Electronic Medical Record Tobacco Use Vital Sign

Transcription

1 TOBACCO INDUCED DISEASES Vol. 2, No. 2: (2004) PTID Society Electroic Medical Record Tobacco Use Vital Sig Joh W. Norris III, 1 Smita Namboodiri, 2 Syed Haque, 2 David J. Murphy, 3 Frak Soeberg 3 Uiversity of Medicie ad Detistry of New Jersey, Newark, New Jersey: 1 Divisio of Medical Iformatics, Departmet of Medicie, New Jersey Medical School; 2 Departmet of Health Iformatics, School of Health Related Professios; 3 Departmet of Medicie, Robert Wood Johso Medical School ABSTRACT: Objective: Determiatio of the prevalece of tobacco use ad impact of tobacco prevetio/treatmet efforts i a electroic medical record eabled practice utilizig a defied tobacco vital sig variable. Desig ad Measuremets: Retrospective cohort study utilizig patiet data recorded i a electroic medical record database betwee July 15, 2001, ad May 31, Patietreported tobacco use status was obtaied for each of 6,771 patiets durig the preprovider period of their 24,824 visits durig the study period with the recorder blided to past tobacco use status etries. Results: A overall curret tobacco use prevalece of 27.1 was foud durig the study period. Tobacco use status was recorded i 96 of visits. Compariso of iitial to fial visit tobacco use status demostrates a cosistecy rate of 75.0 declarig o chage i tobacco status i the 4,522 patiets with two or more visits. A 8.6 et tobacco use declie was see for the practice (p value < 0.001). Coclusios: Self reported tobacco use status as a vital sig embedded withi the workflow of a electroic medical record eabled practice was a quatitative tool for determiatio of tobacco use prevalece ad a measurig stick of risk prevetio/itervetio impact. KEYWORDS: Tobacco, Vital Sig, Electroic, Record BACKGROUND Public health guidelies have log recommeded that patietprofessed tobacco use status be assessed for every patiet at every cliical care visit as a vital sig [1]. I actual cliical practice this recommedatio acts as a prompt for tobacco itervetio to the medical team [2,3]. Implemetatio of this recommedatio withi a electroic medical record has bee described i compariso to a paper system with trackig codes [4]. We report o a ophysicia mediated meas of determiig the prevalece of tobacco use ad impact of tobacco prevetio/treatmet efforts i a electroic medical record eabled practice utilizig a defied tobacco vital sig variable. Electroic medical records have recetly bee advocated as valuable tools i the protectio of patiet safety durig medical care [5]. There ca be a desirable cost beefit ratio related to usig a electroic chartig system istead of the traditioal paper system [6]. Electroic medical records track issues as variables, i this case tobacco use status. Variables permit the aalysis of the discreet data poits they represet. Structurig these data poits with a limitatio o degrees of freedom ad a practical mutual exclusivity aids i the quatitative aalysis of the variable. Collectio of each patiet s tobacco use status as curret, former, or ever at every ambulatory care visit has bee advocated [7]. Followig this recommedatio provides Correspodece: Joh W. Norris III, MD, 185 South Orage Aveue, I506, Newark, New Jersey orrisjw@umdj.edu Fax: + (973)

2 110 Norris JW, Namboodiri S, Haque S, Murphy DJ, Soeberg F Iitially Neutral Etry to Demostrate Curret Tobacco User Etry to Demostrate Couselig structure to the tobacco use status data poits. Icludig o etry to this list of choices provides mutual exclusivity. Fuctioal icorporatio of the data collectio process ito a routie work flow facilitates the collectio of discreet data poits for compariso. Examples of this i a cliical settig iclude graphig of fever curves related to patiet temperature or followig of blood pressure readigs over a series of successive readigs. Udertakig paper medical record based aalysis usually ivolves review of a subset of data istead of all the data that could be extracted from the patiet records [8]. This process itroduces the complicatio of sample error durig the aalysis [9]. Groups have attempted to automate this effort through the trackig of tobacco use status i electroic systems such as registratio systems. Electroic systems offer the opportuity to overcome sample error by extractig all discreet data etries i a give category with great efficiecy. Electroic medical records take this a step further by allowig cliical recommedatios to be embedded ito a specific cliical workflow. These systems have bee reported to cotai more data related to observatios ad patiet educatio tha paper records [10]. Successful icorporatio of a process ito a cliical workflow requires a efficiet embeddig of the process ito the ormal workflow of the practice [11]. Vital sigs are frequetly obtaied i the preprovider portio of patiet care visits. This is the period of the visit at which time the urse or medical techicia calls the patiet from the practice s receptio area ad brigs the patiet to a place for the takig of blood pressure, pulse, height, weight, respiratory rate, temperature, ad patietspecific tests such as a figer stick blood sugar i a diabetic patiet or a peak flow rate i a asthmatic patiet. We chose to study the characteristics ad variability of the ophysicia obtaied EMR facilitated tobacco vital sig. METHODS We preset a retrospective cohort study begiig July 15, 2001, ad edig May 31, Cliic Settig: UMD Care is the geeral iteral medicie ambulatory care practice of the Uiversity Hospital i Newark, New Jersey. The practice is cosidered a safety et practice withi a safety et hospital. The patiets of this practice are as a group socioecoomically eedy. The practice s staff icludes five fulltime attedig physicias, six parttime residet practice attedig physicias, 36 iteral medicie residets, ad 20 support staff. Both private practice ad residet teachig practice is coducted at this site. A electroic medical record, Logicia TM (GE Medical Systems Ic., Hillsboro, Orego), has bee i use at the practice sice May All cliical staff utilize the EMR for documetatio of every visit. Vital Sig Acquisitio Process: All patiets are see iitially by a medical health techicia (MHT) who records vital sigs. MHTs were istructed to iclude a patietprofessed tobacco use history as a vital sig utilizig a computer scree as show i the simulated patiet record i Figure 1. Documetatio of tobacco use is categorized as curret, previous, or ever. All curret tobacco users are couseled to quit

3 Electroic Medical Record Tobacco Use Vital Sig 111 Table 1: Demographics Age (years) Geder Race Average 51.2 Male Black 59.9 Rage Female Hispaic 21.8 Blak 0.02 White 4.8 Other 13.5 by the MHT ad a couselig box is checked to documet related prevetio educatio. The MHT was blided to the previously reported tobacco status i order to provide a ubiased assessmet (Figure 1). The provider has access to this iformatio durig the provider compoet of the visit. Data were extracted from the EMR database with the approval of our istitutioal review board. Vital Sig Data Extractio: Data collected for each patiet icluded age, sex, race, date of visit, ad tobacco status at each visit, ad tobacco couselig. Patiets data was deidetified by usig patiet age at the time of the report, istead of the more specific birth date. Patiets were give a iteger as idetificatio to provide a verificatio mechaism to verify the applicatio of the appropriate data to the appropriate patiet. Tobacco Therapy: A list of all bupropio ad icotie therapy was extracted from the database for the populatio. All data were deidetified as described above ad combied with that of the vital sig data extractio process i order to permit aalysis. Tobacco Related Couselig: MHTs recorded the provisio of their couselig of the patiet to stop smokig by checkig a box o the vital sigs form. Physicia couselig would be recorded as free text, ot a discreet variable, thus is ot aalyzed i this report. OUTCOMES: Demographic data were extracted based o age at time of report, geder ad race for the populatio. Tobacco use status was the aalyzed for compliace with all etries ad iitial visit tobacco use prevalece. For patiets with two or more visits, tobacco use statuses were compared for cosistecy. Cosistecy was defied as o chage i tobacco status from visit to visit. If there was o chage i visittovisit tobacco use status, this was iferred to mea the patiet s use of tobacco had ot chaged betwee visits, while ay chages i status betwee data poits permitted characterizatio of that chage. A perso iitially documeted as reportig curret tobacco use ad later beig documeted as havig previous tobacco use could be iferred to have achieved cessatio at that poit i time. Ay perso iitially documeted as reportig ever tobacco use ad later beig documeted as havig curret tobacco use would be iferred to have started tobacco use i the iterim period. A perso who had achieved cessatio but relapsed ito tobacco use would have a chage from previous to curret. First visit ad last visit data were the placed i visit aggregates ad compared for differeces i order to obtai a et tobacco chage over the study period. It has log bee recogized that physicias could icrease their use of pharmacologic therapies i tobacco cessatio [12]. Tobacco therapy was represeted by evidece of a prescriptio for bupropio or a icotie replacemet therapy or evidece of tobacco cessatio couselig as documeted by the MHT. DATA ANALYSIS: Uivariate aalysis was applied to study data. Tobacco use prevalece as reported i the Behavioral Risk Factor Surveillace Survey (BRFSS) of the Ceter for Disease Cotrol ad Prevetio for the year 2000 was used to compare study data to that of state ad atio [13]. RESULTS: There were 6,771 patiets i the data set with 24,824 visits; this provided 24,824 tobacco use status data poits for the aalysis. Tobacco use status data were preset i 96. Average visits per patiet were 3.6 for the study period with a rage of oe visit per patiet to 39 visits per patiet. Geder of the populatio was 59.2 female ad 40.8 male. Black ad Hispaic patiets made up 81.6 of these idividuals. Average age of the patiets was 51.2 years with a rage from 16 years to 98 years (Table 1). Evaluatio of aggregated visit statuses demostrates a tred for a decreasig percetage of patiet curret tobacco use with icreasig umbers of visits over the study period (Figure 2). Whe compared to

4 112 Norris JW, Namboodiri S, Haque S, Murphy DJ, Soeberg F Figure 2: Tobacco use status aggregates by visit umber Tobacco Status by Visit 70.0 Percetage Resposes Curret Previous Never No Etry Visit Number Table 2. Percet Curret Tobacco Use by Iitial Tobacco Status Total Curret Curret Males Curret Females > 64 UMD Care Study New Jersey ( ) ( ) ( ) ( ) ( ) ( ) ( ) 77 Natioal (USA) 2000* = Cofidece Itervals N = Number of surveyed idividuals i that group

5 Electroic Medical Record Tobacco Use Vital Sig 113 tobacco prevalece as determied by the BRFSS, the practice s 27.1 curret tobacco use rate was outside the cofidece iterval for New Jersey (19.4 to 22.5), though it is i lie with published reports that suggest urba populatios are more proe to active tobacco use (Table 2). Patiets with two or more visits totaled 4,522 idividuals. This group s average umber of visits was 3.6 with a rage of 2 to 39 visits. Evaluatio betwee first ad last visit for these patiets demostrated a 75.0 cosistecy rate i etries (Table 3). The largest variability, 12.4, was foud i those patiets for whom the oly etries were ever ad previous i either order. All other variability made up oly 12.6 of the etries. Aggregate tobacco use statuses o first visit (Table 4) ad o fial visit (Table 5) were compared. Curret tobacco use decreased from 1,146 patiets o the iitial visit to 1,047 o the fial visit (Table 6). This is a et patiet tobacco cessatio of 99 patiets or 8.6 (P value <0.001). Tobacco cessatio couselig was preset i 91.3 of patiet care visits. Tobacco therapies were listed i oly 20 charts. Aalysis of patiet medicatio lists idicated three bupropio ad 17 icotie replacemet prescriptios. CONCLUSION: Tobacco is a major modifiable risk factor for several diseases ad coditios [14]. The recorded tobacco use status professed by patiets is ow a advocated measure of tobacco use prevalece. The character of these data poits is ot well described for variability ad tredig, but has become the chief tool for the measuremet of quality of care provided by physicias ad health care orgaizatios i regard to tobacco itervetio. This cocer is especially true whe related to its documetatio by ophysicias durig the acquisitio of vital sigs for routie patiet care visits i a ambulatory settig. The described electroic medical record ehaced process leds itself to the characterizatio of tobacco use treds i idividuals ad populatios over a series of care visits. Udertakig paper medical record based aalysis would ofte ivolve review of a subset of data istead of all the data that could be extracted from the patiet records, itroducig the further complicatio of sample error i the aalysis. This is required due to the labor requiremets of maual data capture. Electroic systems offer the opportuity to overcome sample error by extractig all discreet data etries i a give category with great efficiecy [15]. Also, they provide a sample set that i this example was the etire populatio, therefore it was uecessary to calculate the cofidece iterval. Groups have attempted to automate this effort through the trackig of tobacco use status i registratio electroic systems [16]. Electroic medical records take this a step further by allowig cliical recommedatios to be embedded ito a specific cliical workflow [17]. This process i these systems permits the tobacco use status to be liked to other cliical data poits formig a tobacco use registry. The cost of the process is egligible. The questios are asked while performig other vital sig related tasks. Beefits obtaied usig this type of system durig the study period have bee demostrated to be maitaied well beyod the ed of that study [18]. Of the patiets preset withi our study, 96 had a tobacco use status recorded, suggestig that the staff was compliat with addressig the documetatio requiremets. There was o chage i status for 73.2 of patiets cocerig their first ad last visit durig the study period despite blidig the MHT to the previous tobacco use history of the idividual patiets. The proportio of curret tobacco use by our populatio meets prevalece expectatios suggested by other published works for similar populatios, suggestig compliace with the process by staff. Aalysis of patiets with variability i these etries shows a predilectio for a Never/Previous pheomeo. For reasos uclear i the data, a relatively large segmet of the patiet populatio was documeted as havig selfreported tobacco status alteratig betwee ever ad previous. Whether this is a product of patiets miimizig their report of a socially egative behavior or a error related Table 3. Cosistecy of Data Etries by Patiet Variability betwee Medical Health Techicia etries Patiet Number Patiet Percet No tobacco status variability Patiet with combiatios of ever ad previous oly All other tobacco status chages (curret to previous, etc.)

6 114 Norris JW, Namboodiri S, Haque S, Murphy DJ, Soeberg F to the documeter s techique for acquirig the data or some other factor, we believe this warrats further ivestigatio. We did ot expect the use of the tobacco use vital sig to demostrate alteratio i physicia behavior sigificatly at this poit [19]. Our attempt to idetify the itervetios provided by physicias to their patiets was ot easily accomplished. Pharmacotherapy is a advocated treatmet process. A review of the medicatio lists of all patiets who had bee icluded i the study demostrated oly 20 medicatio orders. As prescriptios are prited i the practice from the electroic medical record for all medicatios it is ulikely ay physicia is hadwritig these prescriptios. Comorbidities ad cotraidicatios were ot screeed i this aalysis. The socioecoomic ature of the populatio is likely also a factor, i that patiets may ot be acceptig prescriptios for medicatios they caot afford or are ot covered by their health plas. Physicias could be projectig a bias that their patiets would refuse prescriptios for medicatios they caot afford or are ot covered by their health plas. Overthecouter cessatio aids may be discussed with the patiets but ot icluded i the medicatio list. Referral to state fuded programs [20,21] would be embedded i text ad ot structured i discreet, trackable variables. Educatioal sessios have bee started for physicias ad staff i a attempt to have a discussio o the issue ad provide traiig i tobacco treatmet aids as a prelude to further study [22]. A weakesses of this study was the accuracy of the tobacco status beig professed by the patiet to the documetig ophysicia staff member ad the correct subsequet documetatio of that data ito the record. Cosistecy of the data ad the percetage of curret tobacco users are supportive of the correctess of the data. It is possible to attempt to cofirm the tobacco use status at each visit usig cotiie or carbo mooxide testig, however, either was icorporated ito this study due to cocers about the impact o practice workflow ad costs associated with each process. The use of poit prevalece tobacco use status should ot be the stadard by which tobacco use status is used to defie true tobacco cessatio. Work cotiues o this project at this time. The vital sig has bee augmeted with a legth of time from last tobacco use query to go beyod the poit prevalece limitatio we described. Feedback to providers ad staffs related to their itervetios ad impact has begu as a step toward academic detailig of providers [23]. Expasio of the process to ambulatory care practices of two other medical schools has recetly take place. Tailorig of the process as a compoet of ipatiet iitial order etry for all admissios at our Uiversity Hospital with primary diagosis of acute myocardial ifarctio ad cogestive heart failure has bee approved by the hospital s cliical practice committee of the medical staff. Surveys of patiets, ophysicia healthcare workers, ad physicias are beig developed at this time to assess qualitative value ad barriers created by the process. Developmet ad study of poit of care, decisio support tools based o the EMR applied tobacco use vital sig are i the prototype phase of evaluatio. Ackowledgemet: Support for this project was provided by a grat from the New Jersey Departmet of Health ad Seior Services, Comprehesive Tobacco Cotrol Program. We ackowledge the efforts of the followig people: Carol Cook, Stefaie Brow MD, Gitare Gecys DO, Norma Hymowitz PhD, Michael Steiberg MD, Doa Aders, Susa Mettle, Richard Calma, Daw Richmod, Shahida Khwaja, Kriste James, the UMD Care physicias ad staff. REFERENCES: 1. Treatig Tobacco Use ad Depedece. Summary, Jue U.S. Public Health Service. Available from: URL: gov/tobacco/smokesum.htm 2. Robiso MD, Lauret SL, Little JM Jr. Icludig smokig status as a ew vital sig: it works! Joural of Family Practice 1995; 40(6): Ahluwalia JS, Gibso CA, Keey RE, Wallace DD, Resicow K. Smokig Status as a Vital Sig. Joural of Geeral Iteral Medicie 1999; 14(7): Betz CJ, Davis N, Bayley B. The feasibility of paperbased Trackig Codes ad electroic medical record systems to moitor tobaccouse assessmet ad itervetio i a Idividual Practice Associatio (IPA) Model health maiteace orgaizatio (HMO). Nicotie & Tobacco Research 2002; 4 Suppl 1: Bates DW, Cohe M, Leape LL, Overhage JM, Shabot MM, Sherida T. Reducig the frequecy of errors i medicie usig iformatio techology. Joural of the America Medical Iformatics Associatio 2001; 8(4): Wag SJ, Middleto B, Prosser LA, Bardo CG, Spurr CD, Carchidi PJ, Kittler AF, Goldszer RC, Fairchild DG, Sussma AJ, Kuperma GJ, Bates

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