Person:

Feblowitz, Joshua

Background: The clinical problem list is an important tool for clinical decision making, quality measurement and clinical decision support; however, problem lists are often incomplete and provider attitudes towards the problem list are poorly understood. Methods: An ethnographic study of healthcare providers conducted from April 2009 to January 2010 was carried out among academic and community outpatient medical practices in the Greater Boston area across a wide range of medical and surgical specialties. Attitudes towards the problem list were then analyzed using grounded theory methods. Results: Attitudes were variable, and dimensions of variations fit into nine themes: workflow, ownership and responsibility, relevance, uses, content, presentation, accuracy, alternatives, support/education and one cross-cutting theme of culture. Conclusions: Significant variation was observed in clinician attitudes towards and use of the electronic patient problem list. Clearer guidance and best practices for problem list utilization are needed.

Background: Accurate clinical problem lists are critical for patient care, clinical decision support, population reporting, quality improvement, and research. However, problem lists are often incomplete or out of date. Objective: To determine whether a clinical alerting system, which uses inference rules to notify providers of undocumented problems, improves problem list documentation. Study Design and Methods: Inference rules for 17 conditions were constructed and an electronic health record-based intervention was evaluated to improve problem documentation. A cluster randomized trial was conducted of 11 participating clinics affiliated with a large academic medical center, totaling 28 primary care clinical areas, with 14 receiving the intervention and 14 as controls. The intervention was a clinical alert directed to the provider that suggested adding a problem to the electronic problem list based on inference rules. The primary outcome measure was acceptance of the alert. The number of study problems added in each arm as a pre-specified secondary outcome was also assessed. Data were collected during 6-month pre-intervention (11/2009–5/2010) and intervention (5/2010–11/2010) periods. Results: 17,043 alerts were presented, of which 41.1% were accepted. In the intervention arm, providers documented significantly more study problems (adjusted OR=3.4, p<0.001), with an absolute difference of 6,277 additional problems. In the intervention group, 70.4% of all study problems were added via the problem list alerts. Significant increases in problem notation were observed for 13 of 17 conditions. Conclusion: Problem inference alerts significantly increase notation of important patient problems in primary care, which in turn has the potential to facilitate quality improvement.

Background: EHR implementation may improve care quality in the ED. At our institution, we implemented a custom e-documentation system (eDoc) to replace paper documentation. No studies to date have characterized the effect of implementing e-documentation in the ED. Objective: To characterize the operational effects of implementing eDoc in our ED. Methods: We performed a retrospective analysis of data for 1-year periods before and after implementation. We used regression modeling and CEM to identify significant differences in outcome variables. Results: During the pre-implementation period, LOS was 4.29 hours, LOSa was 6.47 hours and LOSd was 3.49 hours; after implementation, LOS for these groups were 4.43 hours, 6.66 hours, and 3.52 hours. TTD was 3.00 hours before and 3.03 hours after implementation. Using regression analysis, there were no differences in outcome variables at 8 weeks; at one year, there were differences in LOS and LOSd patients of ∆+0.10 hours and ∆+0.08 hours. CEM analysis demonstrated a change of ∆+0.15 hours and ∆+0.17 hours for LOS and LOSd. Conclusions: In our study, implementation of e-documentation was associated with significant increases in LOS and LOSd. Though this increase may appear small, this additional time required for e-documentation has the potential to impact ED efficiency.