Active choice through the EHR was associated with a significant increase in influenza vaccination rates.

Generic drugs are low-cost, therapeutically equivalent versions of brand-name drugs. Use of generic drugs increases patient adherence and improves health outcomes. 1 However, a 2009 survey of physicians showed that 23% disagreed that generic dr ugs were as effec tive as brand-name drugs and 50% reported quality concerns, leading more than one-quarter not to recommend generic drugs as first-line therapy. 2 Because generic drugs now make up more than 85% of prescriptions, 3 we reassessed physicians' perceptions and determined how professional or demographic characteristics predict physicians' support of generic drug prescribing. c This question asked whether physicians believe that generics cause more adverse effects than brand-name drugs. Responses inverted for consistency of interpretation with the other questions in this Table.

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.

Objective Learning healthcare systems use routinely collected data to generate new evidence that informs future practice. While implementing an electronic health record (EHR) system can facilitate this goal for individual institutions, meaningfully aggregating data from multiple institutions can be more empowering. Cosmos is a cross-institution, single EHR vendor-facilitated data aggregation tool. This work aims to describe the initiative and illustrate its potential utility through several use cases. Methods Cosmos is designed to scale rapidly by leveraging preexisting agreements, clinical health information exchange networks, and data standards. Data are stored centrally as a limited dataset, but the customer facing query tool limits results to prevent patient reidentification. Results In 2 years, Cosmos grew to contain EHR data of more than 60 million patients. We present practical examples illustrating how Cosmos could further efforts in chronic disease surveillance (asthma and obesity), syndromic surveillance (seasonal influenza and the 2019 novel coronavirus), immunization adherence and adverse event reporting (human papilloma virus and measles, mumps, rubella, and varicella vaccination), and health services research (antibiotic usage for upper respiratory infection). Discussion A low barrier of entry for Cosmos allows for the rapid accumulation of multi-institutional and mostly de-duplicated EHR data to power research and quality improvement queries characteristic of learning healthcare systems. Limitations are being vendor-specific, an “all or none” contribution model, and the lack of control over queries run on an institution's healthcare data. Conclusion Cosmos provides a model for within-vendor data standardization and aggregation and a steppingstone for broader intervendor interoperability.

Performance incentives for preventive care may encourage inappropriate testing, such as cancer screening for patients with short life expectancies. Defining screening colonoscopies for patients with a >50% 4-year mortality risk as inappropriate, the authors performed a pre-post analysis assessing the effect of introducing a cancer screening incentive on the proportion of screening colonoscopy orders that were inappropriate. Among 2078 orders placed by 23 attending physicians in 4 academic general internal medicine practices, only 0.6% (n = 6/1057) of screening colonoscopy orders in the preintervention period and 0.6% (n = 6/1021) of screening colonoscopy orders in the postintervention period were deemed "inappropriate." This study found no evidence that the incentive led to an increase in inappropriate screening colonoscopy orders.