-10-28) Landrigan, Christopher; Rothschild, Jeffrey; Cronin, John W.; Kaushal, Rainu; Burdick, Elisabeth; Katz, Joel; Lilly, Craig M.; Stone, Peter; Lockley, Steven; Bates, David; Czeisler, CharlesBACKGROUND Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have measured its effects on medical errors. METHODS We conducted a prospective, randomized study comparing the rates of serious medical errors made by interns while they were working according to a traditional schedule with extended (24 hours or more) work shifts every other shift (an “every third night” call schedule) and while they were working according to an intervention schedule that eliminated extended work shifts and reduced the number of hours worked per week. Incidents were identified by means of a multidisciplinary, four-pronged approach that included direct, continuous observation. Two physicians who were unaware of the interns' schedule assignments independently rated each incident. RESULTS During a total of 2203 patient-days involving 634 admissions, interns made 35.9 percent more serious medical errors during the traditional schedule than during the intervention schedule (136.0 vs. 100.1 per 1000 patient-days, P<0.001), including 56.6 percent more nonintercepted serious errors (P<0.001). The total rate of serious errors on the critical care units was 22.0 percent higher during the traditional schedule than during the intervention schedule (193.2 vs. 158.4 per 1000 patient-days, P<0.001). Interns made 20.8 percent more serious medication errors during the traditional schedule than during the intervention schedule (99.7 vs. 82.5 per 1000 patient-days, P=0.03). Interns also made 5.6 times as many serious diagnostic errors during the traditional schedule as during the intervention schedule (18.6 vs. 3.3 per 1000 patient-days, P<0.001). CONCLUSIONS Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.Publication The Internet as a Vehicle to Communicate Health Information During a Public Health Emergency: A Survey Analysis Involving the Anthrax Scare of 2001(JMIR Publications Inc., 2004-03-03) Kittler, Anne F; Hobbs, John; Volk, Lynn A; Kreps, Gary L; Bates, DavidBackground The recent public health risks arising from bioterrorist threats and outbreaks of infectious diseases like SARS (Severe Acute Respiratory Syndrome) highlight the challenges of effectively communicating accurate health information to an alarmed public. Objective To evaluate use of the Internet in accessing information related to the anthrax scare in the United States in late 2001, and to strategize about the most effective use of this technology as a communication vehicle during times of public health crises. Methods A paper-based survey to assess how individuals obtained health information relating to bioterrorism and anthrax during late 2001.We surveyed 500 randomly selected patients from two ambulatory primary care clinics affiliated with the Brigham and Women's Hospital in Boston, Massachusetts. Results The response rate was 42%. While traditional media provided the primary source of information on anthrax and bioterrorism, 21% (95% CI, 15% - 27%) of respondents reported searching the Internet for this information during late 2001. Respondents reported trusting information from physicians the most, and information from health websites slightly more than information from any traditional media source. Over half of those searching the Internet reported changing their behavior as a result of information found online. Conclusions Many people already look to the Internet for information during a public health crisis, and information found online can positively influence behavioral responses to such crises. However, the potential of the Internet to convey accurate health information and advice has not yet been realized. In order to enhance the effectiveness of public-health communication, physician practices could use this technology to pro-actively e-mail their patients validated information. Still, unless Internet access becomes more broadly available, its benefits will not accrue to disadvantaged populations.Publication Patient Perceptions of a Personal Health Record: A Test of the Diffusion of Innovation Model(JMIR Publications Inc., 2012-11-05) Emani, Srinivas; Yamin, Cyrus K; Peters, Ellen; Karson, Andrew S; Lipsitz, Stuart; Wald, Jonathan S; Williams, Deborah H; Bates, DavidBackground: Personal health records (PHRs) have emerged as an important tool with which patients can electronically communicate with their doctors and doctor’s offices. However, there is a lack of theoretical and empirical research on how patients perceive the PHR and the differences in perceptions between users and non-users of the PHR. Objective: To apply a theoretical model, the diffusion of innovation model, to the study of PHRs and conduct an exploratory empirical study on the applicability of the model to the study of perceptions of PHRs. A secondary objective was to assess whether perceptions of PHRs predict the perceived value of the PHR for communicating with the doctor’s office. Methods: We first developed a survey capturing perceptions of PHR use and other factors such as sociodemographic characteristics, access and use of technology, perceived innovativeness in the domain of information technology, and perceptions of privacy and security. We then conducted a cross-sectional survey (N = 1500). Patients were grouped into five groups of 300: PHR users (innovators, other users, and laggards), rejecters, and non-adopters. We applied univariate statistical analysis (Pearson chi-square and one-way ANOVA) to assess differences among groups and used multivariate statistical techniques (factor analysis and multiple regression analysis) to assess the presence of factors identified by the diffusion of innovation model and the predictors of our dependent variable (value of PHR for communicating with the doctor’s office). Results: Of the 1500 surveys, 760 surveys were returned for an overall response rate of 51%. Computer use among non-adopters (75%) was lower than that among PHR users (99%) and rejecters (92%) (P < .001). Non-adopters also reported a lower score on personal innovativeness in information technology (mean = 2.8) compared to 3.6 and 3.1, respectively, for users and rejecters (P < .001). Four factors identified by the diffusion of innovation model emerged in the factor analysis: ease of use, relative advantage, observability, and trialability. PHR users perceived greater ease of use and relative advantage of the PHR than rejecters and non-adopters (P<.001). Multiple regression analysis showed the following factors as significant positive predictors of the value of PHR for communicating with the doctor’s office: relative advantage, ease of use, trialability, perceptions of privacy and security, age, and computer use. Conclusion: Our study found that the diffusion of innovation model fits the study of perceptions of the PHR and provides a suitable theoretical and empirical framework to identify the factors that distinguish PHR users from non-users. The ease of use and relative advantage offered by the PHR emerged as the most important domains among perceptions of PHR use and in predicting the value of the PHR. Efforts to improve uptake and use of PHRs should focus on strategies that enhance the ease of use of PHRs and that highlight the relative advantages of PHRs.Publication Physicians and Electronic Health Records: A Statewide Survey(American Medical Association (AMA), 2007-03-12) Simon, Steven R.; Kaushal, Rainu; Cleary, Paul; Jenter, Chelsea A.; Volk, Lynn A.; Orav, Endel; Burdick, Elisabeth; Poon, Eric G.; Bates, DavidBackground: Electronic health records (EHRs) allow for a variety of functions, ranging from visit documen- tation to laboratory test ordering, but little is known about physicians’ actual use of these functions. Methods: We surveyed a random sample of 1884 phy- sicians in Massachusetts by mail and assessed availabil- ity and use of EHR functions, predictors of use, and the relationships between EHR use and physicians’ percep- tions of medical practice. Results: A total of 1345 physicians responded to the sur- vey (71.4% response rate), and 387 (28.8%) reported that their practice had adopted EHRs. More than 80% of phy- sicians with EHRs reported having the ability to view labo- ratory reports (84.8%) and document visits electroni- cally (84.0%), but considerably fewer reported being able to order laboratory tests electronically (46.8%) or trans- mit prescriptions to a pharmacy electronically (44.7%). Fewer than half of the physicians who had systems with clinical decision support, transmittal of electronic pre- scriptions, and radiology order entry actually used these functions most or all of the time. Compared with phy- sicians who had not adopted EHRs, EHR users reported more positive views of the effects of computers on health care; there were no significant differences in these atti- tudes between high and low users of EHRs. Overall, about 1 in 4 physicians reported dissatisfaction with medical practice; there was no difference in this measure by EHR adoption or use. Conclusions: There is considerable variability in the func- tions available in EHRs and in the extent to which phy- sicians use them. Future work should emphasize fac- tors that affect the use of available functions.Publication Ability to Generate Patient Registries Among Practices With and Without Electronic Health Records(JMIR Publications Inc., 2009-08-10) Wright, Adam; McGlinchey, Elizabeth A; Poon, Eric G; Jenter, Chelsea A; Bates, David; Simon, Steven R; Simon, StevenBackground: The ability to generate registries of patients with particular clinical attributes, such as diagnoses or medications taken, is central to measuring and improving the quality of health care. However, it is not known how many providers have the ability to generate such registries. Objectives: To assess the proportion of physician practices that can construct registries of patients with specific diagnoses, laboratory results, or medications, and to determine the relationship between electronic health record (EHR) usage and the ability to perform registry functions. Methods: We conducted a mail survey of a stratified random sample of physician practices in Massachusetts in the northeastern United States (N = 1884). The survey included questions about the physicians’ ability to generate diagnosis, laboratory result, and medication registries; the presence of EHR; and usage of specific EHR features. Results: Theresponseratewas71%(1345/1884).Overall,79.8%ofphysicianpracticesreportedbeingabletogenerateregistries of patients by diagnosis; 56.1% by laboratory result; and 55.8% by medication usage. In logistic regression analyses, adjusting for urban/rural location, practice size and ownership, teaching status, hospital affiliation, and specialty, physician practices with an EHR were more likely to be able to construct diagnosis registries (adjusted odds ratio [OR] 1.53, 95% confidence interval [CI] 1.25 - 1.86), laboratory registries (OR 1.42, 95% CI 1.22 - 1.66), and medication registries (OR 2.30, 95% CI 1.96 - 2.70). Conclusions: Many physician practices were able to generate registries, but this capability is far from universal. Adoption of EHRs appears to be a useful step toward this end, and practices with EHRs are considerably more likely to be able to carry out registry functions. Because practices need registries to perform broad-based quality improvement, they should consider adopting EHRs that have built-in registry functionality.Publication Medication Errors Observed in 36 Health Care Facilities(American Medical Association (AMA), 2002-09-09) Barker, Kenneth N.; Flynn, Elizabeth A.; Pepper, Ginette A.; Bates, David; Mikeal, Robert L.Background: Medication errors are a national concern. Objective: To identify the prevalence of medication errors (doses administered differently than ordered). Design: A prospective cohort study. Setting: Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado. Participants: A stratified random sample of 36 institutions. Twenty-six declined, with random replacement. Medication doses given (or omitted) during at least 1 medication pass during a 1- to 4-day period by nurses on high medication–volume nursing units. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered. Methods: Medication errors were witnessed by observation, and verified by a research pharmacist (E.A.F.). Clinical significance was judged by an expert panel of physicians. Main Outcome Measure: Medication errors reaching patients. Results: In the 36 institutions, 19% of the doses (605/ 3216) were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Seven per- cent of the errors were judged potential adverse drug events. There was no significant difference between error rates in the 3 settings (P = .82) or by size (P = .39). Error rates were higher in Colorado than in Georgia (P = .04). Conclusions: Medication errors were common (nearly 1 of every 5 doses in the typical hospital and skilled nursing facility). The percentage of errors rated potentially harmful was 7%, or more than 40 per day in a typical 300- patient facility. The problem of defective medication ad- ministration systems, although varied, is widespread.Publication Incidence and Preventability of Adverse Drug Events Among Older Persons in the Ambulatory Setting(American Medical Association (AMA), 2003-03-05) Gurwitz, Jerry H.; Field, Terry S.; Harrold, Leslie R.; Rothschild, Jeffrey; Debellis, Kristin; Seger, Andrew; Cadoret, Cynthia; Fish, Leslie S.; Garber, Lawrence; Kelleher, Michael; Bates, DavidContext: Adverse drug events, especially those that may be preventable, are among the most serious concerns about medication use in older persons cared for in the ambulatory clinical setting. Objective: To assess the incidence and preventability of adverse drug events among older persons in the ambulatory clinical setting. Design, setting, and patients: Cohort study of all Medicare enrollees (30 397 person-years of observation) cared for by a multispecialty group practice during a 12-month study period (July 1, 1999, through June 30, 2000), in which possible drug-related incidents occurring in the ambulatory clinical setting were detected using multiple methods, including reports from health care providers; review of hospital discharge summaries; review of emergency department notes; computer-generated signals; automated free-text review of electronic clinic notes; and review of administrative incident reports concerning medication errors. Main outcome measures: Number of adverse drug events, severity of the events (classified as significant, serious, life-threatening, or fatal), and whether the events were preventable. Results: There were 1523 identified adverse drug events, of which 27.6% (421) were considered preventable. The overall rate of adverse drug events was 50.1 per 1000 person-years, with a rate of 13.8 preventable adverse drug events per 1000 person-years. Of the adverse drug events, 578 (38.0%) were categorized as serious, life-threatening, or fatal; 244 (42.2%) of these more severe events were deemed preventable compared with 177 (18.7%) of the 945 significant adverse drug events. Errors associated with preventable adverse drug events occurred most often at the stages of prescribing (n = 246, 58.4%) and monitoring (n = 256, 60.8%), and errors involving patient adherence (n = 89, 21.1%) also were common. Cardiovascular medications (24.5%), followed by diuretics (22.1%), nonopioid analgesics (15.4%), hypoglycemics (10.9%), and anticoagulants (10.2%) were the most common medication categories associated with preventable adverse drug events. Electrolyte/renal (26.6%), gastrointestinal tract (21.1%), hemorrhagic (15.9%), metabolic/endocrine (13.8%), and neuropsychiatric (8.6%) events were the most common types of preventable adverse drug events. Conclusions: Adverse drug events are common and often preventable among older persons in the ambulatory clinical setting. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the prescribing and monitoring stages of pharmaceutical care. Interventions focused on improving patient adherence with prescribed regimens and monitoring of prescribed medications also may be beneficial.Publication Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors(American Medical Association (AMA), 1998-10-21) Bates, David; Leape, Lucian; Cullen, David J; Laird, Nan; Petersen, Laura A; Teich, Jonathan; Burdick, Elizabeth; Hickey, Mairead; Kleefield, Sharon; Shea, Brian; Vander Vliet, Martha; Seger, Diane LContext: Adverse drug events (ADEs) are a significant and costly cause of injury during hospitalization. Objectives: To evaluate the efficacy of 2 interventions for preventing nonintercepted serious medication errors, defined as those that either resulted in or had potential to result in an ADE and were not intercepted before reaching the patient. Design: Before-after comparison between phase 1 (baseline) and phase 2 (after intervention was implemented) and, within phase 2, a randomized comparison between physician computer order entry (POE) and the combination of POE plus a team intervention. Setting: Large tertiary care hospital. Participants: For the comparison of phase 1 and 2, all patients admitted to a stratified random sample of 6 medical and surgical units in a tertiary care hospital over a 6-month period, and for the randomized comparison during phase 2, all patients admitted to the same units and 2 randomly selected additional units over a subsequent 9-month period. Interventions: A physician computer order entry system (POE) for all units and a team-based intervention that included changing the role of pharmacists, implemented for half the units. Main outcome measure: Nonintercepted serious medication errors. Results: Comparing identical units between phases 1 and 2, nonintercepted serious medication errors decreased 55%, from 10.7 events per 1000 patient-days to 4.86 events per 1000 (P=.01). The decline occurred for all stages of the medication-use process. Preventable ADEs declined 17% from 4.69 to 3.88 (P=.37), while nonintercepted potential ADEs declined 84% from 5.99 to 0.98 per 1000 patient-days (P=.002). When POE-only was compared with the POE plus team intervention combined, the team intervention conferred no additional benefit over POE. Conclusions: Physician computer order entry decreased the rate of nonintercepted serious medication errors by more than half, although this decrease was larger for potential ADEs than for errors that actually resulted in an ADE.Publication Lessons learned from implementation of computerized provider order entry in 5 community hospitals: a qualitative study(Springer Nature, 2013-06-24) Simon, Steven; Keohane, Carol A; Amato, Mary; Coffey, Michael; Cadet, Bismarck; Zimlichman, Eyal; Bates, DavidBackground Computerized Provider Order Entry (CPOE) can improve patient safety, quality and efficiency, but hospitals face a host of barriers to adopting CPOE, ranging from resistance among physicians to the cost of the systems. In response to the incentives for meaningful use of health information technology and other market forces, hospitals in the United States are increasingly moving toward the adoption of CPOE. The purpose of this study was to characterize the experiences of hospitals that have successfully implemented CPOE. Methods We used a qualitative approach to observe clinical activities and capture the experiences of physicians, nurses, pharmacists and administrators at five community hospitals in Massachusetts (USA) that adopted CPOE in the past few years. We conducted formal, structured observations of care processes in diverse inpatient settings within each of the hospitals and completed in-depth, semi-structured interviews with clinicians and staff by telephone. After transcribing the audiorecorded interviews, we analyzed the content of the transcripts iteratively, guided by principles of the Immersion and Crystallization analytic approach. Our objective was to identify attitudes, behaviors and experiences that would constitute useful lessons for other hospitals embarking on CPOE implementation. Results Analysis of observations and interviews resulted in findings about the CPOE implementation process in five domains: governance, preparation, support, perceptions and consequences. Successful institutions implemented clear organizational decision-making mechanisms that involved clinicians (governance). They anticipated the need for education and training of a wide range of users (preparation). These hospitals deployed ample human resources for live, in-person training and support during implementation. Successful implementation hinged on the ability of clinical leaders to address and manage perceptions and the fear of change. Implementation proceeded smoothly when institutions identified and anticipated the consequences of the change. Conclusions The lessons learned in the five domains identified in this study may be useful for other community hospitals embarking on CPOE adoption.