Timothy G. Ferris

Bio: Timothy G. Ferris is an academic researcher from Harvard University. The author has contributed to research in topics: Health care & Ambulatory care. The author has an hindex of 40, co-authored 144 publications receiving 7490 citations. Previous affiliations of Timothy G. Ferris include University of Minnesota & Suburban Hospital.

Use of electronic health records in U.S. hospitals.

Abstract: We surveyed all acute care hospitals that are members of the American Hospital Association for the presence of specific electronic-record functionalities. Using a definition of electronic health records based on expert consensus, we determined the proportion of hospitals that had such systems in their clinical areas. We also examined the relationship of adoption of electronic health records to specific hospital characteristics and factors that were reported to be barriers to or facilitators of adoption. Results On the basis of responses from 63.1% of hospitals surveyed, only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals. Larger hospitals, those located in urban areas, and teaching hospitals were more likely to have electronic-records systems. Respondents cited capital requirements and high maintenance costs as the primary barriers to implementation, although hospitals with electronic-records systems were less likely to cite these barriers than hospitals without such systems. Conclusions The very low levels of adoption of electronic health records in U.S. hospitals suggest that policymakers face substantial obstacles to the achievement of health care performance goals that depend on health information technology. A policy strategy focused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of electronic-records systems in U.S. hospitals.

Electronic Health Records in Ambulatory Care — A National Survey of Physicians

Abstract: BACKGROUND Electronic health records have the potential to improve the delivery of health care services. However, in the United States, physicians have been slow to adopt such systems. This study assessed physicians' adoption of outpatient electronic health records, their satisfaction with such systems, the perceived effect of the systems on the quality of care, and the perceived barriers to adoption. METHODS In late 2007 and early 2008, we conducted a national survey of 2758 physicians, which represented a response rate of 62%. Using a definition for electronic health records that was based on expert consensus, we determined the proportion of physicians who were using such records in an office setting and the relationship between adoption and the characteristics of individual physicians and their practices. RESULTS Four percent of physicians reported having an extensive, fully functional electronic-records system, and 13% reported having a basic system. In multivariate analyses, primary care physicians and those practicing in large groups, in hospitals or medical centers, and in the western region of the United States were more likely to use electronic health records. Physicians reported positive effects of these systems on several dimensions of quality of care and high levels of satisfaction. Financial barriers were viewed as having the greatest effect on decisions about the adoption of electronic health records. CONCLUSIONS Physicians who use electronic health records believe such systems improve the quality of care and are generally satisfied with the systems. However, as of early 2008, electronic systems had been adopted by only a small minority of U.S. physicians, who may differ from later adopters of these systems.

How Common Are Electronic Health Records In The United States? A Summary Of The Evidence

Abstract: Electronic health records (EHRs) are promising tools to improve quality and efficiency in health care, but data on their adoption rate are limited. We identified surveys on EHR adoption and assessed their quality. Although surveys returned widely different estimates of EHR use, when available information is limited to studies of high or medium quality, national estimates are possible: Through 2005, approximately 23.9 percent of physicians used EHRs in the ambulatory setting, while 5 percent of hospitals used computerized physician order entry. Large gaps in knowledge, including information about EHR use among safety-net providers, pose critical challenges for the development of policies aimed at speeding adoption.

Limited English proficiency and breast and cervical cancer screening in a multiethnic population.

Abstract: Objectives. We examined the relationship between ability to speak English and receipt of Papanicolaou tests, clinical breast examinations, and mammography in a multiethnic group of women in the United States.Methods. We used longitudinal data from the Study of Women Across the Nation to examine receipt of breast and cervical cancer screening among Chinese, Japanese, Hispanic, and White women who reported reading and speaking (1) only a language other than English, (2) another language more fluently than English, or (3) only English or another language and English with equal fluency. Logistic regression was used to analyze the data.Results. Reading and speaking only a language other than English and reading and speaking another language more fluently than English, were significantly and negatively associated with receipt of breast and cervical cancer screening in unadjusted models. Although these findings were attenuated in adjusted models, not speaking English well or at all remained negatively associated...

Professionalism in Medicine: Results of a National Survey of

Abstract: Context Whether practicing physicians conform to norms of professionalism is unknown. Contribution This survey of 3504 practicing physicians in the United States found that most physicians agreed with principles regarding fair distribution of resources, access to and quality of care, conflicts of interest, and self-regulation that were proposed by professional societies in 2002. Self-reported behaviors, however, showed that about one half did not follow self-regulation principles and that about one third would order unneeded magnetic resonance imaging for back pain in response to a patient's request. Implication Although physicians generally agree with proposed professional norms, they do not always follow all of them. The Editors Attempts to improve the quality and efficiency of health care have primarily relied on government regulation, financial incentives, public reporting, and competition (18). So far, these approaches have not resolved the problems of cost, access, and quality in the U.S. health care system (9). As a complementary approach to addressing these issues, physician groups have been focusing on promoting medical professionalism among physicians (10). In 2002, the American Board of Internal Medicine and other groups published a Charter on Professionalism (the Charter), which has been embraced by many professional organizations in the United States and other countries (11, 12). The Institute on Medicine as a Profession Survey on Medical Professionalism was developed to enhance understanding of physicians' attitudes toward professional norms in the Charter, the extent to which they conform to those norms in daily work, and the factors that may influence professional behaviors. We report the results of that survey. Methods Definition of Professionalism Several definitions of professionalism exist (1318). However, many of these definitions have not been put into effect or endorsed by professional societies. For this investigation, we use the definition in the American Board of Internal Medicine's Charter on Professionalism, because it has been embraced by many organizations nationally and internationally (11, 12). Survey Design and Testing We developed a preliminary set of questions based on a focus group with physicians in which we probed how best to measure physicians' attitudes and behaviors. The survey was revised on the basis of the results of 8 cognitive interviews. The goal of cognitive interviews is to find out how respondents understand and respond to survey items. A cognitive interview involves a researcher reading questions to respondents, having them answer the questions, and then attempting to determine the cognitive processes that the respondents used to formulate their response. Understanding respondents' cognitive processes allows the researcher to sense discrepancies between the way respondents performed a task and the way researchers envision the task will be performed (19). The final survey was approved by the institutional review board of the investigators' institution. Measures of Professionalism Attitudes Related to Professionalism Several questions measured physicians' support for professional norms. Table 1 shows the survey questions and their associated dimensions of professionalism. Table 1. Attitudes toward Professionalism Behaviors Related to Professionalism Table 2 shows the survey questions about self-reported behaviors associated with professional norms in the Charter. We did not seek to cover every conceivable behavior related to all 10 norms. Instead, we asked about selected behaviors that were particularly salient and had substantial face validity as tracer measures of conformance to professionalism norms. Thus, our results do not provide a comprehensive assessment of the professionalism of respondents but instead provide the basis for exploring factors that may influence physicians' behaviors related to professionalism. Table 2. Professional Behaviors Survey Sample The sampling frame was the 2003 American Medical Association Masterfile. We selected all physicians in 3 primary care specialties (general internal medicine, family practice, pediatrics) and 3 nonprimary care specialties (cardiology, anesthesiology, general surgery). We chose the 3 primary care specialties because they represent almost all primary care physicians in the United States, and we chose the nonprimary care specialties because they represent a medical specialty, an inpatient specialty, and surgery. We excluded osteopathic physicians, resident physicians, and physicians in federally owned hospitals. From this list of 271148 physicians, we randomly selected 3504 who were distributed equally among the 6 specialties. We selected equal numbers of physicians in each specialty in order to have sufficient statistical power to examine specialty-specific associations. Survey Administration As described elsewhere (20), the survey was administered between November 2003 and June 2004. Sampled physicians were sent a survey instrument, a cover letter, a fact sheet describing the study, a postage-paid return envelope, and a prepaid incentive check for $20. Of the 3504 sampled physicians, 337 were ineligible because they were dead, out of the country, practicing a nonsampled specialty, on leave, or not providing patient care. This yielded a raw eligibility estimate of 90.3%. Of the 3167 eligible physicians, 1662 completed a questionnaire, for an overall raw response rate of 52%. The weighted overall response rate was 58% (43% in cardiology, 57% in anesthesiology, 55% in family practice, 54% in surgery, 52% in internal medicine, and 64% in pediatrics) (21). The weighted overall response rate was calculated as follows: completed interviews/(completed interviews + partial interviews) + (refusals + noncontacts + other) + (eligibility estimate unknown eligibility physicians). Physicians were classified as unknown eligibility if no information was obtained about their eligibility either directly from the physician or from a gatekeeper. No physicians were classified as other. The specialty-specific weighted response rates account for the differential rates of eligibility within each specialty. Statistical Analysis The primary analyses were multivariable and focused on the determinants of reported behaviors related to selected policy-relevant domains of professionalism, such as improving quality of and access to care, maintaining professional competence, managing conflicts of interest, and self-regulation. The 3 independent variables were physician specialty (general internal medicine, family practice, pediatrics, cardiology, anesthesiology, or general surgery), primary practice location (solo or 2-person practice, single specialty group, multispecialty group, staff- or group-model HMO, university or medical school, hospital, and other), and primary reimbursement mechanism (fee-for-service, partial capitation, full capitation, salary, and other). We ran 3 separate logistic regression models for each professional behavior. Model 1 included gender and specialty as predictors. In models 2 and 3, we examined the effects of primary practice organizations and reimbursement mechanisms while controlling for gender and specialty. In reporting the multivariate analyses, we show regression-adjusted percentages with the corresponding 95% CIs. We report the results of the regression models as the percent predicted to make a given response by each model. For models 2 and 3, these percentages are adjusted for gender and specialty by holding the proportion within each specialty and the proportion of women constant (Table 2) across levels of the predictor variable. The CIs were calculated using the standard error of the fitted values. All analyses were conducted by using Stata statistical software (Stata, College Station, Texas), and we incorporated Stata's survey commands (22). Data were weighted to reflect sampling probability. The sample weights were calculated as the inverse probability of selection within a survey stratum (physician specialty). Role of the Funding Source This study was funded by a grant from the Institute on Medicine as a Profession. The funder had no role in the design, conduct, and analysis of the study or in the decision to submit the manuscript for publication. Results Respondent Characteristics Table 3 shows the weighted characteristics of the respondents. To assess how representative our respondents were, we compared our results with characteristics of all physicians in the American Medical Association database. We found that our respondents were similar to U.S. physicians in terms of gender and foreign medical education status. Our respondents were less likely to be Asian or white than all U.S. physicians. This may be due to the fact that 25% of physicians in the American Medical Association database are classified as unknown race or ethnicity. Table 3. Respondent Characteristics Attitudes toward Professional Norms More than 90% of physicians agreed with 8 of the 12 normative statements regarding professionalism posed in the survey (Table 1). Agreement fell below 80% only for the question about periodic recertification. Self-reported Behaviors Illustrative of Professional Norms The extent to which behaviors were consistent with professional norms varied with the specific norm (Table 2). For example, physicians reported a high level of conformance with the tenet of honesty with patients: Fewer than 1% reported that they had told patients something that was untrue, and only 3% reported that they had withheld information from patients or family that those individuals should have known. Eleven percent reported breaching patient confidentiality. Seventy-four percent of physicians reported delivering free care in a setting that serves an underserved sector in the past 3 years, and 69% said they were accepting Medicaid or uninsured patients. Furthermore, 28% of physicians' patients were on Medicaid or were unins

Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer

Abstract: Background Patients with metastatic non–small-cell lung cancer have a substantial symptom burden and may receive aggressive care at the end of life. We examined the effect of introducing palliative care early after diagnosis on patient-reported outcomes and end-of-life care among ambulatory patients with newly diagnosed disease. Methods We randomly assigned patients with newly diagnosed metastatic non–small-cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone. Quality of life and mood were assessed at baseline and at 12 weeks with the use of the Functional Assessment of Cancer Therapy–Lung (FACT-L) scale and the Hospital Anxiety and Depression Scale, respectively. The primary outcome was the change in the quality of life at 12 weeks. Data on end-of-life care were collected from electronic medical records. Results Of the 151 patients who underwent randomization, 27 died by 12 weeks and 107 (86% of the remaining patients) completed assessments. Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (mean score on the FACT-L scale [in which scores range from 0 to 136, with higher scores indicating better quality of life], 98.0 vs. 91.5; P = 0.03). In addition, fewer patients in the palliative care group than in the standard care group had depressive symptoms (16% vs. 38%, P = 0.01). Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, P = 0.05), median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P = 0.02). Conclusions Among patients with metastatic non–small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival. (Funded by an American Society of Clinical Oncology Career Development Award and philanthropic gifts; ClinicalTrials.gov number, NCT01038271.)

Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda

Abstract: An unresolved issue in the field of implementation research is how to conceptualize and evaluate successful implementation. This paper advances the concept of “implementation outcomes” distinct from service system and clinical treatment outcomes. This paper proposes a heuristic, working “taxonomy” of eight conceptually distinct implementation outcomes—acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability—along with their nominal definitions. We propose a two-pronged agenda for research on implementation outcomes. Conceptualizing and measuring implementation outcomes will advance understanding of implementation processes, enhance efficiency in implementation research, and pave the way for studies of the comparative effectiveness of implementation strategies.

Fundamentals of Queueing Theory

Abstract: Praise for the Third Edition: "This is one of the best books available. Its excellent organizational structure allows quick reference to specific models and its clear presentation . . . solidifies the understanding of the concepts being presented."IIE Transactions on Operations EngineeringThoroughly revised and expanded to reflect the latest developments in the field, Fundamentals of Queueing Theory, Fourth Edition continues to present the basic statistical principles that are necessary to analyze the probabilistic nature of queues. Rather than presenting a narrow focus on the subject, this update illustrates the wide-reaching, fundamental concepts in queueing theory and its applications to diverse areas such as computer science, engineering, business, and operations research.This update takes a numerical approach to understanding and making probable estimations relating to queues, with a comprehensive outline of simple and more advanced queueing models. Newly featured topics of the Fourth Edition include:Retrial queuesApproximations for queueing networksNumerical inversion of transformsDetermining the appropriate number of servers to balance quality and cost of serviceEach chapter provides a self-contained presentation of key concepts and formulae, allowing readers to work with each section independently, while a summary table at the end of the book outlines the types of queues that have been discussed and their results. In addition, two new appendices have been added, discussing transforms and generating functions as well as the fundamentals of differential and difference equations. New examples are now included along with problems that incorporate QtsPlus software, which is freely available via the book's related Web site.With its accessible style and wealth of real-world examples, Fundamentals of Queueing Theory, Fourth Edition is an ideal book for courses on queueing theory at the upper-undergraduate and graduate levels. It is also a valuable resource for researchers and practitioners who analyze congestion in the fields of telecommunications, transportation, aviation, and management science.

Dissecting racial bias in an algorithm used to manage the health of populations

Abstract: Health systems rely on commercial prediction algorithms to identify and help patients with complex health needs. We show that a widely used algorithm, typical of this industry-wide approach and affecting millions of patients, exhibits significant racial bias: At a given risk score, Black patients are considerably sicker than White patients, as evidenced by signs of uncontrolled illnesses. Remedying this disparity would increase the percentage of Black patients receiving additional help from 17.7 to 46.5%. The bias arises because the algorithm predicts health care costs rather than illness, but unequal access to care means that we spend less money caring for Black patients than for White patients. Thus, despite health care cost appearing to be an effective proxy for health by some measures of predictive accuracy, large racial biases arise. We suggest that the choice of convenient, seemingly effective proxies for ground truth can be an important source of algorithmic bias in many contexts.

Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America

Abstract: Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.