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Using active choice within the electronic health record to increase physician ordering and patient completion of high-value cancer screening tests.

ABSTRACT: BACKGROUND:High value screening tests such as colonoscopy and mammography can improve early cancer detection but are often underutilized. METHODS:We evaluated an active choice intervention using the electronic health record (EHR) to confirm patient eligibility for colonoscopy or mammography during the patient's clinic visit and prompt the physician and his/her medical assistant to actively choose to "accept" or "cancel" an order for it. We fit multivariate logistic regression models using a difference-in-differences approach to evaluate changes in physician ordering and patient completion of colonoscopy and mammography at the intervention practice compared to two control practices, adjusting for time trends, patient and clinic visit characteristics. RESULTS:The sample comprised 7560 patients due for colonoscopy and 8337 patients due for mammography. Pre-intervention trends between practices did not differ. In the adjusted models, compared to the control group over time, the intervention practice had a significant increase in ordering of colonoscopy (11.8% points, 95% CI: 8.0-15.6, P<0.001) and mammography (12.4% points, 95% CI: 8.7-16.2, P<0.001). There was a significant increase in patient completion of colonoscopy (3.5% points, 95% CI: 1.1-5.9, P<0.01), but no change in mammography (2.2% points, 95% CI: -1.0 to 5.5, P=0.18). CONCLUSIONS:Active choice through the EHR was associated with an increase in physician ordering of colonoscopy and mammography. The intervention was also associated with an increase in patient completion of colonoscopy but no change in patient completion of mammography.

SUBMITTER: Patel MS

PROVIDER: S-EPMC7240802 | biostudies-literature | 2016 Dec

REPOSITORIES: biostudies-literature

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Using active choice within the electronic health record to increase physician ordering and patient completion of high-value cancer screening tests.

Patel Mitesh S MS Volpp Kevin G KG Small Dylan S DS Wynn Craig C Zhu Jingsan J Yang Lin L Honeywell Steven S Day Susan C SC

Healthcare (Amsterdam, Netherlands) 20160511 4

<h4>Background</h4>High value screening tests such as colonoscopy and mammography can improve early cancer detection but are often underutilized.<h4>Methods</h4>We evaluated an active choice intervention using the electronic health record (EHR) to confirm patient eligibility for colonoscopy or mammography during the patient's clinic visit and prompt the physician and his/her medical assistant to actively choose to "accept" or "cancel" an order for it. We fit multivariate logistic regression mode ...[more]

PMID: 28007228

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Project description:ImportanceEarly cancer detection can lead to improved outcomes, but cancer screening tests are often underused.ObjectiveTo evaluate the association of an active choice intervention in the electronic health record directed to medical assistants with changes in clinician ordering and patient completion of breast and colorectal cancer screening tests.Design, setting, and participantsA retrospective quality improvement study was conducted among 69 916 patients eligible for breast or colorectal cancer screening at 25 primary care practices at the University of Pennsylvania Health System between September 1, 2014, and August 31, 2017. Data analysis was conducted from January 21 to July 8, 2019.InterventionsFrom 2016 to 2017, 3 primary care practices at the University of Pennsylvania Health System implemented an active choice intervention in the electronic health record that prompted medical assistants to inform patients about cancer screening during check-in and template orders for clinicians to review during the visit.Main outcomes and measuresThe primary outcome was clinician ordering of cancer screening tests. The secondary outcome was patient completion of cancer screening tests within 1 year of the primary care visit.ResultsThe sample eligible for breast cancer screening comprised 26 269 women with a mean (SD) age of 60.4 (6.9) years; 15 873 (60.4%) were white and 7715 (29.4%) were black. The sample eligible for colorectal cancer screening comprised 43 647 patients with a mean (SD) age of 59.4 (7.5) years; 24 416 (55.9%) were women, 19 231 (44.1%) were men, 29 029 (66.5%) were white, and 9589 (22.0%) were black. For breast cancer screening, the intervention was associated with a significant increase in clinician ordering of tests (22.2 percentage points; 95% CI, 17.2-27.6 percentage points; P < .001) but no change in patient completion (0.1 percentage points; 95% CI, -4.0 to 4.3 percentage points; P = .45). For colorectal cancer screening, the intervention was associated with a significant increase in clinician ordering of tests (13.7 percentage points; 95% CI, 8.0-18.9 percentage points; P < .001) but no change in patient completion (1.0 percentage points; 95% CI, -3.2 to 4.6 percentage points; P = .36).Conclusions and relevanceAn active choice intervention in the electronic health record directed to medical assistants was associated with a significant increase in clinician ordering of breast and colorectal cancer screening tests. However, it was not associated with a significant change in patient completion of either cancer screening test during a 1-year follow-up.

Project description:ImportanceEfforts to reduce low-value tests and treatments in primary care are often ineffective. These efforts typically target physicians broadly, most of whom order low-value care infrequently.ObjectivesTo measure physician-level use rates of 4 low-value screening tests in primary care to investigate the presence and characteristics of primary care physicians who frequently order low-value care.Design, setting, and participantsA retrospective cohort study was conducted using administrative health care claims collected between April 1, 2012, and March 31, 2016, in Ontario, Canada. This study measured use of 4 low-value screening tests-repeated dual-energy x-ray absorptiometry (DXA) scans, electrocardiograms (ECGs), Papanicolaou (Pap) tests, and chest radiographs (CXRs)-among low-risk outpatients rostered to a common cohort of primary care physicians.ExposuresPhysician sex, years since medical school graduation, and primary care model.Main outcomes and measuresThis study measured the number of tests to which a given physician ranked in the top quintile by ordering rate. The resulting cross-test score (range, 0-4) reflects a physician's propensity to order low-value care across screening tests. Physicians were then dichotomized into infrequent or isolated frequent users (score, 0 or 1, respectively) or generalized frequent users for 2 or more tests (score, ≥2).ResultsThe final sample consisted of 2394 primary care physicians (mean [SD] age, 51.3 [10.0] years; 50.2% female), who were predominantly Canadian medical school graduates (1701 [71.1%]), far removed from medical school graduation (median, 25.3 years; interquartile range, 17.3-32.3 years), and reimbursed via fee-for-service in a family health group (1130 [47.2%]). They ordered 302 509 low-value screening tests (74 167 DXA scans, 179 855 ECGs, 19 906 Pap tests, and 28 581 CXRs) after 3 428 557 ordering opportunities. Within the cohort, generalized frequent users represented 18.4% (441 of 2394) of physicians but ordered 39.2% (118 665 of 302 509) of all low-value screening tests. Physicians who were male (odds ratio, 1.29; 95% CI, 1.01-1.64), further removed from medical school graduation (odds ratio, 1.03; 95% CI, 1.02-1.04), or in an enhanced fee-for-service payment model (family health group) vs a capitated payment model (family health team) (odds ratio, 2.04; 95% CI, 1.42-2.94) had increased odds of being generalized frequent users.Conclusions and relevanceThis study identified a group of primary care physicians who frequently ordered low-value screening tests. Tailoring future interventions to these generalized frequent users might be an effective approach to reducing low-value care.

Project description:ImportanceMany health systems are considering increasing price transparency at the time of order entry. However, evidence of its impact on clinician ordering behavior is inconsistent and limited to single-site evaluations of shorter duration.ObjectiveTo test the effect of displaying Medicare allowable fees for inpatient laboratory tests on clinician ordering behavior over 1 year.Design, setting, and participantsThe Pragmatic Randomized Introduction of Cost data through the electronic health record (PRICE) trial was a randomized clinical trial comparing a 1-year intervention to a 1-year preintervention period, and adjusting for time trends and patient characteristics. The trial took place at 3 hospitals in Philadelphia between April 2014 and April 2016 and included 98 529 patients comprising 142 921 hospital admissions.InterventionsInpatient laboratory test groups were randomly assigned to display Medicare allowable fees (30 in intervention) or not (30 in control) in the electronic health record.Main outcomes and measuresPrimary outcome was the number of tests ordered per patient-day. Secondary outcomes were tests performed per patient-day and Medicare associated fees.ResultsThe sample included 142 921 hospital admissions representing patients who were 51.9% white (74 165), 38.9% black (55 526), and 56.9% female (81 291) with a mean (SD) age of 54.7 (19.0) years. Preintervention trends of order rates among the intervention and control groups were similar. In adjusted analyses of the intervention group compared with the control group over time, there were no significant changes in overall test ordering behavior (0.05 tests ordered per patient-day; 95% CI, -0.002 to 0.09; P = .06) or associated fees ($0.24 per patient-day; 95% CI, -$0.42 to $0.91; P = .47). Exploratory subset analyses found small but significant differences in tests ordered per patient-day based on patient intensive care unit (ICU) stay (patients with ICU stay: -0.16; 95% CI, -0.31 to -0.01; P = .04; patients without ICU stay: 0.13; 95% CI, 0.08-0.17; P < .001) and the magnitude of associated fees (top quartile of tests based on fee value: -0.01; 95% CI, -0.02 to -0.01; P = .04; bottom quartile: 0.03; 95% CI, 0.002-0.06; P = .04). Adjusted analyses of tests that were performed found a small but significant overall increase in the intervention group relative to the control group over time (0.08 tests performed per patient day, 95% CI, 0.03-0.12; P < .001).Conclusions and relevanceDisplaying Medicare allowable fees for inpatient laboratory tests did not lead to a significant change in overall clinician ordering behavior or associated fees.Trial registrationclinicaltrials.gov Identifier: NCT02355496.

Project description:ImportanceThe use of electronic health records (EHRs) is directly associated with physician burnout. An underlying factor associated with burnout may be EHR-related fatigue owing to insufficient user-centered interface design and suboptimal usability.ObjectiveTo examine the association between EHR use and fatigue, as measured by pupillometry, and efficiency, as measured by mouse clicks, time, and number of EHR screens, among intensive care unit (ICU) physicians completing a simulation activity in a prominent EHR.Design, setting, and participantsA cross-sectional, simulation-based EHR usability assessment of a leading EHR system was conducted from March 20 to April 5, 2018, among 25 ICU physicians and physician trainees at a southeastern US academic medical center. Participants completed 4 simulation patient cases in the EHR that involved information retrieval and task execution while wearing eye-tracking glasses. Fatigue was quantified through continuous eye pupil data; EHR efficiency was characterized through task completion time, mouse clicks, and EHR screen visits. Data were analyzed from June 1, 2018, to August 31, 2019.Main outcomes and measuresPrimary outcomes were physician fatigue, measured by pupillometry (with lower scores indicating greater fatigue), and EHR efficiency, measured by task completion times, number of mouse clicks, and number of screens visited during EHR simulation.ResultsThe 25 ICU physicians (13 women; mean [SD] age, 32.1 [6.1] years) who completed a simulation exercise involving 4 patient cases (mean [SD] completion time, 34:43 [11:41] minutes) recorded a total of 14 hours and 27 minutes of EHR activity. All physician participants experienced physiological fatigue at least once during the exercise, and 20 of 25 participants (80%) experienced physiological fatigue within the first 22 minutes of EHR use. Physicians who experienced EHR-related fatigue in 1 patient case were less efficient in the subsequent patient case, as demonstrated by longer task completion times (r = -0.521; P = .007), higher numbers of mouse clicks (r = -0.562; P = .003), and more EHR screen visits (r = -0.486; P = .01).Conclusions and relevanceThis study reports high rates of fatigue among ICU physicians during short periods of EHR simulation, which were negatively associated with EHR efficiency and included a carryover association across patient cases. More research is needed to investigate the underlying causes of EHR-associated fatigue, to support user-centered EHR design, and to inform safe EHR use policies and guidelines.

Project description:ImportanceInfluenza vaccination rates in the United States are suboptimal near 40%, but little is known about variations in care based on clinic appointment time.ObjectivesTo compare differences in influenza vaccination rates by clinic appointment time and to evaluate the association of an active choice intervention in the electronic health record with changes in vaccination rates.Design, setting, and participantsRetrospective, quality improvement study of 11 primary care practices at the University of Pennsylvania Health System from September 1, 2014, to March 31, 2017. Participants included adults eligible for influenza vaccination. Data analysis was conducted from October 20, 2017, to March 9, 2018.InterventionsDuring the 2016 to 2017 influenza season, 3 primary care practices at the University of Pennsylvania Health System implemented an active choice intervention in the electronic health record that prompted medical assistants to ask patients about influenza vaccination during check-in and template vaccination orders for clinicians to review during the visit.Main outcomes and measuresInfluenza vaccination rates.ResultsThe sample comprised 96 291 patients with a mean (SD) age of 56.2 (17.0) years; 41 865 (43.5%) were men, 61 813 (64.2%) were white, and 23 802 (24.7%) were black. Among all practices across all 3 years, vaccination rates were approximately 44% from 8 am to 10 am, declined to 41.2% by 11 am and 38.3% at noon, increased to 40.2% at 1 pm, and then declined to 34.3% at 3 pm and 32.0% at 4 pm (P < .001 for adjusted linear trend). For the 3 years, vaccination rates were 46.9%, 47.2%, and 45.6% at control practices and 49.7%, 52.2%, and 59.3% at intervention practices, respectively. In adjusted analyses, compared with control practices over time, the active choice intervention was associated with a significant 9.5-percentage point increase in vaccination rates (95% CI, 4.1-14.3; P < .001). Vaccination rates increased similarly across times of the day.Conclusions and relevanceInfluenza vaccination rates significantly declined as the clinic day progressed. The active choice intervention was associated with a significant increase in influenza vaccination rates that were similar in magnitude throughout the day.

Project description:BackgroundPhysician burnout has a direct impact on the delivery of high-quality health care, with health information technology tools such as electronic health records (EHRs) adding to the burden of practice inefficiencies.ObjectiveThe aim of this study was to determine the extent of burnout among physicians and learners (residents and fellows); identify significant EHR-related contributors of physician burnout; and explore the differences between physicians and learners with regard to EHR-related factors such as time spent in EHR, documentation styles, proficiency, training, and perceived usefulness. In addition, the study aimed to address gaps in the EHR-related burnout research methodologies by determining physicians' patterns of EHR use through usage logs.MethodsThis study used a cross-sectional survey methodology and a review of administrative data for back-end log measures of survey respondents' EHR use, which was conducted at a large Canadian academic mental health hospital. Chi-square and Fisher exact tests were used to examine the association of EHR-related factors with general physician burnout. The survey was sent out to 474 individuals between May and June 2019, including physicians (n=407), residents (n=53), and fellows (n=14), and we measured physician burnout and perceptions of EHR stressors (along with demographic and practice characteristics).ResultsOur survey included 208 respondents, including physicians (n=176) and learners (n=32). The response rate was 43.2% for physicians (full-time: 156/208, 75.0%; part-time: 20/199, 10.1%), and 48% (32/67) for learners. A total of 25.6% (45/176) of practicing physicians and 19% (6/32) of learners reported having one or more symptoms of burnout, and 74.5% (155/208) of all respondents who reported burnout symptoms identified the EHR as a contributor. Lower satisfaction and higher frustration with the EHRs were significantly associated with perceptions of EHR contributing toward burnout. Physicians' and learners' experiences with the EHR, gathered through open-ended survey responses, identified challenges around the intuitiveness and usability of the technology as well as workflow issues. Metrics gathered from back-end usage logs demonstrated a 13.6-min overestimation in time spent on EHRs per patient and a 5.63-hour overestimation of after-hours EHR time, when compared with self-reported survey data.ConclusionsThis study suggests that the use of EHRs is a perceived contributor to physician burnout. There should be a focus on combating physician burnout by reducing the unnecessary administrative burdens of EHRs through efficient implementation of systems and effective postimplementation strategies.

Dataset Information

Using active choice within the electronic health record to increase physician ordering and patient completion of high-value cancer screening tests.

Publications

Using active choice within the electronic health record to increase physician ordering and patient completion of high-value cancer screening tests.

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