Faculty Bibliography

Changing physician behaviors is difficult. Electronic health record (EHR) clinical decision support (CDS) offers an opportunity to promote guideline adherence. Behavioral economics (BE) has shown success as an approach to supporting evidence-based decision-making with little additional cognitive burden. We applied a user-centered approach to incorporate BE "nudges" into a CDS module in two "vanguard" sites utilizing: (1) semi-structured interviews with key informants (n = 8); (2) a design thinking workshop; and (3) semi-structured group interviews with clinicians. In the 133 day development phase at two clinics, the navigator section fired 299 times for 27 unique clinicians. The inbasket refill alert fired 124 times for 22 clinicians. Fifteen prescriptions for metformin were written by 11 clinicians. Our user-centered approach yielded a BE-driven CDS module with relatively high utilization by clinicians. Next steps include the addition of two modules and continued tracking of utilization, and assessment of clinical impact of the module.

Background. According to the CDC, up to 50% of antibiotic (abx) prescriptions are not needed or inappropriate-often used too long or too broadly. Repercussions include multidrug resistance, adverse reactions, and increased incidence and mortality from Clostridium difficile. A JAMA study demonstrated that IDSA guidelines can influence abx prescribing patterns positively for genitourinary infections. In this electronic age, interventions include providing direct access to guidelines through a Best Practice Alert (BPA) embedded within electronic medical records (EMR). This assists clinicians when recommending abx. The study's goal was to improve compliance with guidelines when treating uncomplicated UTIs at outpatient sites by using targeted education and Clinical Decision Support (CDS). Methods. Outpatient sites were randomized with matching into two groups: BPA intervention group (IG) (71 sites; 4,555 visits) or control group (CG) (56 sites; 2,078 visits). The BPA listed the appropriate abx regimens according to guidelines. A second modification presented all providers with a list of abx options including dosage and frequency. The effects of two CDS interventions were assessed for one year. Results. Results indicate the IG improved in BPA abx compliance over the CG. Figure 1 shows compliance with BPA recommended antibiotics among the IG increased from 17% to 23% during Q1 2014-Q2 2017 compared with a 0% increase in the CG (P <.0001). However, overall IDSA recommended compliance did not significantly increase: IG -2% vs CG 1% (P = .26). UTI patients of providers who saw the BPA alert were 1.9 times (CI: 1.7, 2.3) times more likely to receive recommended abx compared with the CG. Conclusion. This randomized control study provides promising data that the use of CDS, specifically BPAs embedded within EMRs, can be used effectively to assist and encourage compliance with guidelines. Next steps include: continuing to educate providers on best practices, consider including more abx options in BPA to reduce errors in prescribing and improve overall compliance, and implementing similar CDS interventions for upper respiratory infections and other infections. (Figure Presented)

BACKGROUND: Electronic patient portals give patients access to information from their electronic health record and the ability to message their providers. These tools are becoming more widely used and are expected to promote patient engagement with health care. OBJECTIVE: To quantify portal usage and explore potential differences in adoption and use according to patients' socioeconomic and clinical characteristics in a network of federally qualified health centers serving New York City and neighboring counties. DESIGN: Retrospective analysis of data from portal and electronic health records. PARTICIPANTS: 74,368 adult patients seen between April 2008 and April 2010. MAIN MEASURES: Odds of receiving an access code to the portal, activating the account, and using the portal more than once KEY RESULTS: Over the 2 years of the study, 16% of patients (n = 11,903) received an access code. Of these, 60% (n = 7138) activated the account, and 49% (n = 5791) used the account two or more times. Patients with chronic conditions were more likely to receive an access code and to become repeat users. In addition, the odds of receiving an access code were significantly higher for whites, women, younger patients, English speakers, and the insured. The odds of repeat portal use, among those with activated accounts, increased with white race, English language, and private insurance or Medicaid compared to no insurance. Racial disparities were small but persisted in models that controlled for language, insurance, and health status. CONCLUSIONS: We found good early rates of adoption and use of an electronic patient portal during the first 2 years of its deployment among a predominantly low-income population, especially among patients with chronic diseases. Disparities in access to and usage of the portal were evident but were smaller than those reported recently in other populations. Continued efforts will be needed to ensure that portals are usable for and used by disadvantaged groups so that all patients benefit equally from these technologies.