Primary Care Physician Designation and Response to Clinical Decision Support Reminders

Summary

Objective

Clinical decision support (CDS) has been shown to improve process outcomes, but overalerting may not produce incremental benefits. We analyzed providers’ response to preventive care reminders to determine if reminder response rates varied when a primary care provider (PCP) saw their own patients as compared with a partner’s patients. Secondary objectives were to describe variation in PCP identification in the electronic health record (EHR) across sites, and to determine its accuracy.

Methods

We retrospectively analyzed response to preventive care reminders during visits to outpatient primary care sites over a three-month period where an EHR was used. Data on clinician requests for reminders, viewing of preventive care reminders, and response rates were stratified by whether the patient visited their own PCP, the PCP’s partner, or where no PCP was listed in the EHR. We calculated the proportion of PCP identification across sites and agreement of identified PCP with an external standard.

Results

Of 84,937 visits, 58,482 (68.9%) were with the PCP, 10,259 (12.1%) were with the PCP’s partner, and 16,196 (19.1%) had no listed PCP. Compared with PCP partner visits, visits with the patient’s PCP were associated with more requested reminders (30.9% vs 22.9%), viewed reminders (29.7% vs 20.7%), and responses to reminders (28.7% vs 12.6%), all comparisons p<0.001. Visits with no listed PCP had the lowest rates of requests, views, and responses. There was good agreement between the EHR-listed PCP and the provider seen for a plurality of visits over the last year (D = 0.917).

Conclusions

A PCP relationship during a visit was associated with higher use of preventive care reminders and a lack of PCP was associated with lower use of CDS. Targeting reminders to the PCP may be desirable, but further studies are needed to determine which strategy achieves better patient care outcomes.

Abbreviations

primary care physician (PCP), clinical decision support (CDS), electronic health record (EHR), National Provider Identifier (NPI)

Keywords

Primary health care - clinical decision support systems - electronic health records

• References

• 1 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83: 457-502.
• 2 Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, And Cost. Health Aff 2008; 27: 759-769.
• 3 Osheroff JA, Teich JM, Middleton B, Steen EB, Wright A, Detmer DE. A Roadmap for National Action on Clinical Decision Support. J Am Med Inform Assoc 2007; 14: 141-145.
• 4 Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, Sam J, Haynes RB. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: A systematic review. JAMA 2005; 293 (10) 1223-1238.
• 5 Bryan C, Boren SA. The use and effectiveness of electronic clinical decision support tools in the ambulatory/primary care setting: a systematic review of the literature. Inform Prim Care 2008; 16: 79-91.
• 6 Dexheimer JW, Talbot TR, Sanders DL, Rosenbloom ST, Aronsky D. Prompting clinicians about preventive care measures: a systematic review of randomized controlled trials. J Am Med Inform Assoc 2008; 15: 311-320.
• 7 Sequist TD, Gandhi TK, Karson AS, Fiskio JM, Bugbee D, Sperling M, Cook EF, Orav EJ, Fairchild DG, Bates DW. A Randomized Trial of Electronic Clinical Reminders to Improve Quality of Care for Diabetes and Coronary Artery Disease. J Am Med Inform Assoc 2005; 12: 431-437.
• 8 Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J. The effects of on-screen, point of care computer reminders on processes and outcomes of care. ochrane Database of Syst Rev 2009; 3.
• 9 van der Sijs H, Aarts J, Vulto A, Berg M. Overriding of Drug Safety Alerts in Computerized Physician Order Entry. J Am Med Inform Assoc 2006; 13: 138-147.
• 10 Sittig DF, Wright A, Osheroff JA, Middleton B, Teich JM, Ash JS, Campbell E, Bates DW. Grand challenges in clinical decision support. J Biomed Inform 2008; 41 (02) 387-392.
• 11 Murphy DR, Reis B, Sittig DF, Singh H. Notifications Received by Primary Care Practitioners in Electronic Health Records: A Taxonomy and Time Analysis. Am J Med 2012; 125 (02) 209.e1-209.e7.
• 12 Krall MA, Sittig DF. Clinician’s assessments of outpatient electronic medical record alert and reminder usability and usefulness requirements. Proc AMIA Symp 2002; 400-404.
• 13 Medstar Health: Facts and Figures. Available at: http://www.medstarhealth.org/body.cfm?id=20 Accessed September 2, 2012.
• 14 Million Hearts – Home. Atlanta, GA: Centers for Disease Control and Prevention. c2012 [cited 2012 October 10]. Available from: http://millionhearts.hhs.gov/index.html
• 15 Pham HH, Schrag D, O’Malley AS, Wu B, Bach PB. Care patterns in Medicare and their implications for pay for performance. N Engl J Med 2007; 356: 1130-1139.
• 16 Ferrante JM, Balasubramanian BA, Hudson SV, Crabtree BF. Principles of the Patient-Centered Medical Home and Preventive Services Delivery. Ann Fam Med 2010; 08: 108-116.
• 17 McClellan SR, Casalino LP, Shortell SM, Rittenhouse DR. When does adoption of health information technology by physician practices lead to use by physicians within the practice?. J Am Med Inform Assoc 2013; 20: e26-e32.
• 18 Lanham HJ, Sittig DF, Leykum LK, Parchman ML, Pugh JA, McDaniel RR. Understanding differences in electronic health record (EHR) use: linking individual physicians’ perceptions of uncertainty and EHR use patterns in ambulatory care. J Am Med Inform Assoc 2014; 21: 73-81.
• 19 McCormick D, Bor DH, Woolhandler S, Himmelstein DU. Giving Office-Based Physicians Electronic Access To Patients’ Prior Imaging And Lab Results Did Not Deter Ordering Of Tests. Health Aff 2012; 31 (03) 488-496.