Using the Electronic Health Record to Improve Transfer of Medical Info

On September 19, 2011, Anthony Brown made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (1.1 MB). 

Slide 1

Using the Electronic Health Record to Improve Transfer of Medical Information after a Primary Care Office Visit

Anthony E Brown, MD, MPH
J Travis Gossey, MD, MS, MPH
Susan G Nash, PhD
Adriana Linares, MD, DrPH
Valory Pavlik, PhD

Baylor College of Medicine

Slide 2

Disclosure Information
AHRQ Conference, September 18-21, 2011
Anthony Brown MD MPH

• Disclosure of Relevant Financial Relationships:
  • I have no financial relationships to disclose.
• Disclosure of Off-Label and/or Investigative Uses:
  • I will not discuss off label use and/or investigational use in my presentation.

Slide 3

Task Order #17: Using Health Information Technology to Improve Healthcare Quality in Primary Care Practices and in Transitions between Care Settings

• Sponsor: Agency for Healthcare Research and Quality (AHRQ).
• Contract: University of New Mexico (UNM), Robert Williams, MD, MPH (PRIME-Net).
• Subcontract: Baylor College of Medicine.
• PBRN: PRIME-Net/SPUR-Net.

Slide 4

Relevance

• Up to 50% of the information relayed to patients during a visit is forgotten by the time they leave.
• The after-visit summary (AVS) is built from information in the electronic health record (EHR).
• (AVS) may improve patient retention of that information.
• After the project began Centers for Medicare and Medicaid Services (CMS) released Meaningful Use (MU) AVS guidelines.
• Limited evidence exists to inform the design of the AVS.

Slide 5

Goals and AHRQ Priority Population Focus

• To determine the optimal format and content for the AVS in primary care settings serving economically and ethnically diverse patients.
• Three phase study consisting of qualitative data from physicians and patients, development of three different AVS, evaluation of AVS versions in comparison to a fourth group consisting of the usual care AVS at the clinic site.
• Data collection is ongoing and we are presenting initial findings.

Slide 6

Patient Centered Care: Patient Response Summary

• Many reported satisfaction with current AVS.
• Visual appearance of the form was not a concern for most.
• Some requested additional information yielding a list similar to CMS "Meaningful Use" requirements.
• Medication lists were not always current.
• Reinforced education potential of the AVS through explanations of diagnoses and medications, and inclusion of diet/exercise plans and personalized health goals.
• Along with easier to read summaries, many patients requested more details and directions in the AVS, particularly in regard to medications.

Slide 7

Spanish Speaking Patients

• Those with little or no English fluency wished to receive information in Spanish.
• Often share the AVS with their families.
• The free text box can be used for Spanish information.
• Concerns for the monolingual Spanish speaking patient:
  • More detailed instructions for medications.
  • Inclusion of prevention topics such as diet and exercise and ways to stay healthy.
  • Understanding tests ordered.
  • Confidentiality of the AVS.

Slide 8

CMS Meaningful Use (MU) AVS Guidelines

• Patient name.
• Provider's office contact information.
• Date and location of visit.
• Medication list.
• Vitals.
• Reason for visit.
• Symptoms.
• Instructions based on clinical discussions that took place during office visit.
• Problem list.
• Immunizations or medications administered.
• Summary of topics covered.
• Future appointment and test information.
• Recommended patient decision aids.
• Test/laboratory results (if received before 24 hours after visit).

https://questions.cms.hhs.gov/app/answers/detail/a_id/10558/~/%5Behr-incentive-program%5D-what-information-must-an-eligible-professional-provide.

Slide 9

Programming Constraints

• Problem list is generated from ICD-9 codes without the ability to translate to Spanish or into "everyday" language.
• For the Spanish speakers the best we could do would be to translate the headings.
• Medication auto generated by EHR prescribed list.
• AVS given at time of visit so only in office same day lab results available for the AVS.
• Patient instructions free text box:
  • Required by health system to be on every AVS.
  • Used by physicians for personalized instructions and for education materials.
  • Information added here at times extends the length of the AVS by several pages.

Slide 10

Prototype AVS Forms

Slide 11

AVS 1

Image: Screen shots of the After Visit Summary form are shown.

Slide 12

AVS 2

Image: Screen shots of the After Visit Summary form are shown.

Slide 13

AVS 3

Image: Screen shots of the After Visit Summary form are shown.

Slide 14

Translatability

• A program code was developed for each test version.
• The health systems' programming team inserted the code into the EHR environment.
• The design of the three experimental AVS versions was constrained by the existing Epic EHR environment in our research settings.
• Program code can be disseminated to other healthcare settings utilizing the Epic EHR:
  • 56514—AVS: Current Meds" The line to execute this command should be:
    • d CtAcMeds^LARHCR62("Current Medications / Medicamentos Actuales","","",2,"", 3,"","","","","","","","", 1,"",1,1,1,"Facility-Administered Medications",1,"","","","").

Slide 15

Evaluation of AVS

• We are testing the three different AVS versions in a randomized design.
• A fourth group received the existing AVS format in each clinic.
• Primary outcome:
  • Amount of information recalled by patients at the follow up time points.
  • Recall test consists of two parts:
    • Part 1: recall of the general categories of information contained on the AVS.
    • Part 2: ask the patient to generate the list of medications prescribed and instructions given.
  • The total test score is the percent of items correctly recalled.
• Secondary Outcomes:
  • Patient Satisfaction with the AVS.
  • Adherence to Treatment.
• Other Study Variables:
  • Health Literacy—Short Test of Functional Health Literacy in Adults (S-TOFHLA).
  • Demographic and Health.

Slide 16

Conclusions

• Physicians prefer a brief but accurate AVS, whereas patients focus more on inclusiveness and accessibility of the information.
• This is a work in progress; we have recruited 174 of a planned 272 patients to the randomized experiment.
• Our experiment will indicate whether variation in content affects recall, adherence, use of information, or patient satisfaction.
• More details available at our poster on display at this conference.
• Contact: Anthony Brown, MD MPH: anthonyb@bcm.edu.

Slide 17

Acknowledgements

• Research Coordinators: Lillian Carreon, Roshanda Chenier, Abdul Syed, Lizette Rangel, and Ashela Bean.
• Physician and patient participants.