Index by author

The Issue in Brief

Sep/Oct 2011

Meaningful Use of Electronic Prescribing in 5 Exemplar Primary Care Practices

Jesse C. Crosson, and colleagues

Background In the United States, many physicians have adopted e-prescribing but do not regularly use it to write prescriptions. In addition, new approaches to adopting e-prescribing are needed to meet federal policy goals. This study identifies key lessons from 5 primary care practices that effectively e-prescribe.

What This Study Found Successful use of e-prescribing requires substantial investments of planning time and ongoing transformation of work processes. Practices that successfully incorporate e-prescribing have substantial resources to support e-prescribing use, including local physician champions, ongoing training for practice members, and continuous on-site technical support. Even these practices, however, face considerable challenges in e-prescribing, including problems coordinating new work processes with pharmacies and ineffective health information exchange that requires workarounds to ensure the completeness of patient records.

Implications

• Although e-prescribing is among the technologies expected to transform health care in the near future, successful and widespread implementation will require a longer-term commitment to supporting practice transformation, resources to aid in making these changes, and improvements to the infrastructure for health information exchange.

A Diabetes Dashboard and Physician Efficacy and Accuracy in Accessing Data Needed for High-Quality Diabetes Care

Richelle J. Koopman, and colleagues

Background In order for electronic health records (EHRs) to function as effective patient care tools, improvements are needed in a variety of areas, including ease of obtaining information. This study investigates a new "diabetes dashboard" that summarizes information needed to care for diabetes patients.

What This Study Found A diabetes dashboard greatly improves the efficiency and accuracy of finding data. Specifically, the study compares the use of a diabetes dashboard screen with use of a conventional approach of viewing multiple electronic health record screens to find 10 data elements needed for ambulatory diabetes care. The mean time to find all elements using the diabetes dashboard is 1.3 minutes vs. 5.5 minutes using the conventional approach. Participating physicians correctly identify 100 percent of the data requested when using the dashboard vs 94 percent when using the conventional method. Moreover, the average number of mouse clicks is 3 with the diabetes dashboard vs 60 using conventional searching.

Implications

• The authors suggest that, although tools such as the diabetes dashboard require substantial resources to design and develop, they could reduce costs in the long run by saving physician time and preventing unnecessary tests and medical errors.

Coordination of Health Behavior Counseling in Primary Care

Deborah J. Cohen, and colleagues

Background Primary care practices may be well-suited to coordinate counseling for patients in need of health behavior change. Little is known, however, about how to implement such coordination effectively. This study examines barriers and facilitators to coordinating health behavior counseling in primary care.

What This Study Found A combination of in-practice health risk assessment and brief counseling, plus referral with outreach to a valued and known counseling resource, is the best way to consistently coordinate care and encourage follow-through. Researchers evaluating data collected by 9 practice-based research networks in the national Prescription for Health Program found this approach led to improvement in patients' health behaviors.

Implications

• The authors call for implementation of easy-to-use point-of-delivery reminders and decision support tools to help facilitate the coordination of health behavior counseling.

Evaluation of Physical Activity Counseling in Primary Care Using Direct Observation of the 5As

Susan A. Flocke, and colleagues

Background The 5As (ask, advise, assess, assist, arrange) are recommended as a strategy for brief physical activity counseling in primary care. There is no reference standard measurement, however, and patient participation is not well understood. This study reports on a new method to measure the 5As and describes the degree to which patients and physicians accomplish the 5As in discussions of physical activity.

What This Study Found During 361 audio-recorded office visits, the overall frequency of any 5As talk about physical activity was 38 percent. Physicians infrequently assess patients' readiness to change, though it is commonly revealed by patients in response to the physicians' assessment of their current level of activity. Patients often express ambivalence about changing their behavior, and physicians make limited or no attempts to offer assistance.

Implications

• The authors suggest that, in discussions of physical activity, clinicians improve their skills in exploring patient ambivalence and readiness to change and increase explicit mention of recommended guidelines.

Nonsteroidal Anti-Inflammatory Drug Use Among Persons With Chronic Kidney Disease in the United States

Laura Plantinga, and colleagues

Background Nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with kidney injury and progression of kidney disease. As a result, it is recommend that most patients with chronic kidney disease (CKD) avoid NSAIDs. Little is known, however, about patterns of NSAID use among those with CKD in community settings. This study describes the prevalence and patterns of self-reported NSAID use among adults with CKD.

What This Study Found Large numbers of people with CKD, many of whom are unaware of their condition, are using NSAIDs and may be at risk for further kidney injury. Among 12,065 adults, current use of any NSAID is reported by 2.5 percent, 2.5 percent and 5 percent of patients with no, mild, and moderate to severe CKD, respectively. Nearly all NSAIDs used are over-the-counter. Among those with moderate to severe CKD who currently use NSAIDs, 10 percent have a current NSAID prescription, and 66 percent have used NSAIDs for more than 1 year.

Implications

• The authors recommend that primary care physicians, who are likely to manage both early-stage CKD and indications for NSAID use, be aware of rates of NSAID use (both prescribed and over-the-counter), assess the risk of such use, and engage patients in informed decision making about the risks and benefits of using NSAIDs.

Original and REGICOR Framingham Functions in a Nondiabetic Population of a Spanish Health Care Center: A Validation Study

Francisco Buitrago, and colleagues

Background Risk prediction models are designed to estimate the probability of a patient developing a clinical condition based on known risk factors. This study evaluates the performance of 2 long-established risk scoring mechanisms for coronary disease: the original Framingham and REGICOR Framingham mechanisms.

What This Study Found Researchers find that one scoring mechanism overestimates risk, whereas the other underestimates it. This 10-year observational study of 447 adult nondiabetic patients in Spain finds that the Framingham risk function overestimates coronary risk by 73 percent, whereas the REGICOR Framingham function underpredicts the population's coronary risk by 64 percent. Moreover, the original Framingham function selects a greater percentage of candidates for antihypertensive and lipid-lowering therapies than the REGICOR function. The proportion of patients included in the high coronary risk category also is doubled with the original Framingham equation.

Implications

• That both models fail to accurately predict the population's actual coronary risk in the 10-year follow-up period is not surprising to the authors. The original Framingham study was conducted before the widespread use of effective treatment for cardiovascular risk factors, so its equation currently overpredicts cardiovascular risk when applied to populations who have their risk factors actively managed.
• The authors conclude the Framingham risk mechanisms could be improved by revising them to include additional cardiovascular risk factors and variables, such as family history of cardiovascular disease in a first-degree relative, social deprivation, body mass index, and current prescription of antihypertensive therapy.

Suffering in Silence: Reasons for Not Disclosing Depression in Primary Care

Robert A. Bell, and colleagues

Background One-fourth of primary care patients with major depressive disorder do not have their condition diagnosed. This study explores reasons why patients do not disclose depression to their primary care doctors.

What This Study Found Many adults have beliefs that inhibit them from disclosing symptoms of depression to their primary care doctor. In a survey of 1,054 adults, 43 percent of patients report one or more reasons for not talking to a primary care doctor about their depression. The most frequently cited reason is concern that the doctor will recommend antidepressants. Other reported barriers include the belief that it is not the primary care physician's job to deal with emotional issues, concerns about medical record confidentiality, fear of referral to a counselor or psychiatrist, and fear of being labeled a psychiatric patient.

Implications

• Those who most subscribe to potential reasons for not talking to a primary care physicians about their depression tend to be those who have the greatest potential benefit from such conversations: individuals with moderate to severe depressive symptoms.
• The authors call for the development of office-based interventions that address these patients' concerns and encourage patients with depression symptoms to begin a conversation with their doctors.

Patient and Clinician Openness to Including a Broader Range of Healing Options in Primary Care

Clarissa Hsu, and colleagues

Background Although patients and clinicians have expressed strong interest in complementary and alternative medical therapies, larger health care organizations have been slow to integrate such approaches. This study explores beliefs and attitudes of primary care patients and clinicians about integrating additional healing options into primary care.

What This Study Found Doctors and patients are open to integrating complementary and alternative medicine therapies into primary care, especially for patients whose conditions are not responding well to standard medical treatments. Focus groups with 44 patients and 32 clinicians revealed that while patients are open to including a wider variety of healing options, they desire some evidence of effectiveness. Moreover, patients want physicians to introduce recommendations as options, not orders, and are interested in hearing about the clinicians' personal and practice experience with different treatments. Clinicians are most concerned about the safety of treatments, specifically herbs and dietary supplements. They express the need for better information about the nature, effectiveness, and safety of alternative healing options, as well as current and reliable information on practitioners and resources in their communities to whom they can confidently refer patients.

Implications

• The authors call for further research to clarify the safety, clinical effectiveness, and cost-effectiveness of specific healing options and of the integration of various packages of such options into primary care.

Shared Mind: Communication, Decision Making, and Autonomy in Serious Illness

Ronald M. Epstein, and colleagues

Background Individuals often rely on others to help them make difficult medical decisions, especially when dealing with a serious illness. This article explores why, when, and how people involve trusted others in sharing information, deliberating, and decision making.

What This Study Found The authors introduce the concept of "shared mind:" ways in which new ideas and perspectives can emerge when 2 or more people share thoughts, feelings, perceptions, meanings, and intentions. They explore how shared mind manifests in relationships and organizations, how it might be promoted through communication, and its implications for decision making and patient autonomy. The article also looks at a continuum of patient-centered approaches to patient-clinician interactions and proposes that autonomy and decision making consider not only the individual perspectives of patients, their families, and members of the health care team, but also the perspectives that emerge from the interactions between them.

Implications

• Shared mind, like caring, may be difficult to measure, but that should not diminish its importance.
• By being aware of shared mind, clinicians can note ways in which they and others can make helpful contributions to decision-making processes and enhance patient autonomy.