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Background System based practice (SBP) milestones require trainees to effectively navigate the larger health care system for optimal patient care. In gastroenterology training programs, the assessment of SBP is difficult due to high volume, high acuity inpatient care, as well as inconsistent direct supervision. Nevertheless, structured assessment is required for training programs. We hypothesized that objective structured clinical examination (OSCE) would be an effective tool for assessment of SBP. Aim To develop a novel method for SBP milestone assessment of gastroenterology fellows using the OSCE. Methods For this observational study, we created 4 OSCE stations: Counseling an impaired colleague, handoff after overnight call, a feeding tube placement discussion, and giving feedback to a medical student on a progress note. Twenty-six first year fellows from 7 programs participated. All fellows encountered identical case presentations. Checklists were completed by trained standardized patients who interacted with each fellow participant. A report with individual and composite scores was generated and forwarded to program directors to utilize in formative assessment. Fellows also received immediate feedback from a faculty observer and completed a post-session program evaluation survey. Results Survey response rate was 100%. The average composite score across SBP milestones for all cases were 6.22 (SBP1), 4.34 (SBP2), 3.35 (SBP3), and 6.42 (SBP4) out of 9. The lowest composite score was in SBP 3, which asks fellows to advocate for cost effective care. This highest score was in patient care 2, which asks fellows to develop comprehensive management plans. Discrepancies were identified between the fellows' perceived performance in their self-assessments and Standardized Patient checklist evaluations for each case. Eighty-seven percent of fellows agreed that OSCEs are an important component of their clinical training, and 83% stated that the cases were similar to actual clinical encounters. All participating fellows stated that the immediate feedback was "very useful." One hundred percent of the fellows stated they would incorporate OSCE learning into their clinical practice. Conclusion OSCEs may be used for standardized evaluation of SBP milestones. Trainees scored lower on SBP milestones than other more concrete milestones. Training programs should consider OSCEs for assessment of SBP.

Background We developed and implemented a structured clinical documentation support (SCDS) toolkit within the electronic medical record, to optimize patient care, facilitate documentation, and capture data at office visits in a sleep medicine/neurology clinic for patient care and research collaboration internally and with other centers. Methods To build our SCDS toolkit, physicians met frequently to develop content, define the cohort, select outcome measures, and delineate factors known to modify disease progression. We assigned tasks to the care team and mapped data elements to the progress note. Programmer analysts built and tested the SCDS toolkit, which included several score tests. Auto scored and interpreted tests included the Generalized Anxiety Disorder 7-item, Center for Epidemiological Studies Depression Scale, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Insomnia Severity Index, and the International Restless Legs Syndrome Study Group Rating Scale. The SCDS toolkits also provided clinical decision support (untreated anxiety or depression) and prompted enrollment of patients in a DNA biobank. Results The structured clinical documentation toolkit captures hundreds of fields of discrete data at each office visit. This data can be displayed in tables or graphical form. Best practice advisories within the toolkit alert physicians when a quality improvement opportunity exists. As of May 1, 2019, we have used the toolkit to evaluate 18,105 sleep patients at initial visit. We are also collecting longitudinal data on patients who return for annual visits using the standardized toolkits. We provide a description of our development process and screenshots of our toolkits. Conclusions The electronic medical record can be structured to standardize Sleep Medicine office visits, capture data, and support multicenter quality improvement and practice-based research initiatives for sleep patients at the point of care.

La détection d'insatisfaction basée sur les notes de progression rédigées par des soignants de la santé domestique attire de plus en plus d'attention en tant que méthode de sondage, ce qui aidera à réduire le taux de rotation du personnel soignant. Nous proposons d'étudier la détection d'insatisfaction du soignant comme un problème de classification binaire (le soignant est susceptible de quitter ou pas). Dans ce mémoire, les données réelles de six mois recueillies à partir de deux agences de soins à domicile sont utilisées. Après avoir montré la nature des données et le prétraitement des données, trois tâches de classification avec des granularités d'échantillonnage différentes (par note, par période et par soignant) sont conçues et abordées. Différentes combinaisons d'hyper-paramètres d'étiquetage sont soigneusement testées. Différentes méthodes de découpage sont couvertes pour montrer les limites des performances théoriques des modèles. L'aire sous la courbe ROC est utilisée pour évaluer les limites des approches mises en place que nous aurons mis en place. Les 6 ensembles d'attributs textuels et statistiques sont comparées. Enfin, les caractéristiques importantes des résultats sont analysées manuellement et automatiquement. Nous montrons que les modèles fonctionnent mieux "par note" et "par période" que "par soignant" en termes de classification des notes. L'analyse manuelle montre que les modèles capturent les facteurs d'insatisfaction bien qu'il y en ait assez peu. L'analyse automatique n'exprime cependant aucune information utile., Dissatisfaction detection based on the home health caregiver's progress note draws more and more attention as a probing method, which will help lower down the turnover rate. We propose to study the detection of dissatisfaction of health caregiver as a binary classification problem (the caregiver is likely to "leave" or "stay"). In this master thesis, the real six-month data collected from two home care agencies are used. After showing the nature of the data and the prepossessing of data, three classification tasks with different sample granularity (note wise, period wise and employee wise) are designed and tackled. Different combinations of labeling hyper-parameters are tested thoroughly. Different split methods are covered to show the theoretical performance boundaries of the models. The under the ROC curve area (AUC) scores are reported to show the description ability of each model. The 6 sets of textual and statistical features' performance are compared. Lastly, the important features from the results are analyzed manually and automatically. We show that models work better on note wise and period wise than employee wise in terms of classifying the notes. The result of manual analysis shows the models capture the dissatisfaction factors, although there are quite few. The result of automatic analysis doesn't show any useful information.

Background Therapeutic staff-patient interaction is fundamental in psychiatric care. It is recognized as a key to healing in and of itself, or a premise to enhance psychiatric treatment adherence. Still, little is known about how these interactions are recorded in nursing documentation. The purpose of the study was to assess the quality and quantity of staff-patient interactions as recorded in progress notes in nursing documentation. Methods The study has an observational registry study design. A random sample of 3858 excerpts was selected from progress notes in 90 patient journals on an acute psychiatric unit and an open inpatient district psychiatric centre (DPC) in Norway. The Scale for the Evaluation of Staff-Patient Interactions in progress notes (SESPI) was used to assess the progress note excerpts. It is developed to assess the quality and quantity in excerpt descriptions of staff-patient interactions in terms of empathic attunement. Descriptive statistics were calculated for the total sample and for each ward separately. Ordinal and multinomial logistic regression were used to estimate control for shift type, staff education level, and type of hospital ward. Results Only 7.6% of the total number of excerpts (N = 3858) described staff-patient interactions sufficiently to analyze them in terms of attunement. Compared to the DPC, the acute ward reported more staff-patient interactions. The evening excerpts reported more successful types of attunement than those from the night shifts. Education level did not contribute significantly to our models. Conclusion These findings present a unique insight into the quality and quantity of mental health nursing documentation regarding staff-patient interactions. Therapeutic interactions where staff tried to attune to the patients were rarely described. However, this is the first study measuring nursing documentation with the SESPI, and more studies are required to validate the scale and our findings. One potential clinical implication of this research is the development of a scale that personnel in psychiatric wards can have for evaluation of the quality of their reporting practice with emphasis on staff-patient interactions. By regular use this may help keeping up emphasis on emphatic attunement in milieu treatment contexts. Electronic supplementary material The online version of this article (10.1186/s12888-019-2236-y) contains supplementary material, which is available to authorized users.

OBJECTIVES:Physicians increasingly share ambulatory visit notes with patients to meet new federal requirements, and evidence suggests patient experiences improve without overburdening physicians. Whether sharing inpatient notes with parents of hospitalized children yields similar outcomes is unknown. In this pilot study, we evaluated parent and physician perceptions of sharing notes with parents during hospitalization.METHODS:Parents of children aged RESULTS:In all, 25 parents and their children’s discharging attending and intern physicians participated. Parents agreed that the information in notes was useful and helped them remember their child’s care plan (100%), prepare for rounds (96%), and feel in control (91%). Although many physicians (34%) expressed concern that notes would confuse parents, no parent reported that notes were confusing. Some physicians perceived that they spent more time writing and/or editing notes (28%) or that their job was more difficult (15%). Satisfaction with sharing was highest among parents (100%), followed by attendings (81%) and interns (35%).CONCLUSIONS:Parents all valued having access to physicians’ notes during their child’s hospital stay; however, some physicians remained concerned about the potential negative consequences of sharing. Comparative effectiveness studies are needed to evaluate the effect of note sharing on outcomes for hospitalized children, families, and staff.

Seven hours into her overnight shift, Dr Carter opens the computer to complete her sixth admission of the evening. “BEEP! BEEP! BEEP!” her pager interrupts with “Sepsis Alert,” the fourth in the past 48 hours for a 12-year-old boy with metabolic disease, technology dependence, and paroxysmal sympathetic hyperactivity who was admitted 1 week ago for dehydration and increased storming. She leaves her computer to attend the mandatory bedside huddle. The result is the same as the 3 previous ones: storming caused his fever and tachycardia, not sepsis; no change to management. As Dr Carter writes a progress note documenting the huddle, her pager erupts again, requesting orders for her other patient. Pediatric severe sepsis in the United States costs $7.3 billion annually, one-fifth of pediatric hospitalization costs.1 Over the past 2 decades, professional organizations have built awareness, developed guidelines, and driven efforts to recognize sepsis and intervene early in its course.2,3 Early initiatives began in emergency departments (EDs), although state legal mandates and national quality improvement collaboratives have led to implementation hospital-wide, including in general inpatient units.4,5 Most guidelines frame their recommendations around sepsis response systems that incorporate clinical decision support tools (hereinafter referred to as sepsis scores) to identify suspected sepsis and trigger time-sensitive bundles of laboratory evaluation, intravenous fluid resuscitation, …

Background and objectives Type 2 diabetes mellitus (T2DM) is a complex disease that can lead to complications. Electronic decision support in the electronic medical record (EMR) aids management. There is no study demonstrating the effectiveness of electronic decision support in assisting medical student providers in student-run free clinics. Methods There were 71 T2DM patients seen by medical students. Twenty-three encounters used a Diabetes Progress Note (DPN) that was created from consensus, opinion-based guidelines. Each note received a total composite score based on an eight-point scale for adherence to guidelines. Statistical comparisons between mean composite scores were performed using independent t-tests. Results The mean total composite score of DPN users was significantly greater than DPN non-users (5.35 vs. 4.23, p = 0.008), with a significant difference in the physical exam component (1.70 vs. 1.31, p = 0.002). Conclusions In this exploratory study, medical student providers at an attending-supervised, student-run free clinic that used electronic decision support during T2DM patient visits improved adherence to screening for diabetic complications and standard of care.

Introduction Physicians enter residency with varied knowledge regarding the purpose of progress notes and proficiency writing them. The objective of this study was to test whether resident knowledge, beliefs, and confidence writing inpatient progress notes improved after a 2.5-hour workshop intervention. Methods An educational workshop and note assessment tool was constructed by resident and faculty stakeholders based on a review of literature and institutional best practices. The Progress Note Assessment and Plan Evaluation (PNAPE) tool was designed to assess adherence to best practices in the assessment and plan section of progress notes. Thirty-four residents from a midsized pediatric residency program attended the workshop, which consisted of didactics and small-group work evaluating sample notes using the PNAPE tool. Participants completed a four-question online pre- and postworkshop survey to evaluate their knowledge of progress note components and attitudes regarding note importance. Pre-post analysis was performed with Chi-square testing for true/false questions, and Mann-Whitney testing for Likert scale questions and summative scores. Results A majority of pediatric residents completed the preintervention (n = 26, 76% response rate) and postintervention (n = 23, 68% response rate) surveys. Accurate response rate improved in 15 of 20 of the true/false items, with a statistically significant improvement in five items. Resident perceptions of note importance and confidence in note writing also increased. Discussion A workshop intervention may effectively educate pediatric residents about progress note best practices. Further studies should assess the impact of the intervention on sustained knowledge and beliefs about progress notes and subsequent note quality.

Procalcitonin (PCT) is a biomarker that has shown promise to identify bacterial etiology in acute infections, including bacterial lower respiratory tract infection (LRTI). In 2017, the United States Food and Drug Administration (FDA) approved the use of PCT as a diagnostic aid to guide the decisions around antibiotic therapy in acute LRTI.1 Although most of the data supporting the use of PCT for LRTI stems from adult studies, the high disease burden, predominance of viral etiologies, and frequent diagnostic uncertainty resulting in antibiotic overuse make pediatric LRTI an ideal target for the use of PCT as a diagnostic aid. This review evaluates and summarizes the current evidence regarding the role of PCT in the clinical care of pediatric LRTI, including its use in guiding antibiotic use and prognosticating disease severity.

PURPOSE: With the current wide adoption of electronic health records (EHRs) by ophthalmologists, there are widespread concerns about the amount of time spent using the EHR. The goal of this study was to examine how the amount of time spent using EHRs as well as related documentation behaviors changed 1 decade after EHR adoption. DESIGN: Single-center cohort study. PARTICIPANTS: Six hundred eighty-five thousand three hundred sixty-one office visits with 70 ophthalmology providers. METHODS: We calculated time spent using the EHR associated with each individual office visit using EHR audit logs and determined chart closure times and progress note length from secondary EHR data. We tracked and modeled how these metrics changed from 2006 to 2016 with linear mixed models. MAIN OUTCOME MEASURES: Minutes spent using the EHR associated with an office visit, chart closure time in hours from the office visit check-in time, and progress note length in characters. RESULTS: Median EHR time per office visit in 2006 was 4.2 minutes (interquartile range [IQR], 3.5 minutes), and increased to 6.4 minutes (IQR, 4.5 minutes) in 2016. Median chart closure time was 2.8 hours (IQR, 21.3 hours) in 2006 and decreased to 2.3 hours (IQR, 18.5 hours) in 2016. In 2006, median note length was 1530 characters (IQR, 1435 characters) and increased to 3838 characters (IQR, 2668.3 characters) in 2016. Linear mixed models found EHR time per office visit was 31.9±0.2% (P < 0.001) greater from 2014 through 2016 than from 2006 through 2010, chart closure time was 6.7±0.3 hours (P < 0.001) shorter from 2014 through 2016 versus 2006 through 2010, and note length was 1807.4±6.5 characters (P < 0.001) longer from 2014 through 2016 versus 2006 through 2010. CONCLUSIONS: After 1 decade of use, providers spend more time using the EHR for an office visit, generate longer notes, and close the chart faster. These changes are likely to represent increased time and documentation pressure for providers. Electronic health record redesign and new documentation regulations may help to address these issues.

Background Effective pediatric intensive care requires addressing many important aspects of care delivery during morning rounds, often achieved using a rounding checklist. Our objective was to develop a care goal rounding template and then double the reliability of discussion of rounding topics during morning rounds without the use of a checklist. Methods The Institute for Healthcare Improvement Model for Improvement was used for this initiative. A care goal rounding template was established through discussions and consensus with pediatric intensive care unit (PICU) faculty. Rounds were audited in a blinded fashion over a 3-month period to obtain baseline data on rounding topic discussion. Three interventions were then trialed (plan, do, study, act cycles) over a 12-month period. Weekly reliability in rounding topic discussion was tracked. Results Baseline reliability with discussion of rounding topics was 36%. The first intervention included the use of a standardized progress note in the electronic health record, which contained topics and served to prompt the discussion on rounds. The second intervention was implementation of laminated cards provided to PICU fellows highlighting the elements of the care goal rounding template. The third intervention addressed a standardized handoff sheet often used during rounds. Mean reliability for discussion of rounding topics improved to 52% shortly following the second intervention. Reliability was sustained more than 1 year later. Conclusions Following the establishment of a PICU care goal rounding template and various interventions, the reliability in discussing important care goal elements on patient rounds improved.

IntroductionGaps in care have been identified along the disease pathway for specific cancers. However, no real-world data exists to identify wait times along these cancer pathways. Secondary use of family physician (FP) electronic medical record data (EMR) can augment existing health administrative data in measuring steps in the care pathways. Objectives and ApproachWe used FP EMR data to identify care pathways for lung cancer and breast cancer patients from the description of symptoms, to the initiation of investigations, referrals to specialty care and the receipt of specific treatments (surgery, chemotherapy, radiation treatment). Data from the Electronic Medical Record Administrative data Linked Database (EMRALD) held at the Institute for Clinical Evaluative Sciences (ICES) was used to identify a cohort of lung cancer and breast cancer patients. Data abstractors examined the FP EMR notes to identify pre-diagnostic symptoms, pre-diagnostic radiological test, biopsy results, oncology and surgical specialist referrals and post-diagnostic surgical and oncological consultations. ResultsTo date, abstractors have reviewed the FP EMR notes for 300 lung cancer patient and 1200 breast cancer patients. Abstractors identified an index date where there was documentation of the first abnormal test result and/or a FP progress note documenting a “suspicious” or “concerning” sign or symptom. For both lung cancer and breast cancer patients, a pre-diagnostic index date was identified in 88.5% of FP EMR notes. For lung cancer patients 66.7% based were based on abnormal chest x-rays and for breast cancer patients 81.1% were based on abnormal mammograms. Pre-diagnostic symptoms were identified in 62.1% of FP EMR notes and 81.6% had post-diagnostic consultation notes. Wait times from the index date to seeing an oncological specialist were less than four weeks for all patients. Conclusion/ImplicationsWe are able to use information from FP EMRs linked to health administrative data to identify pre-diagnostic care received by patients prior to their cancer diagnosis. This information can be used to identify care gaps and measure wait times in receiving cancer care from a patient’s perspective.

Background Critical care pharmacists are established and valuable members of the critical care team, however there is rarely written evidence of their daily involvement in the patient's electronic medical record (EMR). Documentation in the EMR has the advantage of ensuring a seamless pass-off and provides an opportunity to capture the pharmacist's cognitive and clinical impact in a way that traditional systems of tracking “interventions” fail to do. We investigated implementation of pharmacist progress notes in a surgical intensive care unit (ICU) and their utility in measuring pharmacist activity. Methods Daily pharmacist progress notes written in a surgical ICU over a period of 2 months were reviewed. Each pharmacist action identified through progress note review was quantified and scored by an independent reviewer using a newly developed scoring system, the clinical impact score (CIS). This was developed as a way to quantify pharmacist actions and to classify those actions by clinical impact. Results Four hundred sixty-two daily pharmacist progress notes were reviewed over a 2-month period. There were 1,055 actions identified that resulted in a therapy change. Four of these actions resulted in the potential avoidance of a sentinel event. Of patients with at least 5 progress notes ( n = 44), the majority of pharmacist actions occurred on ICU day 1. Conclusion The results of this descriptive study demonstrate that the implementation of daily pharmacist progress notes is feasible in an advanced practice setting, and the pharmacist's contribution to patient care may be obtained through review of this documentation in the patient's medical record. The critical care pharmacist's daily involvement in patient care most commonly results in optimization of pharmacotherapy and avoidance of drug misadventure.

Background “Routine” daily inpatient labs are ineffective at improving patient outcomes and are associated with antibiotic overuse and delayed hospital discharge. Despite recommendations from the ABIM in the “Choosing Wisely” program, limited progress has been made in curbing inappropriate testing. In particular, admonitions from ID consultants that daily measurement of inflammatory markers is unneeded have gone largely unheeded. Since online messaging tools are helpful in areas such as medication compliance, it was hypothesized that EMR-based “click-able” hyperlinks to “Choosing Wisely” recommendations within the ID consultant daily progress note might provide a psychologically stronger “nudge” toward appropriate use. Methods In a community teaching hospital, from September 1, 2017 through March 31, 2018, 38 stable patients with requested ID consultation and three or more sequential daily measurements of CBC and/or CRP were sequentially assigned to receive either standard ID advice including that daily testing was unneeded, or additionally a hyperlink to the URL for the Choosing Wisely recommendation. At 48 hours, patient data were analyzed for whether daily labs continued or stopped. Significance was assessed with 2 × 2 contingency testing. In addition, relevant provider comments in the daily progress notes were assessed. Results Of 19 consultations with hyperlinked recommendations, 10 showed cessation of daily CBC/CRP testing. Of 19 without the hyperlink, only four showed discontinuation by 48 hours (P = .04 Fisher exact). Comments ranged from appreciative to defensive, with the former more common from House Officers compared with attending physicians. Conclusion Inclusion of a clickable hyperlink in the EMR progress note from an ID consultant may provide a more effective psychological nudge away from inappropriate testing compared with text advice alone. Physicians in training may be more receptive to this messaging. Disclosures All authors: No reported disclosures.

This paper examines physicians’ progress notes, an artifact that, in spiteof its obvious importance in the coordination of cooperative work in clinical settings, has not been subjected to systematic study under CSCW auspices. While several studies have addressed the role of the medical record in patient care, they have not dealt specifically with the role, structure, and content of the progress notes. As a consequence, CSCW research has not yet taken fully into account the fact that progress notes are coordinative artifacts of a rather special kind, an open-ended chain of prose texts, written sequentially by cooperating physicians for their own use as well as for that of their colleagues. We argue that progress notes are the core of the medical record, in that they marshal and summarize the overwhelming amount of data that is available in the modern hospital environment, and that their narrative format is uniquely adequate for the pivotal epistemic aspect of cooperative clinical work: the narrative format enables physicians to not only record ‘facts’ but also—by filtering, interpreting, organizing, and qualifying information—to make sense and act concertedly under conditions of uncertainty and contingency.

Objective. We herein provide a description of a health information technology tool using computer-assisted survey instruments as a methodology for documentation during long-term opioid therapy. Design. We report our experience using the Prescription Opioid Documentation and Surveillance (PODS) System, a medical informatics tool that utilizes validated questionnaires to automate the assessment of opioid prescribing for chronic nonmalignant pain. Setting and Patients. Chronic pain patients answered questions that were presented on a computer terminal prior to each appointment in a Department of Veterans Affairs Pain Clinic. Measures. Pain levels, activities of daily living, and screening for common psychological disorders were sought at each visit. Results were tabulated with some information gathered sequentially permitting evaluation of progress. Following a face-to-face interview, the clinician added additional comments to the medical record. Results. By deploying a systematic series of questions that are recalled by the computer, PODS assures a comprehensive assessment. Conclusions. The PODS fulfills medicolegal requirements for documentation and provides a systematic means of determining outcomes. This process facilitates the determination of the appropriate intervals between clinic visits by stratifying patients into high, moderate, and low risk.

Objective Although electronic notes have advantages compared to handwritten notes, they take longer to write and promote information redundancy in electronic health records (EHRs). We sought to quantify redundancy in clinical documentation by studying collections of physician notes in an EHR. Design and methods We implemented a retrospective design to gather all electronic admission, progress, resident signout and discharge summary notes written during 100 randomly selected patient admissions within a 6 month period. We modified and applied a Levenshtein edit-distance algorithm to align and compare the documents written for each of the 100 admissions. We then identified and measured the amount of text duplicated from previous notes. Finally, we manually reviewed the content that was conserved between note types in a subsample of notes. Measurements We measured the amount of new information in a document, which was calculated as the number of words that did not match with previous documents divided by the length, in words, of the document. Results are reported as the percentage of information in a document that had been duplicated from previously written documents. Results Signout and progress notes proved to be particularly redundant, with an average of 78% and 54% information duplicated from previous documents respectively. There was also significant information duplication between document types (eg, from an admission note to a progress note). Conclusion The study established the feasibility of exploring redundancy in the narrative record with a known sequence alignment algorithm used frequently in the field of bioinformatics. The findings provide a foundation for studying the usefulness and risks of redundancy in the EHR.

I was in the viewing room of the emergency room today, trying to write a progress note on one of my patients. I was tired from being on call the night before and wasn't initially aware of all the commotion in the adjacent room. When I finally tuned in, I saw people rushing in and out, bags of intravenous fluids being hung, emergency medical services rolling in a stretcher. I heard a paramedic ask the emergency department physician if he should begin compressions. The physician nodded, the paramedic began cardiopulmonary resuscitation. I realized then: I was witnessing my first code blue. As I watched, I was surprised mostly at my sense of disconnect. Perhaps it was the large glass windows separating me from the resuscitation room. Perhaps it was one too many Hollywood code blues that had successfully desensitized me to the gravity of the situation. Perhaps it was the cold hard knowledge I possessed after 2 years of medical school, that once cardiopulmonary resuscitation begins very few patients ever truly come back to life. It was probably the latter. I knew the patient was dead before cardiopulmonary resuscitation ever began. Yet, I couldn't take my eyes away. I watched medical personnel taking turns compressing the patient's chest, cooperating so no one would tire. I watched the apparent lack of panic in the room. People moved quickly and efficiently. They likely all knew that in such a situation, one had to keep calm. Indeed, they had probably all been through it so many times before that it had become routine. A pair of nurses stood in the corner, chatting about their shopping while they kept an eye on the telemetry. As I watched, a life slipped away and I was taken aback at my own lack of emotion. Have I become detached and cold, I wondered? And then, just as quickly as it began, it was over. The staff physician thanked everyone involved and most of the people left the room. For a moment I thought the patient had come back, even though my better judgement told me that a man who just emerged from the brink of death would have more nurses milling about, more doctors barking orders. A nurse draped the body with a white sheet, covering his face and eyes. “That's the second death of the day,” she commented. And I returned to my progress note, more unsettled by my lack of a reaction than by the code blue itself. Had medicine already stolen my soul? Later that day, I returned to the same room to write yet another progress note. I looked through the glass windows, and saw that the man was still there. He was now surrounded on 3 sides by a partition, but I could see that someone had lifted his arms from underneath the white sheet. The arms were unmistakably dead. They rested in a stiff angle never known in life, their eerie stillness uninterrupted by the rise and fall of breathing. Only the arms of the dead lie that way. A blonde woman with a hospital badge slowly led 3 people into the room. They appeared to be a family: mother, father, teenage son. The hesitancy in their steps, the way they huddled close together as they walked, told me immediately that they belonged to the dead man and were here to identify the body. The blonde woman led them past me, into the resuscitation room where the dead man lay. I saw the woman nod her head, positively identifying the dead man as someone she knew. I heard her sob. My heart, still so alive within me, twisted. I knew then that my soul was safe. Radhika Dixit BSc Class of 2009 Schulich School of Medicine and Dentistry University of Western Ontario London, Ont. Figure Image by: Fred Sebastian

These two books tell a remarkable series of stories. The first is the authors' own. Dr Anh Nguyen and his elder brother Dung Nguyen were born in Saigon, Vietnam, and grew up in Florida. Both graduated in engineering and then medicine and have been in clinical practice in the US for a decade, collecting a vast anthology from their own and others' practice. With multiple true-life examples, the clinical pitfalls and legal challenges that confront us are graphically shown. They emphasise the value of these parables so that we can avoid, trap and mitigate our errors. Each book runs to over 200 pages in which hundreds of cautionary tales are separated by the authors' commentary and advice. Much is the reiteration of sound clinical principles and a useful reminder of what we all should know. The stories certainly help to dramatise and motivate our learning and the chapters are a series of practical tips, for example, ‘what you should not place in a progress note’ (legal issues) and ‘low back pain’ (clinical problems). Those looking for proof of the adage that ‘if it can go wrong it will’ are sure to find these volumes a handy reference to prove their point. The books have much to commend them and they can be sampled very conveniently to research a particular problem; however, for the reviewer who feels duty-bound to read them from end to end, they present a serious challenge. Simply put, they are difficult to read. At first, I felt my pedantic English criticism was the cause of the discomfort, seasoned as it was with a traditional dislike of defensive medical practice. The profligate use of investigations and the aggressive, litigious atmosphere which pervades some North American practice is here displayed. There are also long sentences of medical jargon that easily offend. However, it is not really these characteristics of practice that make it hard to digest so much as the style. To write well requires knowledge, technique, practice and rigorous editing. The subtleties of our enormous English vocabulary constantly challenge us to reach for an authoritative definition and simultaneously offer the opportunity for near-infinite subtlety. Here, the text reads as though it has been dictated rather than written and has been spared the invigorating benefits of critical review by a meticulous editor. This is a great pity because so much hard work has been done and the result appears unfinished. Atul Gawande, the author of Complications: A surgeon's notes on an imperfect science, produced a book about the misfortunes of North American practice that contains far less material but is compulsive reading and difficult to put down. Even he admitted how difficult it was to write well and how much he had been helped by tuition from the staff of The New Yorker, who made his prose vibrant and accessible. His book was of course much less of a technical manual and more a guide to the personal journey of a surgeon developing maturity and wisdom by the challenging and often distressing experience of his craft. By contrast, these books do not expose the authors as individuals nor do they bring out any of the philosophical or emotional consequences of this litany of catastrophes. We need to learn about that too if we are to remain effective, vigilant, compassionate and sane. Surgeons will find much to engage them in these two volumes but I recommend frequent tasting rather than attempting to drain the bottle at one session.

Objective: To compare out-of-box performance of three commercially available continuous speech recognition software packages: IBM ViaVoice 98 with General Medicine Vocabulary; Dragon Systems NaturallySpeaking Medical Suite, version 3.0; and L&H Voice Xpress for Medicine, General Medicine Edition, version 1.2. Design: Twelve physicians completed minimal training with each software package and then dictated a medical progress note and discharge summary drawn from actual records. Measurements: Errors in recognition of medical vocabulary, medical abbreviations, and general English vocabulary were compared across packages using a rigorous, standardized approach to scoring. Results: The IBM software was found to have the lowest mean error rate for vocabulary recognition (7.0 to 9.1 percent) followed by the L&H software (13.4 to 15.1 percent) and then Dragon software (14.1 to 15.2 percent). The IBM software was found to perform better than both the Dragon and the L&H software in the recognition of general English vocabulary and medical abbreviations. Conclusion: This study is one of a few attempts at a robust evaluation of the performance of continuous speech recognition software. Results of this study suggest that with minimal training, the IBM software outperforms the other products in the domain of general medicine; however, results may vary with domain. Additional training is likely to improve the out-of-box performance of all three products. Although the IBM software was found to have the lowest overall error rate, successive generations of speech recognition software are likely to surpass the accuracy rates found in this investigation.

Objective : To explore different user-interface designs for structured progress note entry, with a long-term goal of developing design guidelines for user interfaces where users select items from large medical vocabularies. Design : The authors created eight different prototypes of a pen-based progress-note-writing system called PEN-Ivory. Each prototype allows physicians to write patient progress notes using simple pen-based gestures such as circle, line-out, and scratch- out. The result of an interaction with PEN-Ivory is a progress note in English prose. The eight prototypes were designed in a principled way, so that they differ from one another in just one of three different user-interface characteristics. Measurements : Five of the eight prototypes were tested by measuring the time it took 15 users, each using a distinct prototype, to document three patient cases consisting of a total of 63 medical findings. Results : The prototype that allowed the fastest data entry had the following three user-interface characteristics: it used a paging rather than a scrolling form, it used a fixed palette of modifiers rather than a dynamic “pop-up” palette, and it made available all findings from the controlled vocabulary at once rather than displaying only a subset of findings generated by analyzing the patient's problem list. Conclusion : Even simple design changes to a user interface can make dramatic differences in user performance. The authors discuss possible influences on performance, such as positional constancy, user uncertainty and system anticipation, that may contribute significantly to the effectiveness of systems that display menus of items from large controlled vocabularies of medicine.

Background Strategies to accurately identify the occurrence of specific health care events in administrative data is central to many quality improvement and research efforts. Many health care quality measures have treatment identification strategies based on diagnosis and procedure codes - an approach that is inexpensive and feasible but usually of unknown validity. In this study, we examined if the diagnosis/procedure code combinations used in the 2006 HEDIS Initiation and Engagement quality measures to identify instances of addiction treatment have high concordance with documentation of addiction treatment in clinical progress notes. Methods Four type of records were randomly sampled from VHA electronic medical data: (a) Outpatient records from a substance use disorder (SUD) specialty clinic with a HEDIS-qualified substance use disorder (SUD) diagnosis/CPT code combination (n = 700), (b) Outpatient records from a non-SUD setting with a HEDIS-qualified SUD diagnosis/CPT code combination (n = 592), (c) Specialty SUD Inpatient/residential records that included a SUD diagnosis (n = 700), and (d) Non-SUD specialty Inpatient/residential records that included a SUD diagnosis (n = 700). Clinical progress notes for the sampled records were extracted and two raters classified each as documenting or not documenting addiction treatment. Rates of concordance between the HEDIS addiction treatment identification strategy and the raters' judgments were calculated for each record type. Results Within SUD outpatient clinics and SUD inpatient specialty units, 92% and 98% of sampled records had chart evidence of addiction treatment. Of outpatient encounters with a qualifying diagnosis/procedure code combination outside of SUD clinics, 63% had chart evidence of addiction treatment. Within non-SUD specialty inpatient units, only 46% of sampled records had chart evidence of addiction treatment. Conclusions For records generated in SUD specialty settings, the HEDIS strategy of identifying SUD treatment with diagnosis and procedure codes has a high concordance with chart review. The concordance rate outside of SUD specialty settings is much lower and highly variable between facilities. Therefore, some patients may be counted as meeting the 2006 HEDIS Initiation and Engagement criteria without having received the specified amount (or any) addiction treatment.

Background Accurate indication classification is critical for obtaining unbiased estimates of colonoscopy effectiveness and quality improvement efforts, but there is a dearth of published systematic classification approaches. The objective of this study was to evaluate the effects of data-source and adjudication on indication classification and on estimates of the effectiveness of screening colonoscopy on late-stage colorectal cancer diagnosis risk. Methods This was an observational study in members of four U.S. health plans. Eligible persons (n = 1039) were age 55–85 and had been enrolled for 5 years or longer in their health plans during 2006–2008. Patients were selected based on late-stage colorectal cancer diagnosis in a case–control design; each case patient was matched to 1–2 controls by study site, age, sex, and health plan enrollment duration. Reasons for colonoscopies received in the 10-year period before the reference date were collected from three medical records sources (progress notes; referral notes; procedure reports) and categorized using an algorithm, with committee adjudication of some tests. We evaluated indication classification concordance before and after adjudication and used logistic regressions with the Wald Chi-square test to compare estimates of the effects of screening colonoscopy on late-stage colorectal cancer diagnosis risk for each of our data sources to the adjudicated indication. Results Classification agreement between each data-source and adjudication was 78.8-94.0% (weighted kappa = 0.53-0.72); the highest agreement (weighted kappa = 0.86-0.88) was when information from all data sources was considered together. The choice of data-source influenced the association between screening colonoscopy and late-stage colorectal cancer diagnosis; estimates based on progress notes were closest to those based on the adjudicated indication (% difference in regression coefficients = 2.4%, p-value = 0.98), as compared to estimates from only referral notes (% difference in coefficients = 34.9%, p-value = 0.12) or procedure reports (% difference in coefficients = 27.4%, p-value = 0.23). Conclusion There was no single gold-standard source of information in medical records. The estimates of colonoscopy effectiveness from progress notes alone were the closest to estimates using adjudicated indications. Thus, the details in the medical records are necessary for accurate indication classification.

Clinical prediction rules (CPRs) represent a method of determining individual patient risk to help providers make more accurate decisions at the point of care. Well-validated CPRs are underutilized but may decrease antibiotic overuse for acute respiratory infections. The integrated clinical prediction rules (iCPR) study builds on a previous single clinic study to integrate two CPRs into the electronic health record and assess their impact on practice. This article discusses study design and implementation of a multicenter cluster randomized control trial of the iCPR clinical decision support system, including the tool adaptation, usability testing, staff training, and implementation study to disseminate iCPR at multiple clinical sites across two health care systems. The iCPR tool is based on two well-validated CPRs, one for strep pharyngitis and one for pneumonia. The iCPR tool uses the reason for visit to trigger a risk calculator. Provider completion of the risk calculator provides a risk score, which is linked to an order set. Order sets guide evidence-based care and include progress note documentation, tests, prescription medications, and patient instructions. The iCPR tool was refined based on interviews with providers, medical assistants, and clinic managers, and two rounds of usability testing. “Near live” usability testing with simulated patients was used to ensure that iCPR fit into providers’ clinical workflows. Thirty-three Family Medicine and General Internal Medicine primary care clinics were recruited at two institutions. Clinics were randomized to academic detailing about strep pharyngitis and pneumonia diagnosis and treatment (control) or academic detailing plus use of the iCPR tool (intervention). The primary outcome is the difference in antibiotic prescribing rates between the intervention and control groups with secondary outcomes of difference in rapid strep and chest x-ray ordering. Use of the components of the iCPR will also be assessed. The iCPR study uses a strong user-centered design and builds on the previous initial study, to assess whether CPRs integrated in the electronic health record can change provider behavior and improve evidence-based care in a broad range of primary care clinics. Clinicaltrials.gov ( NCT02534987 )

Background The context of the current study was mandatory adoption of electronic clinical documentation within a large mental health care organization. Psychiatric electronic documentation has unique needs by the nature of dense narrative content. Our goal was to determine if speech recognition (SR) would ease the creation of electronic progress note (ePN) documents by physicians at our institution. Methods Subjects: Twelve physicians had access to SR software on their computers for a period of four weeks to create ePN. Measurements: We examined SR software in relation to its perceived usability, data entry time savings, impact on the quality of care and quality of documentation, and the impact on clinical and administrative workflow, as compared to existing methods for data entry. Data analysis: A series of Wilcoxon signed rank tests were used to compare pre- and post-SR measures. A qualitative study design was used. Results Six of twelve participants completing the study favoured the use of SR (five with SR alone plus one with SR via hand-held digital recorder) for creating electronic progress notes over their existing mode of data entry. There was no clear perceived benefit from SR in terms of data entry time savings, quality of care, quality of documentation, or impact on clinical and administrative workflow. Conclusions Although our findings are mixed, SR may be a technology with some promise for mental health documentation. Future investigations of this nature should use more participants, a broader range of document types, and compare front- and back-end SR methods.