LINICIANS TEST FOR PROTHROMbotic genetic mutations including factor V Leiden (FVL) (612309.001) and prothrombin G20210A (176930.0009) when treating patients who have had or are at risk of venous thromboembolism (VTE). Factor V Leiden refers to a single base change in the factor V gene (G1691A) that eliminates 1 of its 3 activated protein C cleavage sites. Consequently, factor V is inactivated at a lower rate, leading to more thrombin generation. 1 A single FVL allele is present in about 5%, 2.2%, and 1.2% of white, Hispanic and African American populations in the United States. 2 The prothrombin (factor II) mutation is the second most common inherited risk factor for VTE. This allele is present in 1.1% of non-Hispanic whites and Mexican Americans and in 0.3% of African Americans. 3 The G20210A mutation is associated with an increase in prothrombin levels by approximately 30% in heterozygotes and by 70% in ho-CME available online at www.jamaarchivescme.com and questions on p 2509. Context Testing for genetic risks for venous thromboembolism (VTE) is common, but the safety and utility of such testing need review.Objectives To define rates of recurrent VTE among adults with VTE with a factor V Leiden (FVL) or prothrombin G20210A mutation compared with those without such mutations; to define rates of VTE among family members of adults with a FVL or prothrombin G20210A mutation according to presence or absence of a mutation; and to assess whether testing adults with VTE for FVL or prothrombin G20210A improves outcomes. Data SourcesWe searched MEDLINE, EMBASE, the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature, and PsycInfo through December 2008.Study Selection Studies were included if they assessed rates of VTE in individuals with a history of VTE who were tested for FVL or prothrombin G20210A or in family members of individuals with these mutations. Studies assessing the harms and benefits associated with testing were also included. Data ExtractionTwo investigators abstracted data and assessed study quality. We pooled the odds of VTE associated with the mutations using random-effects models. We assessed the strength of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. ResultsWe reviewed 7777 titles and included 46 articles. Heterozygosity (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.14-2.12) and homozygosity (OR, 2.65; 95% CI, 1.2-6.0) for FVL in probands are predictive of recurrent VTE compared with individuals without FVL. Heterozygosity for FVL predicts VTE in family members (OR, 3.5; 95% CI, 2.5-5.0), as does homozygosity for FVL (OR, 18; 95% CI, 7.8-40) compared with family members of adults without FVL. Heterozygosity for prothrombin G20210A is not predictive of recurrent VTE in probands compared with individuals without prothrombin G20210A (OR, 1.45; 95% CI, 0.96-2.2). Evidence is insufficient regarding the predictive value of prothrombin G20210A homozygosity for recurrent VTE and the risk of VTE in family memb...

Telehealth services that allow remote communication between the patient and the clinical team are an emerging part of care delivery. Given language barriers, patients with limited English proficiency present a unique set of challenges in integrating telehealth and ensuring equity. Using data from 84,419 respondents in the 2015-18 California Health Interview Survey, we assessed the association between limited English proficiency and telehealth use (telephone and video visits) and evaluated the impact of telehealth use on health care access and use. We found that patients with limited English proficiency had lower rates of telehealth use (4.8 percent versus 12.3 percent) compared with proficient English speakers. In weighted multivariable logistic regression, patients with limited English proficiency still had about half the odds of using telehealth. Telehealth use was associated with increased emergency department use for all patients. This study suggests that policy makers and clinicians must focus on limited English proficiency as an important dimension to promote telehealth equity and decrease digital divides. F or the 25.6 million people with limited English proficiency in the US, language barriers pose a significant challenge to their health care experience and receipt of high-quality care. 1 Patients with limited English proficiency experience significant disparities in care including increased numbers of hospitalizations, lengths-ofstay, numbers of thirty-day readmissions, and numbers of emergency department (ED) visits and decreased access to preventive services. [2][3][4][5] The equitable deployment of technology offers opportunities to ameliorate these gaps. 6 Telehealth represents an emerging technology that could bridge gaps in care. Evidence suggests that extending care beyond the clinic setting improves access. 7,8 Telehealth has been shown to improve patient satisfaction, care access, and outcomes in multiple diseases, including dermatologic conditions, diabetes, cerebrovascular disease, and alcohol use disorder. 7,9-13 National-

Both practicing physicians and clinical informaticians need a structured method of developing, studying and evaluating clinical summaries in support of a wide range of clinical tasks. Our proposed model of clinical summarization provides a potential pathway to advance knowledge in this area and highlights directions for further research.

Objective: The United States Office of the National Coordinator for Health Information Technology sponsored the development of a “high-priority” list of drug-drug interactions (DDIs) to be used for clinical decision support. We assessed current adoption of this list and current alerting practice for these DDIs with regard to alert implementation (presence or absence of an alert) and display (alert appearance as interruptive or passive).Materials and methods: We conducted evaluations of electronic health records (EHRs) at a convenience sample of health care organizations across the United States using a standardized testing protocol with simulated orders.Results: Evaluations of 19 systems were conducted at 13 sites using 14 different EHRs. Across systems, 69% of the high-priority DDI pairs produced alerts. Implementation and display of the DDI alerts tested varied between systems, even when the same EHR vendor was used. Across the drug pairs evaluated, implementation and display of DDI alerts differed, ranging from 27% (4/15) to 93% (14/15) implementation.Discussion: Currently, there is no standard of care covering which DDI alerts to implement or how to display them to providers. Opportunities to improve DDI alerting include using differential displays based on DDI severity, establishing improved lists of clinically significant DDIs, and thoroughly reviewing organizational implementation decisions regarding DDIs.Conclusion: DDI alerting is clinically important but not standardized. There is significant room for improvement and standardization around evidence-based DDIs.

BackgroundHealth information technology (HIT) could improve care coordination by providing clinicians remote access to information, improving legibility, and allowing asynchronous communication, among other mechanisms. We sought to determine, from a clinician perspective, how care is coordinated and to what extent HIT is involved when transitioning patients between emergency departments, acute care hospitals, skilled nursing facilities, and home health agencies in settings across the United States.MethodsWe performed a qualitative study with clinicians and information technology professionals from six regions of the U.S. which were chosen as national leaders in HIT. We analyzed data through a two person consensus approach, assigning responses to each of nine care coordination activities. We also conducted a literature review of MEDLINE®, CINAHL®, and Embase, analyzing results of studies that examined interventions to improve information transfer during transitions of care.ResultsWe enrolled 29 respondents from 17 organizations and conducted six focus groups. Respondents reported how HIT is currently used for care coordination activities. HIT is currently used to monitor patients and to align systems-level resources with population needs. However, we identified multiple areas where the lack of interoperability leads to inefficient processes and missing data. Additionally, the literature review identified ten intervention studies that address information transfer, seven of which employed HIT and three of which utilized other communication methods such as telephone calls, faxed records, and nurse case management.ConclusionsSignificant care coordination gaps exist due to the lack of interoperability across the United States. We must design, evaluate, and incentivize the use of HIT for care coordination. We should focus on the domains where we found the largest gaps: information transfer, systems to monitor patients, tools to support patients’ self-management goals, and tools to link patients and their caregivers with community resources.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1373-y) contains supplementary material, which is available to authorized users.

BackgroundDespite considerable financial incentives for adoption, there is little evidence available about providers’ use and satisfaction with key functions of electronic health records (EHRs) that meet “meaningful use” criteria.MethodsWe surveyed primary care providers (PCPs) in 11 general internal medicine and family medicine practices affiliated with 3 health systems in Texas about their use and satisfaction with performing common tasks (documentation, medication prescribing, preventive services, problem list) in the Epic EHR, a common commercial system. Most practices had greater than 5 years of experience with the Epic EHR. We used multivariate logistic regression to model predictors of being a structured documenter, defined as using electronic templates or prepopulated dot phrases to document at least two of the three note sections (history, physical, assessment and plan).Results146 PCPs responded (70%). The majority used free text to document the history (51%) and assessment and plan (54%) and electronic templates to document the physical exam (57%). Half of PCPs were structured documenters (55%) with family medicine specialty (adjusted OR 3.3, 95% CI, 1.4-7.8) and years since graduation (nonlinear relationship with youngest and oldest having lowest probabilities) being significant predictors. Nearly half (43%) reported spending at least one extra hour beyond each scheduled half-day clinic completing EHR documentation. Three-quarters were satisfied with documenting completion of pneumococcal vaccinations and half were satisfied with documenting cancer screening (57% for breast, 45% for colorectal, and 46% for cervical). Fewer were satisfied with reminders for overdue pneumococcal vaccination (48%) and cancer screening (38% for breast, 37% for colorectal, and 31% for cervical). While most believed the problem list was helpful (70%) and kept an up-to-date list for their patients (68%), half thought they were unreliable and inaccurate (51%).ConclusionsDissatisfaction with and suboptimal use of key functions of the EHR may mitigate the potential for EHR use to improve preventive health and chronic disease management. Future work should optimize use of key functions and improve providers’ time efficiency.

Objective. To measure performance by eligible health care providers on CMS's meaningful use measures. Data Source. Medicare Electronic Health Record Incentive Program Eligible Professionals Public Use File (PUF), which contains data on meaningful use attestations by 237,267 eligible providers through May 31, 2013. Study Design. Cross-sectional analysis of the 15 core and 10 menu measures pertaining to use of EHR functions reported in the PUF. Principal Findings. Providers in the dataset performed strongly on all core measures, with the most frequent response for each of the 15 measures being 90-100 percent compliance, even when the threshold for a particular measure was lower (e.g., 30 percent). PCPs had higher scores than specialists for computerized order entry, maintaining an active medication list, and documenting vital signs, while specialists had higher scores for maintaining a problem list, recording patient demographics and smoking status, and for providing patients with an after-visit summary. In fact, 90.2 percent of eligible providers claimed at least one exclusion, and half claimed two or more. Conclusions. Providers are successfully attesting to CMS's requirements, and often exceeding the thresholds required by CMS; however, some troubling patterns in exclusions are present. CMS should raise program requirements in future years.

Objective Many options are currently available for sepsis surveillance clinical decision support (CDS) from electronic medical record (EMR) vendors, third party, and homegrown models drawing on rule-based (RB) and machine learning (ML) algorithms. This study explores sepsis CDS implementation from the perspective of implementation leads by describing the motivations, tool choices, and implementation experiences of a diverse group of implementers. Materials and Methods Semi-structured interviews were conducted with and a questionnaire was administered to 21 hospital leaders overseeing CDS implementation at 15 US medical centers. Participants were recruited via convenience sampling. Responses were coded by 2 coders with consensus approach and inductively analyzed for themes. Results Use of sepsis CDS is motivated in part by quality metrics for sepsis patients. Choice of tool is driven by ease of integration, customization capability, and perceived predictive potential. Implementation processes for these CDS tools are complex, time-consuming, interdisciplinary undertakings resulting in heterogeneous choice of tools and workflow integration. To improve clinician acceptance, implementers addressed both optimization of the alerts as well as clinician understanding and buy in. More distrust and confusion was reported for ML models, as compared to RB models. Respondents described a variety of approaches to overcome implementation barriers; these approaches related to alert firing, content, integration, and buy-in. Discussion While there are shared socio-technical challenges of implementing CDS for both RB and ML models, attention to user education, support, expectation management, and dissemination of effective practices may improve feasibility and effectiveness of ML models in quality improvement efforts. Conclusion Further implementation science research is needed to determine real world efficacy of these tools. Clinician acceptance is a significant barrier to sepsis CDS implementation. Successful implementation of less clinically intuitive ML models may require additional attention to user confusion and distrust.