PPRNet Completed Research

Other Completed Research:

Coxibs and Blood Pressure

PPRNet participated in a study funded by Pharmacia, “The Effects of Vioxx® (Rofecoxib) and Celebrex® (Celecoxib) on Ambulatory Care Patients' Blood Pressure.” The goal of the study was to compare the effects of Rofecoxib and Celecoxib on blood pressure and other outcomes in a PPRNet practices. A manuscript from this project has just been prepared.  

Prevention

Adherence with Recommended Preventive Services in the Primary Care Practices of the Practice Partner Research Network

Collaborators: Ruth Jenkins, M.S., Steven M. Ornstein, MD, Sarah Corley, MD, Marc Silverstein, MD, Qin Pan, MS

Abstract: This study described the preventive services that are monitored in PPRNet primary care practices and measures patient adherence with USPSTF recommendations. Preliminary findings were as follows: Screening services monitored by more than 75% of PPRNet practices include mammography, pap smear, cholesterol screening, fecal occult blood test, breast exam, and tuberculosis screening. Immunizations monitored by more than 75% of practices include influenza, pneumococcal, MMR, hepatitis B, polio, DPT and hemophilis influenza. The percent of patients with services performed within recommended intervals are higher for cholesterol screening (39%; practice range 2%-93%), pap smear (45%; range 12%-84%), mammography (35%; range 1%-75%), pneumococcal vaccine (34%; range 3%-88%), and influenza vaccine (32%; range 2%-84%) and lower for clinical breast examination (28%; range 4%-79%), tetanus booster (27%; range 5%-69%), fecal occult blood testing (22%; range 3%-46%), and sigmoidoscopy (11%; range 4%-34%).

This study has been published: Preventive Services in the Primary Care Practices of the Practice Partner Research Network.  Topics in Health Information Management 2000; 20(3):80-84

Electronic Medical Records

The Impact of Electronic Medical Records on Primary Care Practice

Collaborators: Karen Wager, MS and Steven Ornstein

Abstract: The purpose of this study was to examine the organizational and economical impact of electronic medical records on community-based, primary care practice. Six PPRNet practices that had converted from paper records to electronic medical records within the past five years participated. The researchers used a combination of semi-structured interviews, observations, and review of financial records to examine changes that occurred in practice that may have been attributed to the use of electronic medical records. Different user groups (physicians, nurses, other direct care providers, and office staff) from each participating site were included in the study. The final report was a narrative description and an analysis of themes that emerged. Included were similarities and differences in perspectives between different user groups and different sites regarding changes that occurred in practice that may be attributed to the electronic medical record. The report included changes in costs associated with maintaining paper versus electronic medical record systems, while controlling for patient volume, inflation, and changes in reimbursement rates over time. The study findings were important in furthering our understanding of how electronic medical records have changed physician practice through the perspectives of experienced users. Although the findings from this study may not be generalizable to other physician practices, the study serves as a framework for optimizing the use of electronic medical records in primary care practice.

This study has been published:  Wager KA, Lee FW, White AW, Ward DM, Ornstein SA. Impact of an Electronic Medical Record System on Community-Based Primary Care Practices. J Am Board Fam Pract 2000;13:338-48

Quality Improvement

Quality of Care for Asthma, Coronary Disease, Diabetes Mellitus and Hypertension in the Practice Partner Research Network

Collaborators: Steven Ornstein, MD, Ruth Jenkins, MS, Qin Pan, MS

Abstract: The purpose of this study was to study adherence with practice guidelines for chronic disease PPRNet practices. The focus was on adherence to quality indicators for asthma, coronary disease (CHD), diabetes mellitus (DM), and hypertensive in the fourth quarter of 1997. At the end of 1997, PPRNet had data on more than 380,000 patients, 11,405 with asthma, 7975 with CHD, 13,076 with diabetes mellitus, and 35,762 with hypertension. The mean +/- standard deviation among PPRNet practices in adherence with process indicators was as follows: an anti-inflammatory agent at asthma visits 12%+/-10%, LDL-cholesterol measurement in CHD patients 11%+/-7%, medication for elevated LDL cholesterol 24%+/-26%, glycosylated hemoglobin measurement in DM patients 21%+/-16%, and blood pressure measurement for hypertensive patients 44%+/-13%. The mean +/- standard deviation among PPRNet practices in achievement of clinical outcomes was as follows: CHD patients with LDL-cholesterol <=100 mg/dl 32%+/-26%, DM patients with glycosylated hemoglobin <7% 32%+/-17%, and hypertensive patients with normal blood pressure 37%+/- 13%. We concluded that opportunities for improvement abound in the care of patients with chronic disease and that practice-based research networks like PPRNet are ideal for quality improvement research.

This study has been published: Ornstein SM, Jenkins RG: Quality of Care for Chronic Illness in Primary Care: Opportunity for Improvement in Process and Outcome Measures. The American Journal of Managed Care. 1999; 5(5):621-627

Congestive Heart Failure

Congestive Heart Failure in the Practice Partner Research Network

Collaborators: Douglas Smucker, MD, Steven Ornstein, MD, Ruth Jenkins, MS.

This study was conducted by Dr. Smucker, from the Department of Family Medicine at the University of Cincinnati. Dr. Smucker used PPRNet data to study the epidemiology of congestive heart failure in patients > 50 years of age.

This study was presented at the 27th Annual Meeting of the North American Primary Care Research Group (NAPCRG) in San Diego, California from November 8 - 10, 1999

Respiratory Illness

Antibiotics for Upper Respiratory Infections: Follow-up Utilization and Antibiotic Use

Collaborators: William J. Hueston, M.D., Arch G. Mainous III, Ph.D., Steven Ornstein, M.D., Ruth G. Jenkins, M.S., Qin Pan, M.S.

Abstract:   This study assessed the impact of antibiotic prescribing during an intial visit for viral respiratory infections on future care seeking and the cost of care. 49,862 index visits from 1995 to 1997 were studied. Patients who received antibiotics at the index visit were slightly less likely to return for a follow-up visit (15.4% vs. 17.4%). Those who received antibiotics on the first visit were prescribed more expensive antibiotics in follow-up. The cost of intial antibiotic use outweighed any benefit from reduced utilization.

This study was supported in part by IMS, America, and a Robert Wood Johnson Generalist Scholar Award to Dr. Hueston.

This study has been published:  Arch Fam Med. 1999; 8:426-430

Treatment of Recurrent Ottitis After a Preceding Resistant Case: Which antibiotics work best?

Collaborators: William J. Hueston, M.D., Steven Ornstein, M.D., Ruth G. Jenkins, M.S., Qin Pan, M.S., and Jeffery Wulfman, M.D.

Abstract:    The purpose of this study was to examine if the use of a second-line drug resulted in fewer treatment failures in a recurrent otitis episode following an episode of otitis media resistant to first-line antibiotics. 343 patients with an otitis media episode more than 90 days after an episode of resistant otitis media were selected for study. Of this group, 236 (69%) received first line antibiotics (amoxicillin, ampicillin, penicillin or sulfa-trimethoprim) and 107 (31%) received a second line antibiotic. The primary outcome was the need for an additional antibiotic for otitis media within the next 45 days. Failure rates for first and second line antibiotics in recurrent episodes were not significantly different (13% vs. 18%, p=0.20). We concluded that for a new otitis media episode in a patient with a previous resistant otitis, amoxicillin or sulfa-trimethoprim are just as effective as broader spectrum, more expensive antibiotics.

This study was supported in part by IMS, America, and a Robert Wood Johnson Generalist Scholar Award to Dr. Hueston. 

This study has been published:  The Journal of Family Practice. 1999; 48(1):43-46

EMR Use

PPRNet Members Use of CPR Systems in Practice

Following is summary of results from a 1996 national survey of PPRNet members use of CPR systems in practice. 

The full report is published in:  Wager KA, Ornstein SM, Jenkins RG: The Perceived Value of Computer Based Patient Records Among Clinician Users. MD Computing, September 1997; 14(5) 

Background

In 1996, a national survey was conducted to assess physicians' perceptions of using CPR systems in practice. All of the physicians who participated in this survey were members of the Practice Partner Research Network (PPRNet) and users of the Practice Partner Patient Record®, a CPR product of Physician Micro Systems, Inc. (PMSI). The purpose of the study was to identify the advantages and disadvantages of using CPR systems in practice settings based upon the views of individuals experienced with such systems.

Methods

A survey packet was sent to the designated contact person at each PPRNet member practices; all but two of the 52 practices received the survey by fax, the other two were sent by mail. The survey included 32 items and two major sections. Section A included a list of potential advantages to using CPR systems. Participants were asked to indicate the degree to which they perceived each item to be an advantage or disadvantage to their practice. Section B addressed a broad range of items related to the use of CPR systems in practice, including the frequency in which specific categories of patient information are recorded in their CPR system. Other items addressed the number of users, number and location of CPR workstations, data entry procedures, and current office practices.

Results

Forty-four of the 52 member practices (85%) returned the survey. Seventy-seven (77%) of the surveys were completed by physicians within the various practices, with the remaining having been completed by office managers, nurses, or other contact persons. The practices ranged in size from those with two or three staff to practices with over 50 individuals. The average number practitioners (by position title) who actually use the CPR systems within each practice ranged from fewer than one nurse practitioner and physician assistant to 3.6 nurses and 6.9 physicians.

Participants also reported on current practices for entering data into the CPR system. As Table 1 illustrates, the majority of practices (46%) dictate approximately 75% and directly enter 25% of the data at the point of care.

Table 1. Percent of data entered directly into CPR system at point of care

Description of Data Entry Procedures in Practice	Number of practices
Over 90% of patient information is entered directly into the CPR system at the point of care	12 (27.3%)
75% of patient information is entered directly into the CPR system at the point of care and 25% is entered through dictation/transcription	2 (4.5%)
50% of patient information is entered directly into the CPR system at the point of care and the other half is entered through dictation/transcription	7 (15.9%)
25% of patient information is entered directly into the CPR system at the point of care and 75% is entered through dictation/transcription	20 (45.5%)
Almost none of the data are entered directly.	3 (6.8%)

n=44

Participants reported the frequency with which patient information is recorded in their CPR system. The percentage of participants who indicated that their practice records patient information in the CPR system frequently (or more than 75% of the time) is shown in Table 2. Office visits, medications, vital signs, and patient problems/diagnoses are the types of patient information that are most frequently recorded in the CPR systems. Less frequently recorded are emergency room visits, contacts at outside sites, and telephone contacts with other care providers.

Table 2. Percent of practices that record patient information in CPR system >75% of the time

Type of Patient Information	Number/Percent
Medications	44 (100%)
Office visits	42 (95.5%)
Vital signs	42 (95.5%)
Patient problem/diagnosis	39 (88.6%)
Laboratory results	27 (61.4%)
Referrals	27 (61.4%)
Telephone contacts with patients	27 (61.4%)
Telephone contacts with providers	24 (54.5%)
Health maintenance information	23 (52.3%)
Contact at outside sites	20 (45.5%)
Emergency room visits	9(20.5%)

Thirty-four (77%) participants indicated that their practices currently track some form of health maintenance data: general screenings, screenings for women, immunizations, chemoprophylaxis regimens, and counseling.

Perceived Value of CPR Systems to Physician Practices

The main advantages realized in using CPR systems included the quality of the patient records (e.g., legible, complete, organized), better access to patient records (e.g., available, convenient, fast), and improved documentation for patient care purposes. Participants also found that the CPR systems contributed to improved documentation of preventive services and improved documentation for quality improvement activities. Many found the system relatively easy to use. Items viewed as less of an advantage included administrative cost savings, improved efficiency, and security of patient records. See Table 3 below.

Table 3. Number of practices that view item as an advantage to CPR system

Item	Number/Percent
Improved documentation for patient care	41 (93.2%)
Quality of patient record	38 (86.4%)
Access to patient record	38 (86.4%)
Improved documentation for preventive services	36 (81.8%)
Improved documentation for quality improvement	36 (81.8%)
Ease of use	32 (72.7%)
Security of patient record	28 (63.6%)
Improved efficiency	27 (61.4%)
Administrative cost savings	17 (38.6%)

Participants also had the opportunity to write in any other realized benefit to using the CPR system not listed on the survey. Some of the common responses included:

• improved documentation for coding/reimbursement purposes
• availability of patient record to multiple staff simultaneously
• ability to incorporate e-mail messages into patient records
• access to practice guidelines and outcome measurements
• patient perception of "high tech" office
• ability to comply with managed care guidelines
• ease in tracking lab values in relationship to medications
• recruitment benefits

Discussion

This study describes the use of CPR systems among PPRNet physician practices and highlights the many advantages realized by system users. In general, the PPRNet member practices view their use of the PMSI computer-based patient record as very positive, particularly in improving the overall quality of the patient record and as a tool in providing patient care.

A high percentage of PPRNet member practices are recording office visits, medications, vital signs, and patient problems/diagnoses in the CPR system more than 90% of the time. Laboratory tests are also being recorded, but not as frequently. This may be due to the fact that test results are often done by outside laboratories and, therefore, may require that the physician's practice either electronically import the test results or enter the results manually.

The two most significant benefits realized in using CPR systems related to the overall improvement in the quality of the patient record and its usefulness in patient care. The CPR systems were also found to be useful in tracking preventive services and in monitoring quality improvement activities. In spite of the many advantages cited to using CPR systems, there were also some reported perceived disadvantages. The two most frequently cited disadvantages included the lack of administrative cost savings and efficiency. Although administrative cost savings and efficiency were viewed as disadvantages by nearly half of the participants, over 40% found their CPR systems to save time and money by decreasing the amount of administrative staff needed.

Given that the population for this study included physician practices that currently use the PMSI computer system and only PPRNet members, these results may not be generalizable to other ambulatory care physician practices. There are, however, many advantages to implementing CPR systems in the ambulatory care setting. Such systems provide physicians and other health care professionals with timely access to the patient’s record and improved documentation for patient care and quality improvement purposes. Today’s perceived disadvantages of CPR systems will be overcome as information technology costs continue to decrease and as the demand for efficient and effective information systems continues to rise. Future studies are needed to explore further the impact of CPR systems on decreasing costs and improving patient outcomes in the ambulatory practice setting.

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