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Background: This study was conducted to validate use of electronic health record (EHR) data for measuring colorectal cancer (CRC) screening rates at community health centers (CHCs)., Methods: Electronic health records were queried to assess screening via colonoscopy, flexible sigmoidoscopy, or fecal occult blood testing (FOBT) in 2011., Results: Multiple iterations were required to maximize query accuracy. Manual chart reviews, stratified by screening modality, confirmed query results for 112 of 113 (99.1%) reviewed colonoscopies, 110 of 110 (100%) reviewed FOBTs, and 111 of 120 (92.5%) unscreened patients. At participating CHCs, CRC screening rates ranged from 9.7% to 67.2% (median, 30.6%). Adherence to annual FOBT ranged from 3.3% to 59.0% (median, 18.6%). Most screening was done by colonoscopy., Conclusions: Colorectal cancer screening varies substantially across CHCs. Electronic health record data can validly measure CRC screening, but repeated assessments of programming accuracy are required. Community health centers may need support to measure quality using EHR data and increase screening.

Objective: Incorporating accurate life expectancy predictions into clinical decision making could improve quality and decrease costs, but few providers do this. We sought to use predictive data mining and high dimensional analytics of electronic health record (EHR) data to develop a highly accurate and clinically actionable 5 year life expectancy index., Materials and Methods: We developed the index using EHR data for 7463 patients ≥50 years old with ≥1 visit(s) in 2003 to a large, academic, multispecialty group practice. We extracted 980 attributes from the EHRs of the practices and affiliated hospitals. Correlation feature selection with greedy stepwise search was used to find the attribute subset with best average merit. Rotation forest ensembling with alternating decision tree as underlying classifier was used to predict 5 year mortality. Model performance was compared with the modified Charlson Comorbidity Index and the Walter life expectancy method., Results: Within 5 years of the last visit in 2003, 838 (11%) patients had died. The final model included 24 attributes: two demographic (age, sex), 10 comorbidity (eg, cardiovascular disease), one vital sign (mean diastolic blood pressure), two medications (loop diuretic use, digoxin use), six laboratory (eg, mean albumin), and three healthcare utilization (eg, the number of hospitalizations 1 year prior to the last visit in 2003). The index showed very good discrimination (c-statistic 0.86) and outperformed comparators., Conclusions: The EHR based index successfully distinguished adults ≥50 years old with life expectancy >5 years from those with life expectancy ≤5 years. This information could be used clinically to optimize preventive service use (eg, cancer screening in the elderly).

Background: Many individuals at higher risk for cardiovascular disease (CVD) do not receive recommended treatments. Prior interventions using personalized risk information to promote prevention did not test clinic-wide effectiveness., Objective and Design: To perform a 9-month cluster-randomized trial, comparing a strategy of electronic health record-based identification of patients with increased CVD risk and individualized mailed outreach to usual care., Participants: Patients of participating physicians with a Framingham Risk Score of at least 5 %, low-density lipoprotein (LDL)-cholesterol level above guideline threshold for drug treatment, and not prescribed a lipid-lowering medication were included in the intention-to-treat analysis., Intervention: Patients of physicians randomized to the intervention group were mailed individualized CVD risk messages that described benefits of using a statin (and controlling hypertension or quitting smoking when relevant)., Main Measures: The primary outcome was occurrence of a LDL-cholesterol level, repeated in routine practice, that was at least 30 mg/dl lower than prior. A secondary outcome was lipid-lowering drug prescribing. Clinicaltrials.gov identifier: NCT01286311., Key Results: Fourteen physicians with 218 patients were randomized to intervention, and 15 physicians with 217 patients to control. The mean patient age was 60.7 years and 77% were male. There was no difference in the primary outcome (11.0 % vs. 11.1 %, OR 0.99, 95 % CI 0.56-1.74, P = 0.96), but intervention group patients were twice as likely to receive a prescription for lipid-lowering medication (11.9 %, vs. 6.0 %, OR 2.13, 95 % CI 1.05-4.32, p = 0.038). In post hoc analysis with extended follow-up to 18 months, the primary outcome occurred more often in the intervention group (22.5 % vs. 16.1 %, OR 1.59, 95 % CI 1.05-2.41, P = 0.029)., Conclusions: In this effectiveness trial, individualized mailed CVD risk messages increased the frequency of new lipid-lowering drug prescriptions, but we observed no difference in proportions lowering LDL-cholesterol after 9 months. With longer follow-up, the intervention's effect on LDL-cholesterol levels was apparent.

Unlabelled: Osteoporosis is infrequently addressed during hospitalization for osteoporotic fractures. An EMR-based intervention (osteoporosis order set) was developed with physician and patient input. There was a trend toward greater calcium supplementation from July 2008 to April 2009 (s = 0.058); however, use of antiresorptives (13%) or discharge instructions for BMD testing and osteoporosis treatment (10%) remained low., Introduction: Osteoporosis is infrequently addressed during hospitalization for osteoporotic fractures. The study population consisted of patients over 50 years of age., Methods: Northwestern Memorial Hospital is a tertiary care academic hospital in Chicago. This study was conducted from September 1, 2007 through June 30, 2009., Results: Physicians reported that barriers to care comprised nonacute nature of osteoporosis, belief that osteoporosis should be addressed by the PCP, low awareness of recurrent fractures, and radiographs with terms such as "compression deformity", "wedge deformity", or "vertebral height loss" which in their opinion were not clearly indicative of vertebral fractures. An EMR-based intervention was developed with physician and patient input. Over the evaluation period, 295 fracture cases in individuals over the age of 50 years in the medicine floors were analyzed. Mean age was 72 ± 11 years; 74% were female. Sites of fracture included hip n = 78 (27%), vertebral n = 87 (30%), lower extremity n = 61 (21%), upper extremity n = 43 (15%) and pelvis n = 26 (9%). There was no increase in documentation of osteoporosis in the medical record from pre- to post-EMR implementation (p = 0.89). There was a trend toward greater calcium supplementation from July 2008 to April 2009 (p = 0.058); however, use of antiresorptives (13%) or discharge instructions for BMD testing and osteoporosis treatment (10%) remained low., Conclusion: An electronic medical record intervention without electronic reminders created with physician input achieves an increase in calcium supplementation but fails to increase diagnosis or treatment for osteoporosis at the time of hospitalization for a fragility fracture.

Background: Physicians often do not recognize when their patients are overweight and infrequently counsel them about weight loss., Objective: To evaluate a set of electronic health record (EHR)-embedded tools to assist with identification and counseling of overweight patients., Design: Randomized controlled trial., Participants: Physicians at an academic general internal medicine clinic were randomized to activation of the EHR tools (n = 15) or to usual care (n = 15). Patients of these physicians were included in analyses if they had a body mass index (BMI) between 27 and 29.9 kg/m(2)., Intervention: The EHR tool set included: a physician point-of-care alert for overweight (BMI 27-29. 9 kg/m(2)); a counseling template to help physicians counsel patients on action plans; and an order set to facilitate entry of overweight as a diagnosis and to order relevant patient handouts., Main Measures: Physician documentation of overweight as a problem; documentation of weight-specific counseling; physician perceptions of the EHR tools; patient self-reported progress toward their goals and perspectives about counseling received., Key Results: Patients of physicians receiving the intervention were more likely than those of usual care physicians to receive a diagnosis of overweight (22% vs. 7%; p = 0.02) and weight-specific counseling (27% vs. 15%; p = 0.02). Most patients receiving counseling in the intervention group reported increased motivation to lose weight (90%) and taking steps toward their goal (93%). Most intervention physicians agreed that the tool alerted them to patients they did not realize were overweight (91%) and improved the effectiveness of their counseling (82%); more than half (55%) reported counseling overweight patients more frequently (55%). However, most physicians used the tool infrequently because of time barriers., Conclusions: EHR-based alerts and management tools increased documentation of overweight and counseling frequency; the majority of patients for whom the tools were used reported short-term behavior change.

Background: National organizations historically focused on increasing use of effective services are now attempting to identify and discourage use of low-value services. Electronic health records (EHRs) could be used to measure use of low-value services, but few studies have examined this. The aim of the study was to: (1) determine if EHR data can be used to identify women eligible for an extended Pap testing interval; (2) determine the proportion of these women who received a Pap test sooner than recommended; and (3) assess the consequences of these low-value Pap tests., Methods: Electronic query of EHR data identified women aged 30-65 years old who were at low-risk of cervical cancer and therefore eligible for an extended Pap testing interval of 3 years (as per professional society guidelines). Manual chart review assessed query accuracy. The use of low-value Pap tests (ie, those performed sooner than recommended) was measured, and adverse consequences of low-value Pap tests (ie, colposcopies performed as a result of low-value Pap tests) were identified., Results: Manual chart review confirmed query accuracy. Two-thirds (1120/1705) of low-risk women received a Pap test sooner than recommended, and 21 colposcopies were performed as a result of this low-value Pap testing., Conclusion: Secondary analysis of EHR data can accurately measure the use of low-value services such as Pap testing performed sooner than recommended in women at low risk of cervical cancer. Similar application of our methodology could facilitate efforts to simultaneously improve quality and decrease costs, maximizing value in the US healthcare system.

Introduction: Tobacco cessation medication use increases the likelihood of a successful quit attempt, but few smokers are prescribed medications. Electronic health records (EHRs) may increase cessation medication prescription. This study aimed to assess the impact of an electronic alert and linked order set on cessation medication prescription., Methods: This pre- and postintervention cohort study was conducted in an urban academic general internal medicine practice with a comprehensive EHR. All active smokers with 2 or more visits to the practice in 2008 (preintervention cohort) or 2009 (postintervention cohort) were included. An electronic alert and linked order set were designed and implemented. The primary outcome was prescription of any cessation medication (nicotine replacement therapy, bupropion, or varenicline). Secondary outcomes included counseling referral and change in smoking status to quit during the study period (i.e., "quit rate")., Results: There were 1,349 and 1,346 smokers in the pre- and postintervention cohorts, respectively. Cessation medication prescription did not significantly change after the intervention (14.4% vs. 13.4% of smokers in the preintervention cohort, p = .5). Counseling referrals increased from 2.0% to 7.2% in the postintervention cohort (p < .001). More smokers in the postintervention cohort changed their smoking status to quit during the study period (20.5% vs. 17.1%, p = .06)., Conclusions: This provider-directed electronic alert and linked order set failed to increase cessation medication prescription. The consistent failure of provider-directed efforts to increase cessation medication use suggests that this is a patient-limited process. Future efforts to improve tobacco treatment should focus on overcoming patient-level barriers to cessation medication use.

Background: Previous studies of patient portals have found low rates of enrollment and significant disparities in enrollment by race and ethnicity. As the reasons for these findings are unclear, we sought to identify patient reported barriers to enrollment in a patient portal., Methods: We conducted a telephone survey of patients in one urban general internal medicine clinic. Patients were eligible if they did not enroll within 30 days of receiving an electronic order inviting participation. Our primary outcomes were: (a) reasons for not enrolling in the patient portal; (b) reasons for not attempting enrollment; and (c) perceived benefits of the portal., Results: Participants' (N=159) mean age was 51 years, 48% were black, 72% female, and 70% had a college degree or greater. 63% of respondents not enrolling reported never attempting enrollment despite remembering receiving an order. Most of these 63% did not attempt enrollment because of lack of information or motivation. Smaller proportions reported not attempting enrollment because of negative attitudes toward the portal (30%) or computer related obstacles (8%). Overall, respondents favorably viewed most patient portal features, however black respondents were less likely than white respondents to consider features assisting self-management such as getting test results (69% vs 86%; p<0.05) as important. Adjusting for age, gender, education, and chronic disease did not substantially change results., Conclusion: Strategies to increase enrollment in patient portals need to ensure patients understand patient portal features and receive follow-up reminders. Interventions to reduce racial disparities in enrollment must address attitudinal barriers and not focus solely on improving access.

Objective: We have reported that implementation of an electronic health record (EHR) based quality improvement system that included point-of-care electronic reminders accelerated improvement in performance for multiple measures of chronic disease care and preventive care during a 1-year period. This study examined whether providing pre-visit paper quality reminders could further improve performance, especially for physicians whose performance had not improved much during the first year., Design: Time-series analysis at a large internal medicine practice using a commercial EHR. All patients eligible for each measure were included (range approximately 100-7500)., Measurements: The proportion of eligible patients in the practice who satisfied each of 15 quality measures after removing those with exceptions from the denominator. To analyze changes in performance for individual physicians, two composite measures were used: prescribing seven essential medications and completion of five preventive services., Results: During the year after implementing pre-encounter reminders, performance continued to improve for eight measures, remained stable for four, and declined for three. Physicians with the worst performance at the start of the pre-encounter reminders showed little absolute improvement over the next year, and most remained below the median performance for physicians in the practice., Conclusions: Paper pre-encounter reminders did not appear to improve performance beyond electronic point-of-care reminders in the EHR alone. Lagging performance is likely not due to providers' EHR workflow alone, and trying to step backwards and use paper reminders in addition to point-of-care reminders in the EHR may not be an effective strategy for engaging slow adopters.

Background: With emphasis on the meaningful use of electronic health records, patient portals are likely to become increasingly important. Little is known about patient enrollment in, and use of, patient portals after explicit invitation from providers., Objectives: To examine enrollment in, and use of, an electronic patient portal by race/ethnicity, gender and age., Design: Observational, cross sectional study., Participants: Patients with attending physicians seen at one urban, academic primary care practice between May 2008 and October 2009 who received electronic orders inviting their participation in an electronic patient portal., Main Measures: (a) Enrollment in the patient portal, (b) Solicitation of provider advice among enrollees, (c) Requests for medication refills among enrollees., Key Results: Overall, 69% of 7,088 patients enrolled in the patient portal. All minority patients were significantly less likely to enroll than whites: 55% blacks, 64% Latinos and 66% Asians compared with 74% whites (chi-square p < 0.05 for all pairwise comparisons). These disparities persisted in adjusted analyses, although differences for Asians were no longer significant. In addition, the oldest patients were less likely to enroll than the youngest (adjusted OR 0.79, 95% CI 0.65-0.97). Although there were no racial/ethnic disparities in use of the patient portal among enrollees, we found differences by age and gender. The youngest patients were significantly less likely to solicit provider advice or request medication refills than any other age group in unadjusted and adjusted analyses. Similarly, male patients were less likely to solicit provider advice than women in all analyses., Conclusion: Large racial/ethnic disparities were seen in enrollment in our patient portal. Among enrollees, use of the portal was similar by race/ethnicity, but not by age or gender. Future efforts to expand use of the patient portal need to address potential mechanisms for these disparities to ensure this technology is accessible to diverse patient populations.

Background: Electronic health record (EHR) systems have the potential to revolutionize quality improvement (QI) methods by enhancing quality measurement and integrating multiple proven QI strategies., Objectives: To implement and evaluate a multifaceted QI intervention using EHR tools to improve quality measurement (including capture of contraindications and patient refusals), make point-of-care reminders more accurate, and provide more valid and responsive clinician feedback (including lists of patients not receiving essential medications) for 16 chronic disease and preventive service measures., Design: Time series analysis at a large internal medicine practice using a commercial EHR., Subjects: All adult patients eligible for each measure (range approximately 100-7500)., Measures: The proportion of eligible patients who satisfied each measure after removing those with exceptions from the denominator., Results: During the year before the intervention, performance improved significantly for 8 measures. During the year after the intervention, performance improved significantly for 14 measures. For 9 measures, the primary outcome improved more rapidly during the intervention year than during the previous year (P < 0.001 for 8 measures, P = 0.02 for 1). Four other measures improved at rates that were not significantly different from the previous year. Improvements resulted from increases in patients receiving the service, documentation of exceptions, or a combination of both. For 5 drug-prescribing measures, more than half of physicians achieved 100% performance., Conclusions: Implementation of a multifaceted QI intervention using EHR tools to improve quality measurement and the accuracy and timeliness of clinician feedback improved performance and/or accelerated the rate of improvement for multiple measures simultaneously.

Background: Quality improvement programs that allow physicians to document medical reasons for deviating from guidelines preserve clinicians' judgment while enabling them to strive for high performance. However, physician misconceptions or gaming potentially limit programs., Objective: To implement computerized decision support with mechanisms to document medical exceptions to quality measures and to perform peer review of exceptions and provide feedback when appropriate., Design: Observational study., Setting: Large internal medicine practice., Participants: Patients eligible for 1 or more quality measures., Measurements: A peer-review panel judged medical exceptions to 16 chronic disease and prevention quality measures as appropriate, inappropriate, or of uncertain appropriateness. Medical records were reviewed after feedback was given to determine whether care changed., Results: Physicians recorded 650 standardized medical exceptions during 7 months. The reporting tool was used without any medical reason 36 times (5.5%). Of the remaining 614 exceptions, 93.6% were medically appropriate, 3.1% were inappropriate, and 3.3% were of uncertain appropriateness. Frequencies of inappropriate exceptions were 7 (6.9%) for coronary heart disease, 0 (0%) for heart failure, 10 (10.8%) for diabetes, and 2 (0.6%) for preventive services. After physicians received direct feedback about inappropriate exceptions, 8 of 19 (42%) changed management. The peer-review process took less than 5 minutes per case, but for each change in clinical care, 65 reviews were required., Limitation: The findings could differ at other sites or if financial incentives were in place., Conclusion: Physician-recorded medical exceptions were correct most of the time. Peer review of medical exceptions can identify myths and misconceptions, but the process needs to be more efficient to be sustainable., Primary Funding Source: Agency for Healthcare Research and Quality.