Policies and Procedures

Trident GMEC Handbook

Curriculum

Trident Family Medicine Residency Program
Clinical Scholars Program 200

• University Family Medicine Residents' Survey of Recent Resident Graduates concerning Electronic Medical Records
  Armstrong, Alan; Hetzel, Robert
• Multidisciplinary Quality Improvement Initiative for Cardiovascular Disease and Stroke in the Family Medicine Center. Betsy Blake, PharmD; Andrea Wessell, PharmD; Steven Ornstein, MD
• Factors Affecting Creatine Supplement Use in High School Athletes. Blumer JM, Sheperd TM, Mainous AG
• Residency Education Improvement Project
  Choyah N, Hutchison R, Schuele K, Carek P
• Does Prenatal Care Reduce the Risk of Low Birth Weight?
  Lucy Davis, MD; Vanessa Sturgill, MD; William J. Hueston, MD, Gregory Gilbert, MPH
• Are the Resident Physicians at Trident Family Medicine Effectively Educating Adolescent Patients about Sexually Transmitted Diseases?
  Tara N Vandegrift, MD, K Gabrielle Gaspar, MD
• Development of a Protocol for Inpatient and Outpatient Treatment of Deep Vein Thrombosis and Pulmonary Embolism with Lovenox. John von Lehe, MD
• Using the Electronic Medical Record to Enhance the Use of Combination Drugs.Keith Lobel, MD, Brian Wells, MD
• Fitness level and health risk appraisal in family medicine residents. Andrew Gerken MD, Nameer Qader MD, Peter Carek MD, MS.
• The Evaluation of Education Regarding Inappropriate Prescribing Practices of Addictive Medications. Alden K, Teets R.
• Family Practitioner Involvement in the Provision of Obstetric Care in South Carolina: A Survey of Obstetricians
  Dan Topping, MD

INTRODUCTION
Electronic Medical Records are the future standard for office records in family medicine practices. The impact of EMRs on office productivity and patient care have been studied. To date, there is some evidence that EMRs can provide improvements in these areas. Residents in the Trident Family Medicine program use an EMR to document all patient encounters. Residents learn to utilize templates and blank note capabilities to document patient visits.

OBJECTIVE
This study purports to analyze current opinions of recent TFM graduates to see if they use an EMR, feel adequately trained to use EMRs, have comments on EMRs, and have suggestions for improving the quality of education on EMRs while in residency.

DESIGN
Seventy-one graduates of the TFM program were queried with a four-part open survey. The following questions were used:
1. Do you use an EMR in your practice? Why (and which one) or why not? What do you think of EMRs in general?
2. When you finished the TFM program, did you feel qualified to use an EMR? Why or why no?
3. What features of EMRs do you use? What features might you use later?
4. What changes in EMR would you recommend for future residents?

RESULTS
35 out of 71 surveys were returned. Seven out of 35 respondents reported EMR usage. EMRs used include Medimac, Soapware, Practice partner, Chartware, and self-developed programs. Positive comments about EMRs included: they are excellent, necessary, reduce dictation costs, easy to use and convenient, reduce errors, templates are good, uniformity among providers, eliminate lost paper charts. Negative comments about EMRs included: time consuming, difficult transition to and from paper charts, too expensive, need to wait for improved versions to make worthwhile. Thirty-one out of 35 respondents felt qualified to use EMRs. EMR features currently used include: information management, medications, voice recognition, scheduling, billing, consultation reports, radiology reports, templates, referrals. Features likely to be used later include hand-held devices with interfaces to networks, remote access, more complete scheduling and billing packages. Recommendations for changes in education for EMR use include: exploration of cost effectiveness of EMRs, training on why Practice Partner was chosen by TFM, information on other EMRs with emphasis on comparison of various alternatives, applications for pdas and laptops, more use of EMRs for research and pharmacy applications, better technical support, training on transitioning to and from EMRs to paper charts, and experience with voice recognition software.

CONCLUSION
This survey indicates that few TFM graduates use EMRs. Nearly all respondents felt qualified to use an EMR. Some graduates who use EMRs utilize most available features of EMRs. Respondents suggest many potential improvements in the TFM EMR curriculum.

Multidisciplinary Quality Improvement Initiative for Cardiovascular Disease and Stroke in the Family Medicine Center. Betsy Blake, PharmD; Andrea Wessell, PharmD; Steven Ornstein, MD

INTRODUCTION
The purpose of this quality improvement (QI) project was to evaluate the adherence to clinical practice guidelines for the prevention of cardiovascular disease and stroke in adult patients of Dr. Ornstein at the MUSC Family Medicine Center (n=1200). The project was modeled after "Practice Partner Research Network-Translating Research into Practice (PPRNet-TRIP)", an ongoing study designed to improve adherence with process and outcome measures for the prevention of cardiovascular disease and stroke in primary care practices.

METHODS
Adherence with guidelines was initially evaluated from data in the EMR and compared to target adherence values defined in PPRNet-TRIP. Measures that fell below target adherence rates were selected as focus points for interventions and included: 1) measurement of blood pressure (BP) in prior 3 months for patients with hypertension (HTN) (target 64%), 2) control of BP less than 140/90 in the last year for patients with HTN (target 52%), 3) measurement of BP (target 69%) and 4) LDL-Cholesterol (LDL) (target 72%) in patients with diabetes, 5) control of Hemoglobin A1c (HbA1c) < 7% (target 56%), 6) LDL less than 100 mg/dL (target 46%) and 7) BP less than 130/85 (target 41%) in patients with diabetes, and 8) cholesterol measurement (total cholesterol and HDL) in adult patients within 5 years (target 58%). QI interventions were based on standards of care and consisted of disease case management during clinic visits, patient education, telephone follow-up and outreach via letter templates in the EMR.

RESULTS
One hundred fourteen (114) patients with a diagnosis of HTN were identified. From baseline to study conclusion, BP measurement within 3 months for patients with HTN improved from 38% to 47%. BP control improved significantly from 47% to 65%. Thirty-three (33) patients with a diagnosis of diabetes were identified. During the study evaluation, HbA1c control improved from 31% at baseline to 32%; measurement of BP in the past 3 months improved from 48% to 52%; BP control improved from 20% to 36%; measurement of LDL in previous 2 years decreased from 58% to 55% and control of LDL decreased from 26% to 22%. No change in the proportion of patients with a total cholesterol measurement was observed (55%) and HDL measurement improved from 29% to 35%. Response to patient outreach via letters and telephone contact varied. Statistical analyses are pending.

CONCLUSION
The target was achieved for control of BP in patients with HTN. A trend toward improvement was seen in BP measurement in HTN and diabetes as well as BP and HbA1c control in diabetes. LDL measurement and control in diabetes failed to improve during this intervention. There was no change in total cholesterol measurement in adult patients. Limitations of this evaluation include a small sample size of patients and short study duration.

Factors Affecting Creatine Supplement Use in High School Athletes. Blumer JM, Sheperd TM, Mainous AG

CONTEXT
Previous surveys regarding creatine use in high school athletes have identified significant use of this supplement, especially among boys. However, little is known about the factors associated with the use of creatine among high school students and the patterns of use.

OBJECTIVE
To identify rates and patterns of creatine use among high school athletes from South Carolina, and identify risk factors for use of creatine supplementation.

DESIGN
Cross-sectional survey conducted in the Spring of 2002.

SETTING AND PARTICIPANTS
High school athletes presenting for pre-participation physical exams from Berkeley and Dorchester counties (South Carolina).

MAIN OUTCOME MEASURE
Self-reported prevalence of creatine use, patterns of creatine use, and sources of information and influences regarding creatine supplementation.

RESULTS
TBA

CONCLUSION
TBA

Residency Education Improvement Project
Choyah N, Hutchison R, Schuele K, Carek P

BACKGROUND
A computer-based core curriculum is provided to residents in family medicine. To date, the usage of this material by residents is not known. Furthermore, the applicability to and standardization of the material to family medicine education has not been examined.

INTRODUCTION
To provide an easily accessible standardized educational resource for resident education that is portable and supplemental to the current core curriculum.

SETTING
Trident Family Medicine Residency Program.

METHODS
Survey to examine the usage of the current core curriculum, and to rank the preferred method of educational delivery. In addition, the ten most common diagnoses, based upon on our inpatient/outpatient services and expert recommendations, were selected as topics. Criteria guidelines for references used were developed.

MAIN OUTCOME MEASURE
Resident satisfaction.

RESULTS
Most residents did not utilize the core curriculum on the "O drive". In addition, most residents felt that the current method of educational delivery inadequately prepares them for their rotations and for board examinations. Finally, most residents expressed a preference for practice guidelines and review articles to enhance their clinical knowledge base.

DISCUSSION
This initial study provided information regarding the current use of available educational resources by family medicine residents. In the future, the proposed educational resource will be finalized and made available to residents. After three to six months of availability, the residents will be queried regarding their use and perceived benefit of this educational resource.

CONCLUSION
This project has demonstrated a need for an alternative educational tool to enhance learning for family medicine residents.

Does Prenatal Care Reduce the Risk of Low Birth Weight?
Lucy Davis, MD; Vanessa Sturgill, MD; William J. Hueston, MD, Gregory Gilbert, MPH

OBJECTIVE
A strong association exists between the number of prenatal visits and decreased risk of LBW but studies are very limited in this area. Our objective is to adjust for known risk factors of LBW while investigating the relationship between the timing of prenatal care and LBW.

STUDY DESIGN
Retrospective cohort study using recorded birth certificate data from deliveries in the United States in 1996.

POPULATION
Singleton births to Caucasian (3,011,109) or African-American (577,144) women as recorded on birth certificates in the United States in 1996.

OUTCOME MEASURED
Low birth weight infants, defined as birth weight less than 2500 grams, for singleton pregnancies in women who obtained prenatal care starting in the first, second, or third trimester and in women who received no prenatal care.

RESULTS
When adjusting for race, smoking status, maternal age, education, and alcohol use during pregnancy, women obtaining prenatal care in the second (adjusted RR=0.85; 98.75% CI: 0.83-0.86) and third trimester (RR=0.87; 98.75% CI: 0.84-0.91) had a decreased risk of LBW infants when compared to women starting prenatal care in the first trimester. In addition, after adjusting for the above confounders, women who received no prenatal care had increased rates of LBW infants with a relative risk of 2.65 when compared to women starting prenatal care in the first trimester.

CONCLUSIONS
No prenatal care is indeed an important risk factor for LBW infants. However, the trimester during which prenatal care is initiated does not have a significant effect on LBW when adjusting for the aforementioned well-known risk factors.

INTRODUCTION
Sexually transmitted infections are a common cause of morbidity in this country and account for significant healthcare expenditure. More than 12 million cases of sexually transmitted diseases are reported annually. Of those, approximately 3 million occur in adolescents. These infections not only cause primary symptoms, but also may lead to long term complications. Several factors contribute to the rising number of adolescents becoming infected. A consideration is that adolescents are not receiving adequate information about how to protect themselves against STDs. This study examines the knowledge base of teenagers in a metropolitan area of South Carolina on the topic of sexually transmitted infections. It also investigates whether resident physicians at Trident Family Medicine are effectively providing STD information to their adolescent patients.

METHODS
The study groups consists of patients between the ages of 13 and 19 presenting for annual physical exams or pre-participation sports physical examinations who agree to participate. A brief questionnaire regarding knowledge of STDs is used to measure baseline knowledge as well as post appointment knowledge of the adolescent patients. Participants receive the questionnaires from their nurse during collection of the vital signs. Subjects complete the first questionnaire prior to the encounter with the physician. The second questionnaire is completed after the visit. Both are returned to the receptionist at check out. Any change in score of these questionnaires is analyzed to determine if 1) adolescents need to be educated regarding STDs and 2) whether residents are addressing the topic during patient encounters.

RESULTS
Results are available currently for 26 patient surveys collected over 12 months. Many surveys were not completed. Fifteen of these participants completed both surveys. STDs were discussed 60% of the time by residents. Prior to the visit, respondents answered an average of 72% correctly when STDs were discussed. When the issue was not discussed, participants scored 83%. Percentage of correct responses did not change significantly after the appointment in either group. Deficits in knowledge include modes of transmission and protection against STDs as well as which diseases are sexually transmitted.

DISCUSSION
It seems that discussion with adolescents about STDs does not change their knowledge. However, most of the participants scored well, indicating that they are receiving the information prior to visits to the physician's office.

Fitness level and health risk appraisal in family medicine residents. Andrew Gerken MD, Nameer Qader MD, Peter Carek MD, MS.

CONTEXT
The importance of regular physical activity and a healthy lifestyle in preventing mortality is well established. One might assume that the schedule during the PGY-1 year would not allow a physician to be able to maintain a healthy diet and participate in regular exercise.

OBJECTIVE
To examine the health risk appraisal status and fitness level of family medicine residents and to study whether these levels remain stable or change as physicians progress through residency training.

DESIGN
1) Consists of a cohort study using a standardized health risk appraisal questionnaire (Demographics, smoking and alcohol use, nutrition, etc.) and testing of specific physical parameters through the exercise lab. 2) Cross sectional analysis of data obtained in the year 2000.

PARTICIPANTS
Trident family medicine residents, PGY-1 through PGY-3.

MAIN OUTCOME MEASURES
The absolute change in the BP, BMI, and responses to the health risk appraisal questionnaire.

RESULTS
The cohort consisted of PGY1 in the year 2000 (n=9). This group was examined in the years 2000 and 2001. No statistically significant changes in BMI (p = 0.58 ), BP (p = 0.85 ), present smokers (p = 0.22 ) and amount of weekly exercise (p = 0.25 ) was noted. Similarly, no statistically significant data was obtained from the cross sectional analysis of PGY-1's and PGY-3's for the year 2000.

CONCLUSION
Although one might infer that the rigorous work schedule of a PGY-1 would cause significant changes in one's health and fitness level, this was not proven to be true in this very small study. We found no significant changes in overall fitness level or cardiovascular risk.

Using the Electronic Medical Record to Enhance the Use of Combination Drugs
Keith Lobel, MD, Brian Wells, MD

INTRODUCTION
Medication costs are increasing dramatically and many patients are on treatment regimens with multiple medications that expose them to a greater risk of non-compliance. Medications are now being marketed in combination forms for many diseases (i.e. hypertension, diabetes mellitis, pain, asthma). These medications provide the potential for substantial cost savings as well as improved ease of administration, both of which may enhance patient compliance and result in more effective disease management. Our family medicine residency program serves a relatively high proportion of low-income families on Medicaid that are heavily impacted by new legislation in South Carolina that limits the number and duration of prescriptions.

The advent of the electronic medical record (EMR) provides a powerful tool to review records of our entire patient population. This tool can be used to identify patients taking medications that could potentially be given as combinations, to implement an intervention, and to monitor for cost savings.

METHODS
The EMR was used to identify patients who were potential candidates for one of the following three currently available combination drugs: fluticasone/salmeterol, amlodipine/benazepril, or glyburide/metformin. Point-of-care reminders were attached to the medication record of the EMR for each patient. The reminders asked providers to consider using the available combination medication when appropriate, thus representing a continuous quality improvement intervention. Medication changes were monitored on a continual basis from September 18, 2001 to March 18, 2002. Average prices were obtained from DrugStore.com.

RESULTS
We flagged a total of 241 charts and 73% of these patients were seen in the clinic by a provider during the study period. Forty-seven out of 175 potential candidates were switched to the comparable combination drug. A cost savings analysis showed a total savings of $6,159.30 for the three combination medications.

DISCUSSION
Point-of-care reminders are a simple and effective tool for quality improvement interventions. This quality improvement model can be implemented with minimal effort into other practices that use an EMR. Combination drugs may play an important role in controlling costs of pharmacotherapies. Further research should evaluate the effect of combination drugs on patient outcomes. Future EMR systems could be programmed to automatically apply point-of-care reminders on a variety of quality-improvement topics.

The Evaluation of Education Regarding Inappropriate Prescribing Practices of Addictive Medications. Alden K, Teets R.

INTRODUCTION
In 2001, we performed a study looking at prescribing practices in our clinics, and found a significant proportion of addictive medications were prescribed inappropriately (29%, N= 242). Subsequently, in this study, we initiated educational modalities to see if a decrease could be effected in this proportion. Examination of the patient records served as the outcome measure to see if the rate of inappropriate prescriptions had gone down.

METHODS
Four separate modalities were initiated during the fall 2001 to spring 2002 time period: (1) a lecture was given January 2002 at UFM with VTEL for Calhoun Street that reviewed addictive medications and their correct indications, as well as the DEA scheduling system, (2) an informal discussion occurred during the aforementioned lecture, (3) prompts in all addictive medication templates were included, asking the provider if proper indication had been documented, and (4) a letter template and progress note template were designed to aid in providing a contract for appropriate long-term addictive medication prescribing. All above modalities were available to practitioners at UFM (Trident site), as well as DFM (downtown site). Lastly, a review of prescriptions for addictive medications, including all controlled substances, were retrieved from March 2002, using the electronic medical record (N =614).

Medical records examined were from either Calhoun Street DFM or Trident UFM clinics. The patient record was then examined looking for appropriate documentation and rationale for addictive medicines prescribed. Prescriptions were deemed inappropriate for one of the following reasons: (1) inadequate documentation, (2) refills without exams, (3) indications that are inappropriate, or (4) prescriptions to patients with history of addiction.

RESULTS
614 prescriptions for addictive/controlled substances were identified for the month of March 2002. 11% of these prescriptions were deemed inappropriate (N = 614). The previous rate of inappropriate prescriptions from out study had been 29% (N = 242). Thus an improvement of 18% occurred from late 2000 to early 2002. Of note, attendance for the lecture mentioned above was not very strong for downtown site attendings, but all other modalities were available to both sites.

DISCUSSION
The proportion of inappropriate prescriptions of addictive medications appreciably decreased from the late 2000 to early 2002. This corresponds to the time-period when we initiated our measures to decrease the proportion prescribed, suggesting that our modalities were successful over this time period. There were no other changes during this time period that would likely affect prescribing practices, except some minor changes in attending personnel, and some changes in resident-doctor personnel.

Family Practitioner Involvement in the Provision of Obstetric Care in South Carolina: A Survey of Obstetricians
Dan Topping, MD

The purpose of the study was to describe the characteristics of OB/GYNs and to identify important factors relating to their opinions of family practitioner involvement in the provision of obstetric care in the state of South Carolina. An opinion Survey was mailed to all physicians identifying themselves as OB/GYNs identified in the South Carolina Directory of Licensed Physicians. 244 out of the 458 persons identified were returned for an adjusted response rate of 65%. 82.6% of the respondents currently practice obstetrics. Of those individuals 23.2% planned to quit the practice of obstetrics in the next five years. 44.8% of all respondents felt that FPs should do OB, whereas 55.2% felt that they should not. OB/GYNs that have been sued are less likely to support FP involvement in obstetric care (RR = 0.74, 0.55<RR<0.99). However those that practice nearby and provide back-up and consultation service are more likely to support FP-managed obstetric care (RR = 1.84, 1.25<RR<2.70). OB/GYNs that support FP-managed obstetric care are more in favor of management of medical complications (HTN, GDM, mild preeclampsia, multiple gestations and extremes of age) than those that are not. Factors that did not appear to affect opinions included age, gender and location of practice (rural vs. urban). Fewer and fewer physicians are willing to provide obstetrical services in rural areas for a number of reasons. Among them are malpractice costs/suits, lifestyle, and adequacy of training. Perhaps curbing the current malpractice crisis and fostering better working relationships between OB/GYNs and FPs will slow or reverse the flow of maternity care physicians from rural underserved areas.

Development of a Protocol for Inpatient and Outpatient Treatment of Deep Vein Thrombosis and Pulmonary Embolism with Lovenox. John von Lehe, MD

CONTEXT
Studies show that there is a potential for cost savings and decreased hospital days through use of Low-molecular Weight Heparin (LMWH) as opposed to the use of standard heparin.

OBJECTIVE
To develop an inpatient/outpatient protocol for use of LMWH for the treatment of DVT/PE.

DESIGN
Not applicable

SETTING
Primary and Specialty care in a Community-based hospital.

INTERVENTION
Use of Low-Molecular Weight Heparin (LMWH) (Lovenox)

MAIN OUTCOME MEASURE
Based on the number of patients admitted and/or treated on an outpatient basis for DVT or PE, how many were treated with Lovenox. Then, based on these patients, compare the total cost of inpatient treatment with Standard Heparin versus the cost of treatment with Lovenox. Also, we would compare the length of stay with Standard Heparin versus Lovenox.

RESULTS
No data has been gathered at Trident Regional medical center with regard to its newly introduced protocol. However, recent data from Medical University of South Carolina based on a similar protocol shows a decrease in total costs of approximately one-half and a decrease in length of stay from 4.1 to 1.6 days.

CONCLUSIONS
These results suggest that Trident Regional Medical Center could achieve similar cost savings through their recent implementation of the DVT/PE Protocol.