Resident duty hours in the outpatient electronic health record era: inaccuracies and implications.
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ABSTRACT:
SUBMITTER: Gilleland M
PROVIDER: S-EPMC3963775 | biostudies-other | 2014 Mar
REPOSITORIES: biostudies-other
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Project description:BackgroundIn July 2011, the Accreditation Council for Graduate Medical Education (ACGME) will implemented stricter duty-hour limits and related changes to the training environment. This may affect preventable adverse event (PAE) rates.ObjectivesTo estimate direct costs under various implementation approaches, and examine net costs to teaching hospitals and cost-effectiveness to society across a range of hypothetical changes in PAEs.DesignA decision-analytical model represented direct costs and PAE rates, mortality, and costs.Data sourcesPublished literature and publicly available data.Target populationPatients admitted to hospitals with ACGME-accredited programs.Time horizonOne year.PerspectivesAll teaching hospitals, major teaching hospitals, society.InterventionACGME's 2011 Common Program Requirements.Outcome measuresDirect annual costs (all accredited hospitals), net cost (major teaching hospitals), cost per death averted (society). RESULTS OF BASE-ANALYSIS: Nationwide, duty-hour changes would cost $177 million annually if interns maintain current productivity, vs. up to $982 million if they transfer work to a mixture of substitutes; training-environment changes will cost $204 million. If PAEs decline by 7.2-25.8%, net costs to major teaching hospitals will be zero. If PAEs fall by 3%, the cost to society per death averted would be -$523,000 (95%-confidence interval: -$1.82 million to $685,000) to $2.44 million ($271,000 to $6.91 million). If PAEs rise, the policy will be cost-increasing for teaching hospitals and society.Results of sensitivity analysisThe total direct annual cost nationwide would be up to $1.34 billion using nurse practitioners/physician assistants, $1.64 billion using attending physicians, $820 million hiring additional residents, vs. 1.42 billion using mixed substitutes.LimitationsThe effect on PAEs is unknown. Data were limited for some model parameters.ConclusionImplementation decisions greatly affect the cost. Unless PAEs decline substantially, teaching hospitals will lose money. If PAEs decline modestly, the requirements might be cost-saving or cost-effective to society.
| S-EPMC3270247 | biostudies-literature
Project description:Physicians in general, and residents in particular, are adapting to duty schedules in which they have fewer continuous work hours; however, there are no Canadian guidelines on duty hours restrictions. To better inform resident duty hour policy in Canada, we set out to prepare a set of recommendations that would draw upon evidence reported in the literature and reflect the experiences of resident members of the Canadian Association of Internes and Residents (CAIR). A survey was prepared and distributed electronically to all resident members of CAIR. A total of 1796 eligible residents participated in the survey. Of those who responded, 38% (601) reported that they felt they could safely provide care for up to 16 continuous hours, and 20% (315) said that 12 continuous hours was the maximum period during which they could safely provide care (n=1592). Eighty-two percent (1316) reported their perception that the quality of care they had provided suffered because of the number of consecutive hours worked (n=1598). Only 52% (830) had received training in handover (n=1594); those who had received such training reported that it was commonly provided through informal modelling. On the basis of these data and the existing literature, CAIR recommends that resident duty hours be managed in a way that does not endanger the health of residents or patients; does not impair education; is flexible; and does not violate ethical or legal standards. Further, residents should be formally trained in handover skills and alternative duty hour models.
| S-EPMC4304289 | biostudies-literature
Project description:IntroductionIn 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented new Common Program Requirements to regulate duty hours of resident physicians, with three goals: improved patient safety, quality of resident education and quality of life for trainees. We sought to assess Internal Medicine program director (IMPD) perceptions of the 2011 Common Program Requirements in July 2012, one year following implementation of the new standards.MethodsA cross-sectional study of all IMPDs at ACGME-accredited programs in the United States (N?=?381) was performed using a 32-question, self-administered survey. Contact information was identified for 323 IMPDs. Three individualized emails were sent to each director over a 6-week period, requesting participation in the survey. Outcomes measured included approval of duty hours regulations, as well as perceptions of changes in graduate medical education and patient care resulting from the revised ACGME standards.ResultsA total of 237 surveys were returned (73% response rate). More than half of the IMPDs (52%) reported "overall" approval of the 2011 duty hour regulations, with greater than 70% approval of all individual regulations except senior resident daily duty periods (49% approval) and 16-hour intern shifts (17% approval). Although a majority feel resident quality of life has improved (55%), most IMPDs believe that resident education (60%) is worse. A minority report that quality (8%) or safety (11%) of patient care has improved.ConclusionOne year after implementation of new ACGME duty hour requirements, IMPDs report overall approval of the standards, but strong disapproval of 16-hour shift limits for interns. Few program directors perceive that the duty hour restrictions have resulted in better care for patients or education of residents. Although resident quality of life seems improved, most IMPDs report that their own workload has increased. Based on these results, the intended benefits of duty hour regulations may not yet have been realized.
| S-EPMC4175662 | biostudies-literature
Project description:Monitoring and managing resident workload is a cornerstone of policy in graduate medical education, and the duty hours metric is the backbone of current regulations. While the duty hours metric measures hours worked, it does not capture differences in intensity of work completed during those hours, which may independently contribute to fatigue and burnout. Few such metrics exist. Digital data streams generated during the usual course of hospital operations can serve as a novel source of insight into workload intensity by providing high-resolution, minute-by-minute data at the individual level; however, study and use of these data streams for workload monitoring has been limited to date. Paging data is one such data stream. In this work, we analyze over 500,000 pages-two full years of pages in an academic internal medicine residency program-to characterize paging patterns among housestaff. We demonstrate technical feasibility, validity, and utility of paging burden as a metric to provide insight into resident workload beyond duty hours alone, and illustrate a general framework for evaluation and incorporation of novel digital data streams into resident workload monitoring.
| S-EPMC6733865 | biostudies-literature
Project description:Electronic health record (EHR) log data capture clinical workflows and are a rich source of information to understand variation in practice patterns. Variation in how EHRs are used to document and support care delivery is associated with clinical and operational outcomes, including measures of provider well-being and burnout. Standardized measures that describe EHR use would facilitate generalizability and cross-institution, cross-vendor research. Here, we describe the current state of outpatient EHR use measures offered by various EHR vendors, guided by our prior conceptual work that proposed seven core measures to describe EHR use. We evaluate these measures and other reporting options provided by vendors for maturity and similarity to previously proposed standardized measures. Working toward improved standardization of EHR use measures can enable and accelerate high-impact research on physician burnout and job satisfaction as well as organizational efficiency and patient health.
| S-EPMC8068413 | biostudies-literature
Project description:Background?:Advances in information technology have increased remote access to the electronic health record (EHR). Concurrently, standards defining appropriate resident supervision have evolved. How often and under what circumstances inpatient attending physicians remotely access the EHR for resident supervision is unknown. Objective?:We described a model of attending remote EHR use for resident supervision, and quantified the frequency and magnitude of use. Methods?:Using a mixed methods approach, general medicine inpatient attendings were surveyed and interviewed about their remote EHR use. Frequency of use and supervisory actions were quantitatively examined via survey. Transcripts from semistructured interviews were analyzed using grounded theory to identify codes and themes. Results?:A total of 83% (59 of 71) of attendings participated. Fifty-seven (97%) reported using the EHR remotely, with 54 (92%) reporting they discovered new clinical information not relayed by residents via remote EHR use. A majority (93%, 55 of 59) reported that this resulted in management changes, and 54% (32 of 59) reported making immediate changes by contacting cross-covering teams. Six major factors around remote EHR use emerged: resident, clinical, educational, personal, technical, and administrative. Attendings described resident and clinical factors as facilitating "backstage" supervision via remote EHR use. Conclusions?:In our study to assess attending remote EHR use for resident supervision, attendings reported frequent remote use with resulting supervisory actions, describing a previously uncharacterized form of "backstage" oversight supervision. Future work should explore best practices in remote EHR use to provide effective supervision and ultimately improve patient safety.
| S-EPMC5734323 | biostudies-literature
Project description:Background and objectivesResident duty hours remain a controversial topic in the literature. Competing interests include patient safety, resident education, and resident well-being. No studies, however, have sought family members' perspectives on duty hours in the paediatric context. This study aimed to explore family members' knowledge of trainee duty hours, and their perspectives on the balance between shift duration and hand-off frequency.MethodsWe surveyed family members of patients admitted ≥ 24 hours in the paediatric intensive care unit at an academic center. We simultaneously collected daily logs of hours worked by trainees. Descriptive statistics were used to analyze survey responses and trainee duty hours.ResultsOne-hundred and one family members responded (75%). Respondents demonstrated knowledge of trainees working long duty hours but reported lower averages than the trainee logs (55 versus 66 hours per week and 16 versus 24 hours per shift). Elements related to both potential trainee fatigue and hand-offs raised concern in more than half of respondents. When asked to choose between a familiar trainee working a prolonged shift, or an unfamiliar trainee at the start of their shift, respondents were divided (52% versus 48%, respectively).ConclusionsFamily members of critically ill paediatric patients are aware that trainees provide patient care while working long duty hours with minimal sleep. Despite this awareness, long shifts retain value with some families, possibly due to continuity. Changes to duty hours and hand-off frequency may pose an unrealized harm on family-centered care, as well as patient-provider relationships, and further study is warranted.
| S-EPMC7606163 | biostudies-literature
Project description:ObjectiveThe study sought to characterize rates of problem list completeness and duplications in common chronic diseases and to identify any relationships that they may have with respect to disease type, demographics, and disease severity.Materials and methodsWe performed a retrospective analysis of electronic health record data from Partners HealthCare. We selected 8 common chronic diseases and identified patients with each of those diseases. We then analyzed each patient's problem list for completeness and duplications and also collected information regarding demographics and disease severity. Rates of completeness and duplications were calculated for each disease and compared according to disease type, demographics, and disease severity.ResultsA total of 327 695 unique patients and 383 404 problem list entries were identified. Problem list completeness varied from 72.9% in hypertension to 93.5% in asthma, whereas problem list duplications varied from 4.8% in hypertension to 28.2% in diabetes. There was a variable relationship between demographic factors and rates of completeness and duplication. Rates of completeness were positively correlated with disease severity for most diseases. Rates of duplication were consistently positively correlated with disease severity.ConclusionsIncompleteness and duplications are both important issues in problem lists. These issues vary widely across different diseases and can also be impacted by patient demographics and disease severity. Further studies are needed to investigate the effect of individual user behaviors and organizational policies on problem list utilization, which will aid the development of interventions that improve the utility of problem lists.
| S-EPMC7481031 | biostudies-literature
Project description:To determine whether the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hours reform affected medical knowledge as reflected by written board scores for internal medicine (IM) residents.The authors conducted a retrospective cohort analysis of postgraduate year 1 (PGY-1) Internal Medicine residents who started training before and after the 2003 duty hour reform using a merged data set of American Board of Internal Medicine (ABIM) Board examination and the National Board of Medical Examiners (NMBE) United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge test scores. Specifically, using four regression models, the authors compared IM residents beginning PGY-1 training in 2000 and completing training unexposed to the 2003 duty hours reform (PGY-1 2000 cohort, n = 5,475) to PGY-1 cohorts starting in 2001 through 2005 (n = 28,008), all with some exposure to the reform.The mean ABIM board score for the unexposed PGY-1 2000 cohort (n = 5,475) was 491, SD = 85. Adjusting for demographics, program, and USMLE Step 2 exam score, the mean differences (95% CI) in ABIM board scores between the PGY-1 2001, 2002, 2003, 2004 and 2005 cohorts minus the PGY-1 2000 cohort were -5.43 (-7.63, -3.23), -3.44 (-5.65, -1.24), 2.58 (0.36, 4.79), 11.10 (8.88, 13.33) and 11.28 (8.98, 13.58) points respectively. None of these differences exceeded one-fifth of an SD in ABIM board scores.The duty hours reforms of 2003 did not meaningfully affect medical knowledge as measured by scores on the ABIM board examinations.
| S-EPMC4139168 | biostudies-literature
Project description:Although complete and accurate clinical records do not guarantee the provision of excellent dental care, they do provide an opportunity to evaluate the quality of care provided. However, a lack of universally accepted documentation standards, incomplete record-keeping practices, and unfriendly electronic health care record (EHR) user interfaces are factors that have allowed for persistent poor dental patient record keeping.Using 2 different methods-a validated survey, and a 2-round Delphi process-involving 2 appropriately different sets of participants, we explored what a dental clinical record should contain and the frequency of update of each clinical entry.For both the closed-ended survey questions and the open-ended Delphi process questions, respondents had a significant degree of agreement on the "clinical entry" components of an adequate clinical record. There was, however, variance on how frequently each of those clinical entries should be updated.Dental providers agree that complete and accurate record keeping is essential and that items such as histories, examination findings, diagnosis, radiographs, treatment plans, consents, and clinic notes should be documented. There, however, does not seem to be universal agreement how frequently such items should be recorded.As the dental profession moves towards prevalent use of electronic health care records, the issue of standardization and interoperability becomes ever more pressing. Settling issues of standardization, including record documentation, must begin with guideline-creating dental professional bodies, who need to clearly define and disseminate what these standards should be and everyday dentists who will ultimately ensure that these standards are met and kept.
| S-EPMC5119920 | biostudies-literature