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J Am Coll Cardiol. Author manuscript; available in PMC 2017 July 17. Published in final edited form as: J Am Coll Cardiol. 2017 May 02; 69(17): 2242–2245. doi:10.1016/j.jacc.2017.03.539.
Health Services Research: Cardiology in the Changing Health Care Landscape Joseph Ebinger, MD Cedars-Sinai Heart Institute, Los Angeles, California. Dr. Ebinger has reported that he has no relationships relevant to the contents of this paper to disclose
Author Manuscript Author Manuscript
Training in cardiology is designed to prepare young physicians to care for their future patients. They gain experience in managing complex disease, mastering procedures, and making difficult clinical decisions: all vital tools to appropriately manage and treat cardiovascular disease. As any practicing cardiologist will attest, however, these are far from the only skills required to navigate the complex and rapidly changing landscape of health care today. The American College of Cardiology's (ACC's) Board of Trustees recognized that “economic pressures related to health care costs, concerns about quality, evolving medical technology and improvements in metrics have combined to change the environment” (1). As physicians, how do we systematically address these issues, study our efforts to improve outcomes, and ensure that we provide high-value care to our patients? These factors combine in the burgeoning field of health services research (HSR). This paper seeks to describe how HSR influences the practice of cardiology, the tools and technologies it utilizes, as well as how fellows-in-training (FITs) can take advantage of the opportunities this creates.
Author Manuscript
HSR is frequently defined as the study of how, “social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health” (2). This field seeks to explore the effectiveness of care, a different concept than the more familiar idea of efficacy. Efficacy describes how well a drug, procedure, or device improves clinical outcomes under ideal conditions. Often addressed by randomized controlled trials, this allows us to determine if a therapy can, for example, lower blood pressure, relieve chest pain, or abort sudden cardiac death. HSR addresses the question of effectiveness: how a given intervention performs in the real world (3). In short, it seeks to answer the question posed by Congressman John Porter in 1998, when he asked Department of Health and Human Services officials, “What we really want to get at is not how many reports have been done, but how many people's lives are being bettered by what has been accomplished. In other words, is it being used, is it being followed, is it actually being given to patients?” (4). An example of the difference between efficacy and effectiveness is seen in the E-LITE (Evaluation of Lifestyle Interventions to Treat Elevated Cardiometabolic Risk in Primary Care) study, which concluded that a primary care-based coaching program for diabetes
Address for Correspondence: Dr. Joseph Ebinger, 127 South San Vicente Boulevard, Suite A3100, Los Angeles, California 90048. Joseph. [email protected].
Ebinger
Page 2
Author Manuscript
prevention could achieve more weight loss than usual care (5). Critics point out that the study used paid researchers to perform the coaching, had 31 exclusion criteria, and only randomized 15% of screened participants (6). Although coaching patients is likely an efficacious way to improve weight loss, the effectiveness of this intervention in a busy clinical practice remains unknown.
Author Manuscript
The measures of interest in HSR include more than just hard endpoints like weight loss, but rather extend across the classic Donabedian framework of structure, process, and outcome (7) into the realm of cost-effectiveness (8,9). The latter is captured in the concept of value, generally defined as “outcomes achieved per dollar spent” (10). This serves to help us understand the need to balance clinical interventions with cost, focusing not just on acute disease management, but also on prevention, care coordination, and continuity (11). These goals align with the “triple aim,” developed by Berwick and endorsed in the ACC's strategic mission, to improve the care experience, enhance the population's health, and reduce costs (12,13). The ability to collect, study, and understand this type of data at a population level requires new tools and a unique set of skills. This process is becoming easier with rapid advances in medical technology, which continue to fundamentally change the way HSR is performed. Tools such as the electronic medical record (EMR), clinical databases, and patient registries are examples of how technology can help address these questions.
Electronic Medical Record
Author Manuscript
An EMR is now utilized by nearly 80% of all clinical practices (14), and physicians can harness its capabilities to do far more than obtain test results, enter orders, or write notes. The ability to track data from the patient to population level allows providers and health service researchers to examine the effects of care like never before. The EMR allows us to determine, for example, if the use of a new heart failure drug truly reduces admissions in a real-world setting and, if so, determine its cost-effectiveness.
Author Manuscript
More than a simple recorder of information, the EMR can play a vital role in helping provide high-quality care. Implementation of decision support tools, risk calculators, and best practice alerts have demonstrated the ability to improve quality and decrease cost (15,16). For example, we have previously shown that an EMR-based decision support tool can decrease rates of post-operative atrial fibrillation. Based on clinical trials and guidelines (17,18), we developed a decision support tool that prompts providers to prescribe prophylactic amiodarone to eligible patients prior to cardiac surgery. Although efficacy was previously shown in trials, this work demonstrated the effectiveness of this intervention, with a reduction in post-operative atrial fibrillation rates from 38% to 11% and an estimated cost savings of >$200,000 annually (19). Such advances, however, require a new type of physician scientist, one who can understand and grapple with the complex challenges associated with EMR-based research: fragmented data structure, data standardization, electronic security, data management, and real-time
J Am Coll Cardiol. Author manuscript; available in PMC 2017 July 17.
Ebinger
Page 3
Author Manuscript
analytics (20). As the EMR continues to evolve, health services researchers will be needed to ensure its effective design, implementation, and study.
Databases and Registries
Author Manuscript
Similarly, the rapid expansion of databases and registries has transformed the way clinical research is conducted. The ACC has led the way with the development of the National Cardiovascular Data Registry, Transcatheter Valve Therapy, and PINNACLE, among other registries. Such datasets, collecting massive amounts of information from a heterogeneous patient population, are uniquely suited to answer questions on practice patterns, variations in care and clinical outcomes (21). The development, implementation, and analysis of these databases demand a specialized skillset, requiring practice and directed mentorship to develop. The ACC's leadership with such registries provides FITs with an incredible opportunity to gain experience, develop necessary skills, and improve population-based care through mentored research using these resources.
HSR, Data Personalization, and Training As our ability to track outcomes on a population level continues to expand, we must not lose sight of our patients as individuals. HSR expands the field of personalized medicine, offering the possibility of tailored medication dosing, avoidance of side effects, and individual patient risk stratification (22). The integration of individual patient data and the latest clinical research will allow providers to confidently recommend the best test, drug, and procedure for their patient. HSR can help take our knowledge from clinical trials and apply it to the patient in front of us.
Author Manuscript
Collecting, tracking, and acting upon these data require systematic changes to the structure and process or cardiac care. This bold new field will require great thought in its development and implementation to ensure both privacy and effectiveness. The processes necessary to implement and utilize this data must be designed with the same rigor, if not more so, than the design of randomized control trials.
Author Manuscript
FITs are now entering their careers at the beginning of a new era, one in which we are no longer responsible solely for the individual patient in our office, but also for the health of the general population as a whole. To tackle this challenge, clinical exposure and research mentorship in such arenas as those mentioned in the previous text are necessary, but not sufficient for young physicians to develop into health services researchers. Fortunately, a growing number of advanced training opportunities exist in which FITs can expand their knowledge and expertise. Given the breadth of topics requiring in depth understanding, FITs may consider pursuing a master's or doctoral degree in HSR. Others may benefit from advanced fellowships, such as the National Clinical Scholars Program, an outgrowth of the Robert Wood Johnson Foundation Clinical Scholars Program, focused on research training in community-based experiences. These opportunities provide the foundation upon which future work may grow, teaching trainees what questions to ask, how to answer them, and the ways in which their work can affect patients across the country. This type of educational investment must be J Am Coll Cardiol. Author manuscript; available in PMC 2017 July 17.
Ebinger
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Author Manuscript
fostered by institutional leadership, providing the time and support for FITs to pursue such endeavors. Collaborations between clinical training institutions, the RAND Corporation, and the Agency for Healthcare Research and Quality offer unique funding mechanisms, such as T32 grants, that allow young physicians the opportunity to hone their skills and become HSR leaders. These examples are by no means comprehensive, but they serve to demonstrate the depth and breadth of the opportunities and challenges that can be addressed by HSR. To provide the highest value care for our patients, cardiologists, especially FITs and early career physicians, must embrace HSR as a unifying methodology, weaving through all aspects of cardiology.
Author Manuscript
From exciting technology to radical change in data collection and management, large new challenges await. To adapt a quote from Ralph Waldo Emerson, “[Challenging] times have a scientific value. These are occasions a good learner would not miss” (23).
References
Author Manuscript Author Manuscript
1. Chazal RA, Casale PN, Martin GR. Preparing for a value-based health care system. J Am Coll Cardiol. 2016; 68:1698–700. [PubMed: 27712784] 2. Lohr KN, Steinwachs DM. Health services research: an evolving definition of the field. Health Serv Res. 2002; 37:7–9. [PubMed: 11949927] 3. Nallamothu BK, Hayward RA, Bates ER. Beyond the randomized clinical trial: the role of effectiveness studies in evaluating cardiovascular therapies. Circulation. 2008; 118:1294–303. [PubMed: 18794402] 4. One Hundred Fifth Congress, Second Session, Part 3. Department of Health and Human Services, Public Health Service; Washington, DC: Mar 4. 1998 Hearings before a Subcommittee of the Committee on Appropriations, House of Representatives. 1998. https://www.gpo.gov/fdsys/pkg/ CHRG-105hhrg48432/html/CHRG-105hhrg48432.htm [Accessed on March 4, 2017] 5. Ma J, Yank V, Xiao L, et al. Translating the diabetes prevention program lifestyle intervention for weight loss into primary care: a randomized trial. JAMA Intern Med. 2013; 173:113–21. [PubMed: 23229846] 6. Pagoto SL, Lemon SC. Efficacy vs effectiveness. JAMA Intern Med. 2013; 173:1262–3. [PubMed: 23836268] 7. Donabedian A. Evaluating the quality of medical care. The Milbank Memorial Fund Quarterly. 1966; 44(Suppl):166–206. 8. McDonald, KM., Sundaram, V., Bravata, DM., et al. Care coordination. In: Shojania, KG.McDonald, KM.Wachter, RM., Owens, DK., editors. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Rockville, MD: Agency for Healthcare Research and Quality; 2007. 9. Nuckols TK, Escarce JJ, Asch SM. The effects of quality of care on costs: a conceptual framework. The Milbank Quarterly. 2013; 91:316–53. [PubMed: 23758513] 10. Porter ME. What is value in health care? N Engl J Med. 2010; 363:2477–81. [PubMed: 21142528] 11. Ayanian JZ, Markel H. Donabedian's lasting framework for health care quality. N Engl J Med. 2016; 375:205–7. [PubMed: 27468057] 12. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff. 2008; 27:759–69. 13. Brush JE Jr, Handberg EM, Biga C, et al. 2015 ACC health policy statement on cardiovascular team-based care and the role of advanced practice providers. J Am Coll Cardiol. 2015; 65:2118– 36. [PubMed: 25975476]
J Am Coll Cardiol. Author manuscript; available in PMC 2017 July 17.
Ebinger
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Author Manuscript Author Manuscript
14. Hsiao, CJ., Hing, E. NCHS data brief 143. Hyattsville, MD: National Center for Health Statistics; 2014. Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001-2013. 15. Fedosov V, Dziadzko M, Dearani JA, Brown DR, Pickering BW, Herasevich V. Decision support tool to improve glucose control compliance after cardiac surgery. AACN Adv Crit Care. 2016; 27:274–82. [PubMed: 27959310] 16. Minami CA, Yang AD, Ju M, et al. Evaluation of an institutional project to improve venous thromboembolism prevention. J Hosp Med. 2016; 11(Suppl 2):S29–37. [PubMed: 27925424] 17. Mitchell LB, Exner DV, Wyse DG, et al. Prophylactic oral amiodarone for the prevention of arrhythmias that begin early after revascularization, valve replacement, or repair: Papabear: a randomized controlled trial. JAMA. 2005; 294:3093–100. [PubMed: 16380589] 18. January CT, Wann LS, Alpert JS, Calkins H, et al. American College of Cardiology/American Heart Association Task Force on Practice G. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014; 64:el–76. 19. Ebinger JE, Porten BR, Strauss CE, et al. Design, challenges, and implications of quality mprovement projects using the electronic medical record: case study: a protocol to reduce the burden of postoperative atrial fibrillation. Circ Cardiovasc Qual Outcomes. 2016; 9:593–9. [PubMed: 27553597] 20. Kruse CS, Goswamy R, Raval Y, Marawi S. Challenges and opportunities of big data in health care: a systematic review. JMIR Med Inform. 2016; 4:e38. [PubMed: 27872036] 21. Krumholz HM. Outcomes research: Myths and realities. Circ Cardiovasc Qual Outcome. 2009; 2:1–3. 22. Kirchhof P, Sipido KR, Cowie MR, et al. European Affairs Work Shop on Personalized Medicine. The continuum of personalized cardiovascular medicine: a position paper of the European Society of Cardiology. Eur Heart J. 2014; 35:3250–7. [PubMed: 25148837] 23. BrainyQuote. [Accessed March 22, 2017] Ralph Waldo Emerson quotes. Available at: https:// www.brainyquote.com/quotes/quotes/r/ralphwaldol21718.html
Author Manuscript Author Manuscript J Am Coll Cardiol. Author manuscript; available in PMC 2017 July 17.
J Am Coll Cardiol. Author manuscript; available in PMC 2017 July 17. Published in final edited form as: J Am Coll Cardiol. 2017 May 02; 69(17): 2242–2245. doi:10.1016/j.jacc.2017.03.539.
Health Services Research: Cardiology in the Changing Health Care Landscape Joseph Ebinger, MD Cedars-Sinai Heart Institute, Los Angeles, California. Dr. Ebinger has reported that he has no relationships relevant to the contents of this paper to disclose
Author Manuscript Author Manuscript
Training in cardiology is designed to prepare young physicians to care for their future patients. They gain experience in managing complex disease, mastering procedures, and making difficult clinical decisions: all vital tools to appropriately manage and treat cardiovascular disease. As any practicing cardiologist will attest, however, these are far from the only skills required to navigate the complex and rapidly changing landscape of health care today. The American College of Cardiology's (ACC's) Board of Trustees recognized that “economic pressures related to health care costs, concerns about quality, evolving medical technology and improvements in metrics have combined to change the environment” (1). As physicians, how do we systematically address these issues, study our efforts to improve outcomes, and ensure that we provide high-value care to our patients? These factors combine in the burgeoning field of health services research (HSR). This paper seeks to describe how HSR influences the practice of cardiology, the tools and technologies it utilizes, as well as how fellows-in-training (FITs) can take advantage of the opportunities this creates.
Author Manuscript
HSR is frequently defined as the study of how, “social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health” (2). This field seeks to explore the effectiveness of care, a different concept than the more familiar idea of efficacy. Efficacy describes how well a drug, procedure, or device improves clinical outcomes under ideal conditions. Often addressed by randomized controlled trials, this allows us to determine if a therapy can, for example, lower blood pressure, relieve chest pain, or abort sudden cardiac death. HSR addresses the question of effectiveness: how a given intervention performs in the real world (3). In short, it seeks to answer the question posed by Congressman John Porter in 1998, when he asked Department of Health and Human Services officials, “What we really want to get at is not how many reports have been done, but how many people's lives are being bettered by what has been accomplished. In other words, is it being used, is it being followed, is it actually being given to patients?” (4). An example of the difference between efficacy and effectiveness is seen in the E-LITE (Evaluation of Lifestyle Interventions to Treat Elevated Cardiometabolic Risk in Primary Care) study, which concluded that a primary care-based coaching program for diabetes
Address for Correspondence: Dr. Joseph Ebinger, 127 South San Vicente Boulevard, Suite A3100, Los Angeles, California 90048. Joseph. [email protected].
Ebinger
Page 2
Author Manuscript
prevention could achieve more weight loss than usual care (5). Critics point out that the study used paid researchers to perform the coaching, had 31 exclusion criteria, and only randomized 15% of screened participants (6). Although coaching patients is likely an efficacious way to improve weight loss, the effectiveness of this intervention in a busy clinical practice remains unknown.
Author Manuscript
The measures of interest in HSR include more than just hard endpoints like weight loss, but rather extend across the classic Donabedian framework of structure, process, and outcome (7) into the realm of cost-effectiveness (8,9). The latter is captured in the concept of value, generally defined as “outcomes achieved per dollar spent” (10). This serves to help us understand the need to balance clinical interventions with cost, focusing not just on acute disease management, but also on prevention, care coordination, and continuity (11). These goals align with the “triple aim,” developed by Berwick and endorsed in the ACC's strategic mission, to improve the care experience, enhance the population's health, and reduce costs (12,13). The ability to collect, study, and understand this type of data at a population level requires new tools and a unique set of skills. This process is becoming easier with rapid advances in medical technology, which continue to fundamentally change the way HSR is performed. Tools such as the electronic medical record (EMR), clinical databases, and patient registries are examples of how technology can help address these questions.
Electronic Medical Record
Author Manuscript
An EMR is now utilized by nearly 80% of all clinical practices (14), and physicians can harness its capabilities to do far more than obtain test results, enter orders, or write notes. The ability to track data from the patient to population level allows providers and health service researchers to examine the effects of care like never before. The EMR allows us to determine, for example, if the use of a new heart failure drug truly reduces admissions in a real-world setting and, if so, determine its cost-effectiveness.
Author Manuscript
More than a simple recorder of information, the EMR can play a vital role in helping provide high-quality care. Implementation of decision support tools, risk calculators, and best practice alerts have demonstrated the ability to improve quality and decrease cost (15,16). For example, we have previously shown that an EMR-based decision support tool can decrease rates of post-operative atrial fibrillation. Based on clinical trials and guidelines (17,18), we developed a decision support tool that prompts providers to prescribe prophylactic amiodarone to eligible patients prior to cardiac surgery. Although efficacy was previously shown in trials, this work demonstrated the effectiveness of this intervention, with a reduction in post-operative atrial fibrillation rates from 38% to 11% and an estimated cost savings of >$200,000 annually (19). Such advances, however, require a new type of physician scientist, one who can understand and grapple with the complex challenges associated with EMR-based research: fragmented data structure, data standardization, electronic security, data management, and real-time
J Am Coll Cardiol. Author manuscript; available in PMC 2017 July 17.
Ebinger
Page 3
Author Manuscript
analytics (20). As the EMR continues to evolve, health services researchers will be needed to ensure its effective design, implementation, and study.
Databases and Registries
Author Manuscript
Similarly, the rapid expansion of databases and registries has transformed the way clinical research is conducted. The ACC has led the way with the development of the National Cardiovascular Data Registry, Transcatheter Valve Therapy, and PINNACLE, among other registries. Such datasets, collecting massive amounts of information from a heterogeneous patient population, are uniquely suited to answer questions on practice patterns, variations in care and clinical outcomes (21). The development, implementation, and analysis of these databases demand a specialized skillset, requiring practice and directed mentorship to develop. The ACC's leadership with such registries provides FITs with an incredible opportunity to gain experience, develop necessary skills, and improve population-based care through mentored research using these resources.
HSR, Data Personalization, and Training As our ability to track outcomes on a population level continues to expand, we must not lose sight of our patients as individuals. HSR expands the field of personalized medicine, offering the possibility of tailored medication dosing, avoidance of side effects, and individual patient risk stratification (22). The integration of individual patient data and the latest clinical research will allow providers to confidently recommend the best test, drug, and procedure for their patient. HSR can help take our knowledge from clinical trials and apply it to the patient in front of us.
Author Manuscript
Collecting, tracking, and acting upon these data require systematic changes to the structure and process or cardiac care. This bold new field will require great thought in its development and implementation to ensure both privacy and effectiveness. The processes necessary to implement and utilize this data must be designed with the same rigor, if not more so, than the design of randomized control trials.
Author Manuscript
FITs are now entering their careers at the beginning of a new era, one in which we are no longer responsible solely for the individual patient in our office, but also for the health of the general population as a whole. To tackle this challenge, clinical exposure and research mentorship in such arenas as those mentioned in the previous text are necessary, but not sufficient for young physicians to develop into health services researchers. Fortunately, a growing number of advanced training opportunities exist in which FITs can expand their knowledge and expertise. Given the breadth of topics requiring in depth understanding, FITs may consider pursuing a master's or doctoral degree in HSR. Others may benefit from advanced fellowships, such as the National Clinical Scholars Program, an outgrowth of the Robert Wood Johnson Foundation Clinical Scholars Program, focused on research training in community-based experiences. These opportunities provide the foundation upon which future work may grow, teaching trainees what questions to ask, how to answer them, and the ways in which their work can affect patients across the country. This type of educational investment must be J Am Coll Cardiol. Author manuscript; available in PMC 2017 July 17.
Ebinger
Page 4
Author Manuscript
fostered by institutional leadership, providing the time and support for FITs to pursue such endeavors. Collaborations between clinical training institutions, the RAND Corporation, and the Agency for Healthcare Research and Quality offer unique funding mechanisms, such as T32 grants, that allow young physicians the opportunity to hone their skills and become HSR leaders. These examples are by no means comprehensive, but they serve to demonstrate the depth and breadth of the opportunities and challenges that can be addressed by HSR. To provide the highest value care for our patients, cardiologists, especially FITs and early career physicians, must embrace HSR as a unifying methodology, weaving through all aspects of cardiology.
Author Manuscript
From exciting technology to radical change in data collection and management, large new challenges await. To adapt a quote from Ralph Waldo Emerson, “[Challenging] times have a scientific value. These are occasions a good learner would not miss” (23).
References
Author Manuscript Author Manuscript
1. Chazal RA, Casale PN, Martin GR. Preparing for a value-based health care system. J Am Coll Cardiol. 2016; 68:1698–700. [PubMed: 27712784] 2. Lohr KN, Steinwachs DM. Health services research: an evolving definition of the field. Health Serv Res. 2002; 37:7–9. [PubMed: 11949927] 3. Nallamothu BK, Hayward RA, Bates ER. Beyond the randomized clinical trial: the role of effectiveness studies in evaluating cardiovascular therapies. Circulation. 2008; 118:1294–303. [PubMed: 18794402] 4. One Hundred Fifth Congress, Second Session, Part 3. Department of Health and Human Services, Public Health Service; Washington, DC: Mar 4. 1998 Hearings before a Subcommittee of the Committee on Appropriations, House of Representatives. 1998. https://www.gpo.gov/fdsys/pkg/ CHRG-105hhrg48432/html/CHRG-105hhrg48432.htm [Accessed on March 4, 2017] 5. Ma J, Yank V, Xiao L, et al. Translating the diabetes prevention program lifestyle intervention for weight loss into primary care: a randomized trial. JAMA Intern Med. 2013; 173:113–21. [PubMed: 23229846] 6. Pagoto SL, Lemon SC. Efficacy vs effectiveness. JAMA Intern Med. 2013; 173:1262–3. [PubMed: 23836268] 7. Donabedian A. Evaluating the quality of medical care. The Milbank Memorial Fund Quarterly. 1966; 44(Suppl):166–206. 8. McDonald, KM., Sundaram, V., Bravata, DM., et al. Care coordination. In: Shojania, KG.McDonald, KM.Wachter, RM., Owens, DK., editors. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Rockville, MD: Agency for Healthcare Research and Quality; 2007. 9. Nuckols TK, Escarce JJ, Asch SM. The effects of quality of care on costs: a conceptual framework. The Milbank Quarterly. 2013; 91:316–53. [PubMed: 23758513] 10. Porter ME. What is value in health care? N Engl J Med. 2010; 363:2477–81. [PubMed: 21142528] 11. Ayanian JZ, Markel H. Donabedian's lasting framework for health care quality. N Engl J Med. 2016; 375:205–7. [PubMed: 27468057] 12. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff. 2008; 27:759–69. 13. Brush JE Jr, Handberg EM, Biga C, et al. 2015 ACC health policy statement on cardiovascular team-based care and the role of advanced practice providers. J Am Coll Cardiol. 2015; 65:2118– 36. [PubMed: 25975476]
J Am Coll Cardiol. Author manuscript; available in PMC 2017 July 17.
Ebinger
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Author Manuscript Author Manuscript
14. Hsiao, CJ., Hing, E. NCHS data brief 143. Hyattsville, MD: National Center for Health Statistics; 2014. Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001-2013. 15. Fedosov V, Dziadzko M, Dearani JA, Brown DR, Pickering BW, Herasevich V. Decision support tool to improve glucose control compliance after cardiac surgery. AACN Adv Crit Care. 2016; 27:274–82. [PubMed: 27959310] 16. Minami CA, Yang AD, Ju M, et al. Evaluation of an institutional project to improve venous thromboembolism prevention. J Hosp Med. 2016; 11(Suppl 2):S29–37. [PubMed: 27925424] 17. Mitchell LB, Exner DV, Wyse DG, et al. Prophylactic oral amiodarone for the prevention of arrhythmias that begin early after revascularization, valve replacement, or repair: Papabear: a randomized controlled trial. JAMA. 2005; 294:3093–100. [PubMed: 16380589] 18. January CT, Wann LS, Alpert JS, Calkins H, et al. American College of Cardiology/American Heart Association Task Force on Practice G. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014; 64:el–76. 19. Ebinger JE, Porten BR, Strauss CE, et al. Design, challenges, and implications of quality mprovement projects using the electronic medical record: case study: a protocol to reduce the burden of postoperative atrial fibrillation. Circ Cardiovasc Qual Outcomes. 2016; 9:593–9. [PubMed: 27553597] 20. Kruse CS, Goswamy R, Raval Y, Marawi S. Challenges and opportunities of big data in health care: a systematic review. JMIR Med Inform. 2016; 4:e38. [PubMed: 27872036] 21. Krumholz HM. Outcomes research: Myths and realities. Circ Cardiovasc Qual Outcome. 2009; 2:1–3. 22. Kirchhof P, Sipido KR, Cowie MR, et al. European Affairs Work Shop on Personalized Medicine. The continuum of personalized cardiovascular medicine: a position paper of the European Society of Cardiology. Eur Heart J. 2014; 35:3250–7. [PubMed: 25148837] 23. BrainyQuote. [Accessed March 22, 2017] Ralph Waldo Emerson quotes. Available at: https:// www.brainyquote.com/quotes/quotes/r/ralphwaldol21718.html
Author Manuscript Author Manuscript J Am Coll Cardiol. Author manuscript; available in PMC 2017 July 17.
