The CDS had a significant, beneficial effect on the recognition of hypertension, with a moderate increase in guideline-adherent management.

Context:Blood pressure (BP) is routinely measured in children and adolescents during primary care visits. However, elevated BP or hypertension is frequently not diagnosed or evaluated further by primary care providers. Barriers to recognition include lack of clinician buy-in, competing priorities, and complexity of the standard BP tables.Case Description:We have developed and piloted TeenBP— a web-based, electronic health record (EHR) linked system designed to improve recognition of prehypertension and hypertension in adolescents during primary care visits.Major Themes:Important steps in developing TeenBP included the following: review of national BP guidelines, consideration of clinic workflow, engagement of clinical leaders, and evaluation of the impact on clinical sites. Use of a web-based platform has facilitated updates to the TeenBP algorithm and to the message content. In addition, the web-based platform has allowed for development of a sophisticated display of patient-specific information at the point of care. In the TeenBP pilot, conducted at a single pediatric and family practice site with six clinicians, over a five-month period, more than half of BPs in the hypertensive range were clinically recognized. Furthermore, in this small pilot the TeenBP clinical decision support (CDS) was accepted by providers and clinical staff. Effectiveness of the TeenBP CDS will be determined in a two-year cluster-randomized clinical trial, currently underway at 20 primary care sites.Conclusion:Use of technology to extract and display clinically relevant data stored within the EHR may be a useful tool for improving recognition of adolescent hypertension during busy primary care visits. In the future, the methods developed specifically for TeenBP are likely to be translatable to a wide range of acute and chronic issues affecting children and adolescents.

Objective To examine the relationship between primary care medical home clinical practice systems (PCMH clinical practice systems) corresponding to the domains of the Chronic Care Model and diabetes-related healthcare costs incurred by members of a health plan who have diagnosed Type 2 diabetes and received care at one of 27 Minnesota-based medical groups over a 12-month period. Study Design Cross-sectional analysis of patient-level cost data in relation to the presence of PCMH clinical practice systems by Chronic Care Model domain using the Physician Practice Connections Readiness Survey (PPC-RS). Methods Multivariate regressions adjusting for patient demographics, health status and comorbidities estimated the relationship between the presence of PCMH clinical practice systems as measured by the PPC-RS and three outcomes: total diabetes-related healthcare costs, ambulatory care management costs, and potentially avoidable costs (e.g. unscheduled inpatient and emergency care). Results Two domains of PCMH clinical practice systems as measured by the PPC-RS were significantly associated with reductions in potentially avoidable costs. These were Health Care Organization (p=.04) and clinical reminder systems in the Decision Support domain (p=.01). Compared to medical groups with only quality improvement, those with improved Health Care Organization defined as performance measurement and individual provider feedback averaged $245/patient less. Similarly, medical groups with clinical reminders for counseling averaged $338/patient less. Conclusions PCMH clinical practice systems that correspond to some domains of the Chronic Care Model are related to reduced inpatient and emergency care costs. Further research is needed about how these systems impact costs over time.

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Dentistry has historically seen tobacco dependence as a medical problem. As a consequence, dentistry has not adopted or developed effective interventions to deal with tobacco dependence. With the expanded use of electronic dental records, the authors identiied an opportunity to incorporate standardized expert support for tobacco dependence counseling during the dental visit. Using qualitative results from observations and focus groups, a decision support system was designed that suggested discussion topics based on the patient's desire to quit and his or her level of nicotine addiction. Because dental providers are always pressed for time, the goal was a three-minute average intervention interval. To fulill the provider's need for an easy way to track ongoing interventions, script usage was recorded. This process helped the provider track what he or she had said to the patient about tobacco dependence during previous encounters and to vary the messages. While the individual elements of the design process were not new, the combination of them proved to be very effective in designing a usable and accepted intervention. The heavy involvement of stakeholders in all components of the design gave providers and administrators ownership of the inal product, which was ultimately adopted for use in all the clinics of a large dental group practice in Minnesota.