text:
Page 1
Impact of EHR-Based Clinical Decision Sup-
port on Adherence to Guidelines for Patients
on NSAIDs: A Randomized Controlled Trial
PURPOSE Electronic health records (EHRs) with clinical decision support hold
promise for improving quality of care, but their impact on management of chronic
conditions has been mixed. This study examined the impact of EHR-based clinical
decision support on adherence to guidelines for reducing gastrointestinal complica-
tions in primary care patients on nonsteroidal anti-infl ammatory drugs (NSAIDs).
METHODS This randomized controlled trial was conducted in a national network
of primary care offi ces using an EHR and focused on patients taking traditional
NSAIDs who had factors associated with a high risk for gastrointestinal complica-
tions (a history of peptic ulcer disease; concomitant use of anticoagulants, anti-
platelet medications [including aspirin], or corticosteroids; or an age of 75 years
or older). The offi ces were randomized to receive EHR-based guidelines and
alerts for high-risk patients on NSAIDs, or usual care. The primary outcome was
the proportion of patients who received guideline-concordant care during the
1-year study period (June 2007-June 2008), defi ned as having their traditional
NSAID discontinued (including a switch to a lower-risk medication), having a gas-
troprotective medication coprescribed, or both.
RESULTS Participants included 27 offi ces with 119 clinicians and 5,234 high-
risk patients. Intervention patients were more likely than usual care patients to
receive guideline-concordant care (25.4% vs 22.4%, adjusted odds ratio = 1.19;
95% confi dence interval, 1.01-1.42). For individual high-risk groups, patients
on low-dose aspirin were more likely to receive guideline-concordant care with
the intervention vs usual care (25.0% vs 20.8%, adjusted odds ratio = 1.30;
95% confi dence interval, 1.04-1.62), but there was no signifi cant difference for
patients in other high-risk groups.
CONCLUSIONS This study showed only a small impact of EHR-based clinical
decision support for high-risk patients on NSAIDs in primary care offi ces. These
results add to the growing literature about the complexity of EHR-based clinical
decision support for improving quality of care.
Ann Fam Med 2011;9:22-30. doi:10.1370/afm.1172.
particularly high for persons who are elderly, have a previous history of
GI complications, or are taking concomitant medications that increase the
risk of GI complications.1,2 Current national guidelines recommend that
persons at higher risk either receive a cyclooxygenase (COX)-2 inhibitor
instead of a traditional NSAID, or receive a gastroprotective medication
such as a proton pump inhibitor (PPI) or misoprostol along with the tra-
ditional NSAID.1-3 Studies show, however, that most high-risk patients on
NSAIDs are not managed as recommended in these guidelines.4-7
t is well known that nonsteroidal anti-infl ammatory drugs (NSAIDs) are
associated with a substantial risk of gastrointestinal (GI) complications,
such as peptic ulcer disease, perforation, or GI bleeding.1 The risk is
James M. Gill, MD, MPH1
Arch G. Mainous III, PhD2
Richelle J. Koopman, MD, MS3
Marty S. Player, MD, MS2
Charles J. Everett, PhD2
Ying Xia Chen, MS1
James J. Diamond, PhD4
Michael I. Lieberman, MD, MS5
1Delaware Valley Outcomes Research,
Newark, Delaware
2Medical University of South Carolina,
Charleston, South Carolina
3University of Missouri, Columbia, Missouri
4Jefferson Medical College, Philadelphia,
5Oregon Health and Sciences University,
Portland, Oregon
Confl icts of interest: This study was funded by Astra-
Zeneca Pharmaceuticals. The funder participated
in discussions regarding study design and protocol
development but did not signifi cantly participate in
decisions regarding these issues. The investigators had
full responsibility for all other aspects of the study.
Dr Gill has worked as a research consultant for GE
Health Care Information Technology, which licenses
the electronic health record used in this study; Dr
Lieberman was employed by General Electric Health
Care Information Technology at the time of the
study; Drs Player, Diamond, Mainous, Koopman,
and Everett, and Ms Chen have no real or perceived
confl icts to disclose.
James M. Gill, MD, MPH
Delaware Valley Outcomes Research
17 Henderson Hill Rd
Newark, DE 19711
Page 2
One promising approach to improving care in
clinical practice is through information technology
such as electronic health records (EHRs). An EHR
can make guidelines available to physicians and pro-
vide clinical decision support at the point of care. For
example, an EHR can determine when a patient for
whom an NSAID is being prescribed has a risk factor
that would warrant coprescription of a gastroprotec-
tive medication. One previous study in an inpatient
cardiology service did fi nd that automated prompts
increased coprescription of PPIs for high-risk patients
on NSAIDs.8 Studies have not, however, examined
this issue in outpatient primary care settings, which is
where the majority of treatment for musculoskeletal
conditions occurs.9 Although it makes sense that clini-
cal decision support should have a similar effect in
primary care offi ces, many studies have not found that
to be the case, particularly for chronic conditions.10-13
A systematic review of the impact of EHRs found that
EHR-based clinical decision support has a positive
impact mainly for preventive care rather than chronic
disease care.14 Another systematic review that focused
specifi cally on the impact of clinical decision support
for prescribing behavior found mixed results, with
positive results mainly for avoiding inappropriate pre-
scriptions based on age alone, rather than on a more
complex array of medical conditions.15
The purpose of this randomized controlled trial
was to examine the impact of EHR-based clinical deci-
sion support coupled with clinician education about
national guidelines regarding GI risk reduction for
patients on NSAIDs in outpatient primary care. Our
hypothesis was that patients in the intervention group
would be more likely to receive guideline-concordant
care, by either having their NSAID discontinued or
having a gastroprotective medication coprescribed,
compared with patients in the control group.
Setting and Population
The study was conducted within the Centricity
Healthcare User Research Network (CHURN). This
national network is composed of physicians and other
clinicians in ambulatory practices that use a particu-
lar outpatient EHR, Centricity Provider Offi ce (GE
Healthcare, Waukesha, Wisconsin). CHURN members
share data through a data consortium called the Medi-
cal Quality Improvement Consortium (MQIC), which
regularly uploads demographic and clinical data. The
data are cleaned, standardized, deidentifi ed, and put
into a central data repository. This repository is used
by CHURN for prospective studies to improve quality
of care13; by MQIC members for monitoring quality
of care at the practice level; by researchers conduct-
ing retrospective studies on quality of care16-19; and for
national surveillance and other purposes. Only MQIC
members who agree to participate in prospective stud-
ies on quality of care are members of CHURN.
At the initiation of the study, MQIC consisted of
approximately 5,000 clinicians (approximately two-
thirds in primary care) with 6.3 million patients from
34 states and the District of Columbia, practicing in
varied settings including private solo practices as well
as single-specialty and multispecialty group practices.
Because this study was only the second prospective
CHURN study, fewer than 200 of these clinicians were
already CHURN members before the study began.
For this study, offi ces participating in MQIC were
recruited if they were primary care offi ces that cared
for adults (family medicine, general internal medicine,
or general practice), were not primarily residency
teaching sites, and had been using the Centricity Offi ce
EHR for at least 1 year. The 27 offi ces that agreed to
participate were from 14 states. Within these offi ces,
we included all physicians and midlevel clinicians (nurse
practitioners or physician assistants) who practiced
primary care at least 8 hours per week. The offi ces
were randomized to an intervention group or a control
group. Randomization was by offi ce rather than clini-
cian to minimize contamination that could result from
a control clinician using the study tools while seeing
a patient of an intervention clinician from the same
practice. There was no formal consent for the indi-
vidual clinicians, but consent was considered implicit
on completion of their baseline survey questionnaire
(described below). Practice size varied from 1 to 16 cli-
nicians (mean, 5) in the 13 intervention offi ces and 1 to
13 clinicians (mean, 5) in the 14 control offi ces.
The patient population included all active patients
of participating clinicians at high risk for NSAID-
related GI complications. Active status required at least
1 offi ce visit to a participating clinician each in the year
before the study and during the study year. Patients
were defi ned as being at high risk if they were taking
a traditional NSAID and had a GI risk factor, but were
not taking a gastroprotective medication (a PPI or miso-
prostol). GI risk factors were a history of GI complica-
tions, an age of 75 years or older, or concomitant use
of anticoagulants, antiplatelet medications (including
aspirin), or systemic corticosteroids. GI complications,
assessed from International Classifi cation of Diseases, Ninth
Revision (ICD-9) codes, included a history of peptic ulcer
(codes 531.xx-534.xx), gastritis and duodenitis (code
535.xx), or gastrointestinal hemorrhage (code 578.xx).
The risk factor defi nitions were based on guidelines
from the American College of Gastroenterology20
with some modifi cations. For example, although these
Page 3
guidelines defi ne an age of older than 60 years as a risk
factor20 and most guidelines use this age or an age of
65 years or older,2 we chose an age of 75 years or older
because a recent publication suggested that this is the
age at which risk rises dramatically.21 There was no
consent for individual study patients, because data were
deidentifi ed and patients were receiving usual care as
deemed appropriate by their clinician.
The main intervention was EHR-based clinical deci-
sion support that was designed to be used during
offi ce visits for high-risk patients as defi ned above. A
2-part form (shown in Supplemental Figure 1, available
online at http://www.annfammed.org/cgi/content/
full/9/1/22/DC1) automatically activated when an
EHR offi ce note was started for these patients. The
fi rst part was an alert indicating that the patient was on
an NSAID and had a risk factor putting them at higher
risk for GI complications. The second part provided
tools to prescribe a gastroprotective medication, dis-
continue their NSAID, or change it to one with less
GI risk. The form also included tools to print patient
education handouts, as well as clinician education mate-
rials, including an option to do a 30-minute Web-based
continuing medical education module (either immedi-
ately, or later by having an e-mail reminder sent with a
link to the module). This Web-based module was also
provided to intervention clinicians before the start of
the study. Because the clinical decision support form
was integrated into the EHR at the practice level, the
form automatically activated for all offi ce visits for all
high-risk patients for all participating clinicians in the
intervention group. Participating clinicians could "deac-
tivate" the form for an individual offi ce visit (by click-
ing "Not This Time") or could "deactivate" the form for
the current visit and all future visits for that individual
patient (by clicking "Never (for this patient)"). Indi-
vidual clinicians generally did not have the ability to
deactivate the form for all of their patients, however.
The EHR-based clinical decision support form
was pilot tested with focus groups of clinicians who
used the same EHR but were not study participants.
Their feedback was used to modify the form and cre-
ate the fi nal version. Intervention clinicians received
training on use of this fi nal form before the start of
the 1-year study period (June 2007-June 2008). Train-
ing consisted of a live 1-hour session conducted over
telephone and Internet; clinicians who could not
participate were asked to view an archived version.
Intervention clinicians also received a printed newslet-
ter after the study began, reinforcing the purpose and
use of the clinical decision support form and educa-
tional material. In summary, all intervention clinicians
received the full intervention packet, including the
EHR-based clinical decision support form, training
regarding this form, the educational module, and the
newsletter. The control clinicians did not receive any
of these interventions.
Outcomes and Analysis
The main outcome was guideline-concordant care,
defi ned as discontinuation of the traditional NSAID
(including switching to a lower-risk medication), copre-
scription of a new gastroprotective medication, or
both during the 1-year study period as determined by
the EHR medication list. We compared this outcome
between the intervention and control groups control-
ling for patient age, sex, and number of offi ce visits
during the study period, using multivariate logistic
regression models. Odds ratios (ORs) and 95% confi -
dence intervals (CIs) were calculated after controlling
for 2 levels of clustering: the clinician level and the
practice level (since patients are not independent of
either clinician or practice). For this clustered analysis,
we used an estimated intraclass correlation coeffi cient
of 0.03, based on multimethod quality improvement
work by Ornstein et al.22 In addition to comparing
the main outcome across the intervention and control
groups, we also compared the 2 individual components
of the main outcome—discontinuation of the tradi-
tional NSAID and coprescription of a new gastropro-
tective medication—using the same analytic approach.
We also compared the main outcome (guideline-
concordant care) for intervention and control patients
in different categories of GI risk (history of peptic
ulcer disease, aged ≥75 years, on low-dose aspirin, on
other concomitant medication), because studies have
suggested that patients are treated differently depend-
ing on which GI risk factor they have.5,7 For this analy-
sis, we excluded patients with more than 1 risk factor.
Logistic regression models were built for each risk
group, controlling for patient age, sex, number of offi ce
visits, and 2 levels of clustering, as described above.
In addition to the primary analysis, we surveyed
clinicians before and at the end of the study regarding
how they would manage high-risk persons who were
candidates for NSAIDs. Responses were categorized as
guideline-concordant if the clinicians said they would
not prescribe a nonselective NSAID or would copre-
scribe a gastroprotective medication with a nonselective
NSAID. Responses were categorized as not guideline-
concordant if the clinicians said they would prescribe a
nonselective NSAID alone or would coprescribe a hista-
mine-2 blocker with the NSAID. Other responses were
categorized as guideline-concordant or not, depending
on whether they fi t with the American College of Gas-
troenterology guidelines used for this study.
Page 4
The baseline questionnaire also included questions
about clinician and practice characteristics, including
sex, race/ethnicity, specialty, years in practice, and
practice location. The end-of-study questionnaire
included questions about use of and opinion regard-
ing the clinical decision support form; these questions
were asked only of intervention clinicians. Both ques-
tionnaires were completed via Internet.
We performed a power analysis based on the main
outcome, assuming a cluster analysis. Using a conserva-
tive estimate of an average of 150 eligible patients per
practice, it was calculated that we would need about
1,900 high-risk patients and 13 practices per group to
have an 80% power to detect a 10% difference in the
main outcome (which the study team considered to be
a reasonable threshold for clinical signifi cance). These
sample sizes were met or exceeded. This study was
approved by the institutional review board of the fi rst
author's institution.
Table 1 shows the characteristics of the clinicians in
the study. They were predominantly physicians with
more than 5 years of practice experience; most were
male and the majority were Caucasian. The interven-
tion offi ces were somewhat more likely to be in sub-
urban locations and their physicians were somewhat
more likely to be in family medicine, but these differ-
ences were not statistically signifi cant.
Of the 53 intervention clinicians, 69% (37 clini-
cians) used the continuing medical education module,
by accessing it directly through the EHR, completing
it (including applying for the credit) before the start
of the intervention, or both. Additional clinicians may
have viewed the module before the start of the inter-
vention without applying for credit and
without accessing it through the EHR dur-
ing the intervention, but we were not able
to track this activity.
At the start of the study, there were
30,448 active adult patients in the inter-
vention group and 37,095 in the control
group (Figure 1). Of these patients, 2,781
(9.1%) in the intervention group and
3,726 (10%) in the control group were
on a traditional NSAID and had at least
1 GI risk factor. And of these patients,
20.1% in the intervention group and
19.2% in the control group were already
on a gastroprotective medication at the
start of the study (P >0.1). The remaining
patients—2,222 in the intervention group
and 3,012 in the control group—were
considered high risk and were the target of the inter-
vention and analysis.
The characteristics of the fi nal patient popula-
tion are shown in Table 2. More than one-half of the
Table 1. Clinician Characteristics
(n = 53)
No. (%)
(n = 66)
No. (%)
African American
Years since residency
Family medicine
Internal medicine
Clinician type
Midlevel clinician
Practice location
30 (56.6)
23 (43.4)
1 (1.9)
2 (3.8)
49 (92.4)
1 (1.9)
5 (9.4)
6 (11.3)
22 (41.5)
19 (35.9)
1 (1.9)
25 (65.8)
11 (28.9)
2 (5.3)
38 (71.7)
15 (28.3)
14 (26.4)
34 (64.2)
5 (9.4)
41 (62.1)
25 (37.9)
1 (1.5)
6 (9.1)
54 (81.8)
5 (7.6)
2 (3.0)
15 (22.7)
16 (24.2)
30 (45.5)
3 (4.6)
22 (45.8)
24 (50.0)
2 (4.2)
48 (72.7)
18 (27.3)
23 (34.8)
30 (45.5)
13 (19.7)
a Pertains only to medical doctors (MDs) and doctors of osteopathy (DOs);
n = 38 in intervention group and n = 48 in control group.
Note: P values >.05 for all comparisons by Fisher 2-tailed exact test.
Figure 1. Patient selection fl owchart.
Total number
of active adult
Had ≥1 GI risk fac-
tor and were on a
traditional NSAID
at study start
Already on
gastro protective
Study population
GI = gastrointestinal; NSAID = nonsteroidal anti-infl ammatory drug.
Page 5
patients were aged 65 years or older, with control
patients being signifi cantly more likely to be in this
older age-group. Both groups were slightly more than
50% female, and about 25% of patients had 6 or more
offi ce visits during the study year.
For these at-risk patients, 25.4% in the interven-
tion group and 22.4% in the control group were pro-
vided guideline-concordant care during the study year
(Table 3). This difference was statistically signifi cant
after controlling for age, sex, number of offi ce visits,
and clustering (adjusted OR = 1.19; 95% CI, 1.01-1.42).
When looking at the individual components of guide-
line-concordant care, 9.6% in the intervention group
and 7.5% in the control group were prescribed a new
gastroprotective medication during the study (adjusted
OR = 1.33; 95% CI, 1.01-1.74), while 18.6% in the
intervention group and 16.4% in the control group had
their traditional NSAID discontinued during the study
(adjusted OR = 1.18; 95% CI, 0.99-1.40).
Table 3 also shows the main outcome for patients
with different GI risk factors. For patients on low-dose
aspirin, the intervention group was signifi cantly more
likely than the control group to receive guideline-
concordant care (25.0% vs 20.8%, adjusted OR = 1.30;
95% CI, 1.04-1.62). There were no statistically signifi -
cant differences for patients with any of the other risk
factors studied after controlling for clustering.
Forty-three intervention clinicians and 53 control
clinicians completed both the baseline and end-of-
study survey questionnaires, for response rates of 81%
and 80%, respectively. Table 4 shows the clinicians'
survey responses regarding endorsement of the guide-
lines. At baseline, the large majority of clinicians in
both groups said that they would provide care that is
concordant with American College of Gastroenterol-
ogy guidelines for patients with a history of peptic
ulcer disease (91% and 85% of the intervention and
control groups, respectively) and those on concomitant
corticosteroids (79% and 78%, respectively) or antico-
agulants (93% and 91%, respectively). Fewer clinicians
responded in this manner for patients on low-dose aspi-
rin (23% and 34%, respectively) or for elderly patients
with no other risk factors (44% and 47%, respectively).
Although intervention clinicians increased their
endorsement of the guidelines for these last 2 groups
after the study, still, only 42% would provide care
according to American College of Gastroenterology
guidelines for patients on low-dose aspirin and 58% for
elderly patients with no other risk factors.
Of the 43 intervention clini-
cians completing the end-of-study
questionnaire, 51% reported
that they were using the form
and 17% of these were using it
frequently. Sixteen percent said
they accessed patient education
materials on more than rare occa-
sions, and 14% said they accessed
clinician education materials on
more than rare occasions. Thirty
percent found the form help-
ful for improving patient care,
whereas 44% found it disruptive
to offi ce work fl ow on more than
rare occasions. The most com-
mon reason cited for disrupting
work fl ow was that it took too
much time during patient visits.
Table 2. Patient Characteristics
(n = 2,222)
No. (%)
(n = 3,012)
No. (%)
Age, years
Number of offi ce
visits during study
122 (5.5)
862 (38.8)
1,238 (55.7)
122 (4.1)
1,030 (34.2)
1,860 (61.8)
1,055 (47.5)
1,167 (52.5)
1,443 (47.9)
1,569 (52.1)
315 (14.2)
406 (18.3)
407 (18.3)
317 (14.3)
231 (10.4)
546 (24.6)
485 (16.1)
552 (18.3)
486 (16.1)
378 (12.6)
320 (10.6)
791 (26.3)
a For difference across patient groups, by χ2 test.
Table 3. Guideline-Concordant Care Overall and by Risk Factors
Risk Factor
No. (%) of Patients With
Guideline-Concordant Carea
OR (95% CI)b
Overall (any risk factor)
Individual risk factors
History of peptic ulcer disease
Any concomitant medicationc
Low-dose aspirin
Other concomitant medicationd
Age ≥75 y
564 (25.4)
118 (30.0)
394 (26.8)
228 (25.0)
166 (29.7)
171 (20.9)
675 (22.4)
104 (25.9)
477 (23.3)
254 (20.8)
223 (27.1)
253 (19.8)
1.194 (1.005-1.419)
1.314 (0.920-1.877)
1.232 (0.998-1.521)
1.298 (1.041-1.618)
1.160 (0.875-1.537)
1.043 (0.826-1.316)
CI = confi dence interval; OR = odds ratio.
a Traditional nonsteroidal anti-infl ammatory drug was discontinued and/or a new gastroprotective medication
was coprescribed.
b For patients with risk factor vs patients without risk factor, controlling for age, sex, and number of offi ce visits
during study, and clustering by clinician and practice.
c Anticoagulant, antiplatelet medication (including aspirin), and/or systemic corticosteroid.
d Other than low-dose aspirin.
Page 6
Only 23% said they were likely to continue using the
form after the study was complete d.
This study showed that EHR-based clinical decision
support coupled with clinician education about reduc-
ing GI risk for patients on NSAIDs had a small but sta-
tistically signifi cant positive impact on guideline-con-
cordant care in primary care practices. The interven-
tion had a signifi cant effect for the main outcome of
discontinuing the traditional NSAID, coprescribing a
gastroprotective medication, or both. But the absolute
difference was only 3%, with just 25% of patients in
the intervention group receiving guideline-concordant
care. There was also a small but statistically signifi cant
impact on the individual component of prescribing a
new gastroprotective medication (with a 2% absolute
difference), but not the component of discontinuing
the traditional NSAID. When examining patients with
different risk factors, the intervention had a signifi cant
impact for only 1 subgroup of patients—those on
low-dose aspirin. Even for this group, the impact was
relatively small, with less than a 5% difference between
the intervention and control patients. For other risk
groups, the differences were not statistically signifi cant
after controlling for clustering.
These results may seem surprising given the enthu-
siasm about EHRs as a promising strategy for improv-
ing quality of care. In its report Crossing the Quality
Chasm, the Institute of Medicine
recommended the "use of infor-
mation technologies to improve
access to clinical information
and support clinical decision
making."23 The enthusiasm about
EHRs is also apparent in the
Health Information Technol-
ogy for Economic and Clinical
Health provisions of the Ameri-
can Recovery and Reinvestment
Act, which includes $19.2 billion
in reimbursements to physi-
cians who implement EHRs and
more than $500 million for
Health Information Technol-
ogy Regional Extension Centers
to assist small offi ces in these
Despite the optimism that
EHRs will lead to improved
quality of care, it is uncertain
whether they improve quality
or outcomes. Two recent stud-
ies attracted attention by showing that care was no
better and sometimes even worse for physicians using
an EHR.24,25 Neither study examined the impact of
advanced features of the EHR, such as having clinical
guidelines at the point of care with real-time clinical
decision support. Many experts have suggested that
clinical decision support is essential for EHRs to fulfi ll
the promise of quality improvement.26-28
The current study suggests that even when clini-
cal decision support is incorporated into the EHR,
improvements in quality of care may be small. In fact,
this is not the fi rst study to fi nd little benefi t from EHR-
based clinical decision support. Although EHR-based
reminders and prompts have generally shown a positive
impact on preventive care measures,12,14,29-40 the results
seen for management of chronic diseases have been
more mixed.14,41 Several studies have found benefi ts for
diabetes care,12,42-45 appropriate prescribing for patients
with hypertension,46 and management of osteoporosis.47
But other studies have not found benefi ts for diabetes
care48; management of hypertension,49 hyperlipidemia,13
and other cardiovascular diseases12; or management of
depression.10 A systematic review of studies examining
the impact of clinical decision support on prescribing
behavior found mixed results.15 Three out of 4 stud-
ies found such support to result in better avoidance
of inappropriate prescriptions for elderly patients, but
studies of appropriate prescribing for more complex
medical conditions in outpatient settings found no posi-
tive results. The only previous study of computerized
Table 4. Clinician-Stated Treatment for High-Risk Patients
Who Are Candidates for NSAIDs
Risk FactorTreatment
Group, %
(n = 43)
Group, %
(n = 53)
End of
End of
History of peptic
ulcer disease
Guideline concordant
Prescribe GPM
Do not prescribe NSAID
On corticosteroidsGuideline concordant
Prescribe GPM
Do not prescribe NSAID
On anticoagulantsGuideline concordant
Prescribe GPM
Do not prescribe NSAID
On low-dose
Guideline concordant
Prescribe GPM
Do not prescribe NSAID
Age ≥75 yGuideline concordant
Prescribe GPM
Do not prescribe NSAID
GPM = gastroprotective medication; NSAID = nonsteroidal anti-infl ammatory drug.
Page 7
decision support specifi cally for GI risk reduction in
the outpatient setting found no positive results.12 The
one study that did show a large positive impact of auto-
mated prompts for high-risk patients on NSAIDs was
conducted on an inpatient cardiology service.8
There are several reasons why EHR-based clini-
cal decision support may not always improve quality
of care. First, clinical decision support must facilitate
behaviors that clinicians agree are desirable. If clinicians
do not agree with guidelines on which the support is
based, it is unlikely to be effective. This could be part
of the reason for why our results are less than robust.
Our survey results showed that for the 2 groups rep-
resenting the largest percentage of high-risk patients
(elderly patients and patients on low-dose aspirin),
fewer than one-half of clinicians endorsed the guide-
lines before the start of the study. Although there was
some increase in guideline endorsement in the inter-
vention group after those clinicians received education
and prompting regarding the guidelines, only about
one-half endorsed the guidelines for these patient popu-
lations at the end of the study. This lack of endorse-
ment does not fully explain the low impact of the
intervention, however, because even for patient groups
for whom almost all clinicians endorsed the guidelines,
guideline-concordant behavior was low and did not
increase signifi cantly after the intervention. It is inter-
esting to note that the risk group for which clinician
behavior did change signifi cantly after the intervention
(patients on low-dose aspirin) was also the group for
which clinician endorsement of the guidelines increased
the most from before to after the intervention.
Even if clinicians endorse the guidelines that the
clinical decision support facilitates, the support must
fi t well into the clinical work fl ow in order to work
optimally.28,50,51 Clinicians tend not to use clinical
decision support if it is too disruptive to their work
fl ow.50,52 Results from our clinician survey suggest
that this might have been another reason for minimal
impact in our study. About one-half of the inter-
vention clinicians stated they did not generally use
the form, mostly because of the extra staff or clini-
cian time required during a patient visit. Only 30%
thought the form was helpful for improving patient
care, and more than 40% said that the form was dis-
ruptive on more than rare occasions.
These results highlight the complexity of using
EHRs to implement clinical decision support. This
complexity is especially pertinent to primary care set-
tings where patients are generally seen for multiple
problems,53,54 requiring clinicians to prioritize among
these competing demands.55,56 Clinicians might be less
likely to respond to a clinical decision support prompt
that addresses one medical issue that might not be the
most pressing issue for that patient. Addressing this
barrier requires new approaches to care, such as having
nonclinician staff assist with these problems, or manag-
ing the problems outside of the context of offi ce visits.
These new approaches to quality improvement are
part of the chronic care model57 as well as the patient-
centered medical home model of care.58 In order for
these models to work, what is needed is not only
clinical decision support systems, but also additional
reimbursement to support the required resources.
Managing GI risk is one example where additional
reimbursement for additional resources may be offset
by reducing hospitalizations for GI complications.
The results of this study should be interpreted in
light of certain limitations. As with any study using
offi ce records, data would not be captured if they
were not available to the physician using the EHR (eg,
medications prescribed by a specialist but not known
to the primary care physician). Also, diagnoses or
medications that are recorded only on paper or in EHR
text notes would be underestimated because they do
not appear in structured EHR data fi elds. An example
might be if a physician gives a sample PPI or recom-
mends a nonprescription PPI as a gastroprotective
medication, but does not record this in the medication
list. Conversely, medications may be overestimated if
they are discontinued but not removed from the medi-
cation list. These data limitations would be unlikely to
substantially affect the main results, however, as the
methods of entering data in the EHR are unlikely to
differ between the intervention and control clinicians.
Finally, there are limitations to how the results
can be generalized. The study included only users of
a single, particular EHR who also participate in the
MQIC and agreed to participate in this practice-based
research network study. One study found the MQIC
patient population to be similar to the general US
population in terms of disease prevalence59; however,
studies have not examined differences between the
MQIC population and other outpatient populations in
terms of quality of care.
Despite these limitations, this study has noteworthy
implications for improving quality of care in primary
care settings. The study suggests that EHRs, even
when coupled with robust clinical decision support,
might not result in large improvements in quality of
care. In order to fulfi ll the promise of improving qual-
ity of care, it is important that EHRs are implemented
in a manner that fi ts well into the clinical work fl ow of
primary care offi ces. Additionally, improving quality
will require not only clinical decision support within
EHRs, but also changes in practice that are consistent
with new models of care as well as changes in reim-
bursement that can support these models.
Page 8
To read or post commentaries in response to this article, see it
online at http://www.annfammed.org/cgi/content/full/9/1/22.
Key words: Quality improvement; electronic health record; electronic
medical record; clinical decision support; primary care; digestive system
(GI); nonsteroidal anti-infl ammatory drugs; adverse effects; practice-
based research
Submitted February 24, 2010; submitted, revised, May 26, 2010;
accepted June 23, 2010.
Funding support: This study was funded by AstraZeneca
Acknowledgments: The authors would like to thank Ms Katherine
Rosch Hegedus for assisting in study coordination and Ms Angie Grimes
for assisting in data preparation. The authors would also like to thank
Ms Cheryl Mongillo for assistance with manuscript preparation.
1. Lanza FL, Chan FKL, Quigley EMM; Practice Parameters Commit-
tee of the American College of Gastroenterology. Guidelines for
prevention of NSAID-related ulcer complications. Am J Gastroenterol.
2. American Gastroenterological Association, Wilcox CM, Jeroan A, et
al. Consensus development conference on the use of nonsteroidal
anti-Infl ammatory agents, including cyclooxygenase-2 enzyme inhib-
itors and aspirin. Clin Gastroenterol Hepatol. 2006;4(9):1082-1089.
3. Schnitzer TJ; American College of Rheumatology. Update of ACR
guidelines for osteoarthritis: role of the coxibs. J Pain Symptom Man-
age. 2002;23(4 Suppl):S24-S30, discussion S31-S34.
4. Smalley W, Stein CM, Arbogast PG, Eisen G, Ray WA, Griffi n M.
Underutilization of gastroprotective measures in patients receiving
nonsteroidal antiinfl ammatory drugs. Arthritis Rheum. 2002;46(8):
5. Abraham NS, El-Serag HB, Johnson ML, et al. National adherence
to evidence-based guidelines for the prescription of non-steroidal
anti-infl ammatory drugs. Gastroenterology. 2005;129(4):1171-1178.
6. Sturkenboom MC, Burke TA, Dieleman JP, Tangelder MJ, Lee F, Gold-
stein JL. Underutilization of preventive strategies in patients receiving
NSAIDs. Rheumatology (Oxford). 2003;42(Suppl 3):iii23-iii31.
7. Vonkeman HE, Fernandes RW, van de Laar MA, Vonkeman HE,
Fernandes RW, van de Laar MAFJ. Under-utilization of gastroprotec-
tive drugs in patients with NSAID-related ulcers. Int J Clin Pharmacol
Ther. 2007;45(5):281-288.
8. Coté GA, Rice JP, Bulsiewicz W, et al. Use of physician education
and computer alert to improve targeted use of gastroprotection
among NSAID users. Am J Gastroenterol. 2008;103(5):1097-1103.
9. Caudill-Slosberg MA, Schwartz LM, Woloshin S. Offi ce visits and
analgesic prescriptions for musculoskeletal pain in US: 1980 vs.
2000. Pain. 2004;109(3):514-519.
10. Rollman BL, Hanusa BH, Lowe HJ, Gilbert T, Kapoor WN, Schulberg
HC. A randomized trial using computerized decision support to
improve treatment of major depression in primary care. J Gen Intern
Med. 2002;17(7):493-503.
11. Gill J, Chen Y, Glutting J, Diamond J, Lieberman M. Using electronic
health record-based disease management tools to improve lipid
management in primary care. Fam Med. 2008;40(Suppl 1) .
12. Demakis JG, Beauchamp C, Cull WL, et al. Improving residents'
compliance with standards of ambulatory care. JAMA. 2000;284
13. Gill JM, Chen YX, Glutting JJ, Diamond JJ, Lieberman MI. Impact of
decision support in electronic medical records on lipid management
in primary care. Popul Health Manag. 2009;12(5):221-226.
14. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of
health information technology on quality, effi ciency, and costs of
medical care. Ann Intern Med. 2006;144(10):742-752.
15. Schedlbauer A, Prasad V, Mulvaney C, et al. What evidence supports
the use of computerized alerts and prompts to improve clinicians'
prescribing behavior? J Am Med Inform Assoc. 2009;16(4):531-538.
16. Gill J, Chen YX. Quality of lipid management in outpatient care:
a national study using electronic health records. Am J Med Qual.
17. Gill JM, Chen YX, Lieberman MI. Management of depression in
ambulatory care for patients with medical co-morbidities: a study
from a national Electronic Health Record (EHR) network. Int J Psy-
chiatry Med. 2008;38(2):203-215.
18. Gill JM, Fleischut P, Haas S, Pellini B, Crawford A, Nash DB. Use of
antibiotics for adult upper respiratory infections in outpatient set-
tings: a national ambulatory network study. Fam Med. 2006;38(5):
19. Gill JM, Foy AJ, Ling Y. Quality of outpatient care for diabetes mel-
litus in a national electronic health record network. Am J Med Qual.
20. Lanza FL. A guideline for the treatment and prevention of NSAID-
induced ulcers. Am J Gastroenterol. 1998;93(11):2037-2046.
21. Clinician's Guide: Choosing Non-Opioid Analgesics for Osteoarthritis.
Rockville, MD: Agency for Healthcare Research and Policy; 2007.
Report 06(07)EHC0093:4.
22. Ornstein S, Jenkins RG, Nietert PJ, et al. A multimethod quality
improvement intervention to improve preventive cardiovascular care:
a cluster randomized trial. Ann Intern Med. 2004;141(7):523-532.
23. Institute of Medicine Committee on Quality of Health Care in
America. Crossing the Quality Chasm: A New Health System for the 21st
Century. Washington, DC: National Academy Press; 2001.
24. Crosson JC, Ohman-Strickland PA, Hahn KA, et al. Electronic medi-
cal records and diabetes quality of care: results from a sample of
family medicine practices. Ann Fam Med. 2007;5(3):209-215.
25. Linder JA, Ma J, Bates DW, Middleton B, Stafford RS. Electronic
health record use and the quality of ambulatory care in the United
States. Arch Intern Med. 2007;167(13):1400-1405.
26. Gill JM. EMRs for improving quality of care: promise and pitfalls.
Fam Med. 2009;41(7):513-515.
27. Bryan C, Boren SA. The use and effectiveness of electronic clinical
decision support tools in the ambulatory/primary care setting: a sys-
tematic review of the literature. Inform Prim Care. 2008;16(2):79-91.
28. Berner ES. Clinical Decision Support Systems: State of the Art. Rock-
ville, MD: Agency for Healthcare Research and Quality; 2009.
29. Chambers CV, Balaban DJ, Carlson BL, Ungemack JA, Grasberger
DM. Microcomputer-generated reminders. Improving the compli-
ance of primary care physicians with mammography screening
guidelines. J Fam Pract. 1989;29(3):273-280.
30. Chambers CV, Balaban DJ, Carlson BL, Grasberger DM. The effect
of microcomputer-generated reminders on infl uenza vaccination
rates in a university-based family practice center. J Am Board Fam
Pract. 1991;4(1):19-26.
31. McDonald CJ, Hui SL, Smith DM, et al. Reminders to physicians
from an introspective computer medical record. A two-year ran-
domized trial. Ann Intern Med. 1984;100(1):130-138.
32. Ornstein SM, Garr DR, Jenkins RG, Rust PF, Arnon A. Computer-
generated physician and patient reminders. Tools to improve
population adherence to selected preventive services. J Fam Pract.
33. Turner RC, Peden JG Jr, O'Brien K. Patient-carried card prompts
vs computer-generated prompts to remind private practice physi-
cians to perform health maintenance measures. Arch Intern Med.
Page 9
34. Tierney WM, Hui SL, McDonald CJ. Delayed feedback of phy-
sician performance versus immediate reminders to perform
preventive care. Effects on physician compliance. Med Care.
35. Burack RC, Gimotty PA, Simon M, Moncrease A, Dews P. The effect
of adding Pap smear information to a mammography reminder
system in an HMO: results of randomized controlled trial. Prev Med.
36. Apkon M, Mattera JA, Lin Z, et al. A randomized outpatient trial
of a decision-support information technology tool. Arch Intern Med.
37. Schriefer SP, Landis SE, Turbow DJ, Patch SC. Effect of a computer-
ized body mass index prompt on diagnosis and treatment of adult
obesity. Fam Med. 2009;41(7):502-507.
38. Tang PC, LaRosa MP, Newcomb C, Gorden SM. Measuring the effects
of reminders for outpatient infl uenza immunizations at the point of
clinical opportunity. J Am Med Inform Assoc. 1999;6(2):115-121.
39. Rosser WW, Hutchison BG, McDowell I, Newell C. Use of remind-
ers to increase compliance with tetanus booster vaccination. CMAJ.
40. McDowell I, Newell C, Rosser W. Comparison of three methods of
recalling patients for infl uenza vaccination. CMAJ. 1986;135(9):
41. Garg AX, Adhikari NK, McDonald H, et al. Effects of computerized
clinical decision support systems on practitioner performance and
patient outcomes: a systematic review. JAMA. 2005;293(10):
42. Lobach DF, Hammond WE. Computerized decision support based
on a clinical practice guideline improves compliance with care stan-
dards. Am J Med. 1997;102(1):89-98.
43. Meigs JB, Cagliero E, Dubey A, et al. A controlled trial of web-
based diabetes disease management: the MGH diabetes primary
care improvement project. Diabetes Care. 2003;26(3):750-757.
44. Montori VM, Dinneen SF, Gorman CA, et al; Translation Project
Investigator Group. The impact of planned care and a diabetes
electronic management system on community-based diabetes care:
the Mayo Health System Diabetes Translation Project. Diabetes Care.
45. Filippi A, Sabatini A, Badioli L, et al. Effects of an automated
electronic reminder in changing the antiplatelet drug-prescribing
behavior among Italian general practitioners in diabetic patients:
an intervention trial. Diabetes Care. 2003;26(5):1497-1500.
46. Rossi RA, Every NR. A computerized intervention to decrease the
use of calcium channel blockers in hypertension. J Gen Intern Med.
47. Feldstein A, Elmer PJ, Smith DH, et al. Electronic medical record
reminder improves osteoporosis management after a fracture: a
randomized, controlled trial. J Am Geriatr Soc. 2006;54(3):450-457.
48. Nilasena DS, Lincoln MJ. A computer-generated reminder system
improves physician compliance with diabetes preventive care guide-
lines. Paper presented at: Annual Symposium on Computer Applica-
tions in Medical Care; 1995; Salt Lake City, UT.
49. Murray MD, Harris LE, Overhage JM, et al. Failure of computerized
treatment suggestions to improve health outcomes of outpatients
with uncomplicated hypertension: results of a randomized con-
trolled trial. Pharmacotherapy. 2004;24(3):324-337.
50. Karsh B-T. Clinical Practice Improvement and Redesign: How Change
in Workfl ow Can Be Supported by Clinical Decision Support. Rockville,
MD: Agency for Healthcare Research and Quality; 2009.
51. Schnipper JL, Linder JA, Palchuk MB, et al. "Smart Forms" in an
Electronic Medical Record: documentation-based clinical decision
support to improve disease management. J Am Med Inform Assoc.
52. Margolis CZ, Warshawsky SS, Goldman L, Dagan O, Wirtschafter
D, Pliskin JS. Computerized algorithms and pediatricians' man-
agement of common problems in a community clinic. Acad Med.
53. Flocke SA, Frank SH, Wenger DA. Addressing multiple problems in
the family practice offi ce visit. J Fam Pract. 2001;50:211-216.
54. Beasley JW, Hankey TH, Erickson R, et al. How many problems do
family physicians manage at each encounter? A WReN study. Ann
Fam Med. 2004;2(5):405-410.
55. Bayliss EA, Edwards AE, Steiner JF, Main DS. Processes of care
desired by elderly patients with multimorbidities. Fam Pract. 2008;
56. Pollak KI, Arredondo EM, Yarnall KS, et al. How do residents priori-
tize smoking cessation for young "high-risk" women? Factors associ-
ated with addressing smoking cessation. Prev Med. 2001;33(4):
57. Hroscikoski MC, Solberg LI, Sperl-Hillen JM, Harper PG, McGrail
MP, Crabtree BF. Challenges of change: a qualitative study of chronic
care model implementation. Ann Fam Med. 2006;4(4):317-326.
58. American Academy of Family Physicians, American Academy of Pedi-
atrics, American College of Physicians, American Osteopathic Associa-
tion. Joint Principles of the Patient-Centered Medical Home. http://
www.acponline.org/hpp/approve_jp.pdf?hp. Accessed Nov 26, 2007.
59. Oderda G, Brixner D, Lieberman M. Comparison of EMR data to
US national data. Paper presented at: International Society for
Pharmacoeconomics and Outcomes Research (ISPOR) 10th Annual
European Congress; 2007; Dublin, Ireland.


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Apr 18
Alyssa will be playing at Record Archive as part of Record Store Day! Alyssa will be kicking things off at 10:00am. Be sure to stick around after Alyssa's performance to hear the other artists in the lineup! In addition to live music, there will be multiple food vendors on site!
SaveApr 22
Alyssa will be playing from 9:00pm - 12:00am! Come see Alyssa at the Cottage every 4th wednesday of every month!
SaveApr 24
Alyssa will be opening for MoChester and the Neil Van Dorn band at Johnny's Irish Pub! She will be playing at 10pm for about 30-45 minutes with her acoustic trio!
SaveApr 24
Alyssa will be opening for MoChester at Johnny's Irish Pub, along with Neil Van Dorn Band! Show starts at 10:00pm!
Sounds Like: Carrie Underwood, Miranda Lambert, Danielle Bradbery, Taylor Swift
Bio: Multi-instrumentalist Alyssa Trahan is a country singer-songwriter originally from Rochester, NY. She has written over 70 songs, not to mention those done with co-writers, and continues to add to her long list of originals. Alyssa also performs on a regular basis, nearly 100 shows every year, and...See Full Bio
: RT @OneStopCountry: ROCHESTER, NY - Record Archive welcomes @lysstrahan tonight - http://t.co/PWy43Yc94S
"She's a true performer...remember the name Alyssa Trahan because you'll be hearing a lot more from this rock star."

subset: commoncrawl


text:
Art of Markiplier playing "One Chance" by Rhueniea-the-Echidna (http://rhueniea-the-echidna.deviantart.com/) Posted with the artist's permission.
Seriously that letsplay tho.
FollowArt of Markiplier playing "One Chance" by Rhueniea-the-Echidna (http://rhueniea-the-echidna.deviantart.com/) Posted with the artist's permission.
Seriously that letsplay tho.
Happy Birthday to the prettiest angel ♡ Luhan ♡
"Maybe life should be about more than just surviving."
Mazda USA
I don't wanna be your friend..
Ahhh here you go! Hinata eating a cinnamon bun! ^^
went for a bit of a purple eyeshadow today :)
Well, good morning, everybody, and welcome to day 255,642 aboard the Axiom.
get to know me meme » favorite movies [4/5] » WALL·E (2008)
i never know how to start these things
because what is actual sentiment omg. i'm just—in all honesty, i never thought this blog would go much of anywhere, given that dearest cutler beckett is sometimes forgotten when it comes to potc ( he barely has half an hour of sceentime over the span of dmc & awe after all, give or take a few minutes ). even so, i've gotten the chance to meet & write with so many talented people, and i'm so thankful to each and every one of you for sticking with me & for giving me a chance to explore cutler's character to the extent that i have. you guys really are the best & ily all so much!! <3
without further ado, here's a special shout out to those i fully admire & love seeing on my dashboard—you're all such wonderful people and friends!! ;u;
abyssalgoddess ▪ alluriis ▪ bxthory ▪ calicohs ▪ damnbutcher ▪ davyjxnes
deslibertes ▪ donapirata ▪ dxdger ▪ falsedivinity ▪ forliiberty
herladydauntless ▪ kalyptousa ▪ leerofthevinegaroons
lt-theodoregroves ▪ miabxlla ▪ ms-maryread ▪ murroyilodel ▪ nativesque
piraticalwit ▪ republici ▪ ruusalki ▪ sakrifye ▪ sanctamater
scotchandcaffeine ▪ seadxg ▪ simplify-your-vibrations
stopthinkingaboutthewoods ▪ templiere ▪ thefastestship ▪ weestley
wehavenokingshere ▪ undauntedloyalty ▪ victorianasteampunk
also i'd like to give an extra-special shout out to a few people under the cut:
suga - 花樣年華 (mood for love)
What does red velvet cake taste like?
endlessnightsofthedoomedchildren asked:
'If I met you in real life...' Beer, Metal, Cannabis, Food.
what does alchohol taste like
So I ordered a textbook and they gave me a 'gift.'
For special snowflake Sunday?
26, demisexual.
Grad student and professional fine artist. Freelance illustrator, fan girl and casual video game nerd.
sexual assault survivor, battling depression and anxiety, occasional synesthetic or disassociation episodes, chronic migraines.
What is bubble tea actually like?
I have never tried to do the whole winged eye liner thingy am I still human?
Has anyone tried burning incense before?
Does it smell good or is it overpowering? If it is good where should I look, what scent? Cheap preferably.
Or should I stick to candles?


text:
Woman charged with prescription, ID fraud
Police say Kelly Naudascher used the name of a woman she was staying with. A 37-year-old New Castle-area woman without a home has been charged with illegally obtaining prescription painkillers, using the name ... via News Journal
Read moreComments
1 - 7 of 7 Comments
Last updated Nov 29, 2013
Jul 28, 2008
Unfortunately it is easy to become addicted to the opiate pain killers that are prescribed. I did not seek out to get high nor did I use street drugs. I was injured at work and therefore was prescribed percocets for a very long period of time. Hence, I became addicted, not one doctor hesitated to prescribe them to me because of my injury. I was a victim as well. And as for using other peoples names, well when you pick up a prescription the pharmacist confirms your name and asks for ID, which was shown by the person whom I was picking up the script under, they knew and willingly went along with it.
Mar 5, 2009
You are still at it...after all these years. How do you live with yourself?
May 14, 2013
If you had a brain you would realize that I am not still at it! In fact, I have earned my Bachelors degree, and now my MBA I am completing. I was accepted to medical school and I have a lovely home on three acres. Your son is dead because he kept doing drugs not because he was smart and wanted more out of life. I take offense to your ridiculous comment. Now leave me alone no wonder he was the way he was! You shouldn't have given him up for adoption! |
May 14, 2013
Its amazing, Robin as she has called herself seems to know everything. Well at least when I dated her son he was good and wasnt into shooting drugs. When I left him, he went to harder and harder drugs and was depressed because Robin gave him up for adoption. Maybe you should look at yourself before you judge others. You have alot to atone for!
Aug 17, 2013
Robin - Can you contact me about this? email@example.com
Nov 26, 2013
It looks from the court proceedings she is a career criminal. She is bad news and just about everything that comes out of her mouth are lies. She has an excuse for everything that happens. She knows how to game the system for maximum benefit. It is shocking how brazing she is. It will come back to her one day 10 fold.
Nov 29, 2013
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Ichthys Sterling Silver Bracelet
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Monday, December 12, 2011 5 comments I find myself rummaging through my closets and drawers to find something to wear to the gym. Sometimes i end up skipping workouts because a lot of my old gym clothes don't fit! Where do you get your fitness apparel from? I'm really on a budget a... Read more
Thursday, June 30, 2011 5 comments Yesterday morning I stepped on the scale at 227. Later that night after an awesome workout and eating within range I was up to 231. Now today I am at 230. If anything i thought the scale would have gone down. So tonight the motivation is going ... Read more
Tuesday, June 28, 2011 1 comments Well I've been at a steady weight for almost 2 months now. I feel like I have lost a lot of motivation to lose, but i still have the willingness to maintain and not to gain uncontrolably. Today I was on track and got a lot of activitiy in, but i... Read more
Wednesday, May 25, 2011 6 comments I guess I can start off by saying how disappointed I am in myself. I left my guard down for a weekend 2 weeks ago and have been on a rough path since. I was going on binges, eating fast food, and drinking regular soda. What the heck? Where did m... Read more
Sunday, May 01, 2011 3 comments Today is the first of May. It's time for a fresh start and a clean slate. My goal is to lose 10 -12 lbs this month. I kind of slacked in April and am ready to change things up and lose this month. I think I really need some new food choice... Read more
Tuesday, April 26, 2011 3 comments So today was my day off. I had a list of things to do around the house that i thought could burn off calories, but of course it rained so i couldn't do any of those outdoor chores. I told my friend I'd just meet her in the gym rather than outsi... Read more
Sunday, April 24, 2011 14 comments Went to easter dinner with family and didn't get anybody to notice my efforts. I lost nearly forty pounds since i saw them last. It's not that i wanted compliments, it just would have been nice if someone noticed. I know i still have a lot to lo... Read more
Thursday, April 21, 2011 1 comments So tonight i watched one of my favorite movies, Confession of a Shopoholic. There are some parts in there that can be identified the same way as food addiction. I am definatly one to judge when people have shopping or spending problems, drug or... Read more
Wednesday, April 20, 2011 4 comments Today I ate a bunch of crap that i shouldn't have ate. I don't understand how i can be on such a great streak and then i go and eat like a pig. I feel especially terrible knowing that my "gym weigh in" is tomorrow. I know I've either gained or s... Read more
Tuesday, April 19, 2011 3 comments So I've kind of been on an overeating trend lately. Not that I'm going over calories, but just eating the wrong foods and ending up on the higher end of my range. I would like to eat less, but also excercise more. I am on my feet all day at work... Read more
Thursday, April 07, 2011 3 comments Already I'm feeling awesome motivation to take on this weekend! I will make good choices! It is my weekend to work which can get me into trouble with vending machine and what not. I am determined to set my food out and stick to the plans for the... Read more
Sunday, April 03, 2011 3 comments I just started a new weight challenge with my girlfriends. This includes us weighing in at the gym once a week. I want to keep doing my weight ins on tuesdays that i have been doing for 2 months also. The thing that bothers me is how the two sca... Read more
Tuesday, March 29, 2011 2 comments So this last week I went to the mall. I thought to myself, hey i've lost some weight maybe i can take a look around. Well that was about all I did. I didn't buy anything but this one shirt from a specialty store. This was actually a little ... Read more
Tuesday, March 15, 2011 2 comments I've been working a lot of nights lately and running around til 10 pm gets me real hungry. I eat my last s... Read more
Saturday, March 12, 2011 1 comments Today I'm noticing a few changes in myself. For one my bmi is almost out of the obese range. Thank god. I'm about 3 points away from just being considered overweight. Also, checked my blood pressure at a machine today. When I started I was into ... Read more


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1993 Ford Festiva Radiator, 12.62 x 15.25 x 1 in. core size, 1.13 in. inlet size, 1.13 in. outlet size, 2 x 16 in. top header, 2 x 16 in. bottom header, plastic tanks, aluminum core, top left inlet location, bottom right outlet location; With 7.88 in. transmission oil cooler; Without engine oil cooler; A high quality, direct fit OE replacement radiator.. | $113.06 | |
1993 Ford Festiva Headlight, Driver Side, Bulbs included; Composite type; DOT and SAE approved; A high quality, OE replacement headlight assembly; Backed by 1-year, unlimited-mileage warranty.. | $126.23 | |
1993 Ford Festiva Radiator, Radiator; Automatic Transmission; Air/HD Cooling, , . | $165.50 | |
1993 Ford Festiva GL L4, 1.3 L, 1295 CC Rebuilt Engine, Warranty: 3-Year/100,000 Mile, . | Ad Hoc | |
1990 Ford Festiva Used Starter, 1.3, AUTO, FWD Automatic Transmission, Very Good. | $87.00 | |
1990 Ford Festiva Used Starter, Automatic Transmission, Very Good. | $95.00 | |
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Used 1991 Ford Festiva Transmission Assembly 1991 Ford Festiva Hatchback, 4-Cyl, 5-Speed-Std, FWD Transmission Assembly 4 cylinder puyallup, Washington 98372 | |||
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I bought here in Prague where I am coming from black 8X on the launch day (1st of November) and so far within 3 days of use I had 2 random reboots. Device just suddenly reboots itself ending in PIN screen. Quite annoying, but not sure whether go for service or is it a software issue. Can you share if you have same experience. So far both reboots happened when in car connected to bluetooth.
I've had my 8X for a couple of days, and it's been having multiple reboots. Lots of people over on WPCentral seem to be having the same problemPretty sure it's a software problem as have seen people complaining of the Lumia 920 doing the same thing.Seems like Microsoft rushed WP8 a bit.
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Man dies after car overturns following 'roll-start'
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And here, we thought that new section of the High Line was cool. One-upping us over in Vienna, you'll find FLEDERHAUS, a new public space project by Austrian design firm Heri & Salli; the five-story "hangout spot" is meant to "serve as an oasis of relaxation and a symbol of a vertical public sphere." Why it has the gigantic boob tower out front is beyond us, but anything that involves so many hammocks is aces in our book. What do you think of it? [Photo credit: © Mischa Erben, via Gizmodo]
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Let there be class NaturalFood and two classes inherit from this class; class Fruits and class Vegetables
abstract class NaturalFood
enum AllList
//empty list as a placeholder
protected string Name;
class Fruits : NaturalFood
enum AllList
Apple = 1,
Banana = 2
class Vegetables : NaturalFood
enum AllList
Carrot = 1,
Potatoes = 2
I want to enforce that any class derived from class NaturalFood must declare and/or override the AllList enumeration. Effectively the enumeration will contain list specific to the derived class. How do I do this ?
Edit: My basic requirement is that each class deriving from a base class must have its own list of "something" that is specific to it. Enumeration is just a way of creating a list. I hope you get the gist from my example. I want to take advantage of what Enumeration offers viz. intellisense, toString() etc.
Edit2: Isn't my example very practical enough ? If I put the entire enumeration in the base class (NaturalFood), how do I know which of the enumerated values are specific to which derived class ? Let us say each derived class is "publishing something" it has to offer in form of enumerated constants and I want to enforce this constraint on every derived class. So in other words, my question is how to enforce a constraint on derived class like in scenario described here ?


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Alexander Wang Spring 2014 Hair and Makeup | Runway Pictures
Alexander Wang Does a Beach Wave and Shocks Everyone
While he's typically known for sending full-on androgynous looks down the runway, Alexander Wang took a different approach for his Spring 2014 show. Beach waves and barely there makeup were the main looks of the evening. Guido for Redken opted to play with the natural texture of the models' hair, pulling inspiration from the '80s. Extensions were added, then curled, to achieve extra thickness. "It's Alexander Wang's take on big hair," Guido said. Diane Kendal for Nars focused on the skin, using only concealer and brow gel for the entire makeup look.
The one puzzle piece that fit Wang's typical aesthetic was the nails. Usually one to opt for texture, Wang asked for chalkboard nails. Lead nail artist Michelle Saunders used two coats of Essie Sand Tropez, followed by the brand's Matte About You top coat. It seems that at Alexander Wang, the more things change, the more they stay the same.
Want more? Be sure to check out POPSUGAR Fashion's complete gallery of the show, along with our retrospective of Alexander Wang's best-ever runway beauty looks.
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Gefðu gömlu fötin til góðgerðarstofnana eða aðila sem taka á móti þeim.
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For references, please go to www.eea.europa.eu/soer or scan the QR code.
This briefing is part of the EEA's report The European Environment - State and Outlook 2015. The EEA is an official agency of the EU, tasked with providing information on Europe's environment.
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- I don't know about you, but i'm excited with the release of the
Futurama season two DVD on August 12th! Did you see the season one,
in DVD? I liked a lot!!!!
And now, the second season DVD has 19 episodes in 4 discs!!! ...so,
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I already pre-ordered it at foxstore.com ...and saved some
money...hehehehe...but you can test your luck in some
contests...there's dvd's giveaways at voxonline.com and
themanroom.com !
Anyone else into Futurama???


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laziest meals...that look like you made an effort
(253 Posts)can we pool ideas, those meals that get brownie points but are very little effort.
My contribution:
lamb casserole:
diced meat
frozen veg (tesco do nice and chunky mix)
few spices
throw in big pot, oven 90min. looks lovely, don't even get a knife dirty and takes about 2 min prep.
My easy but posh recipe is...
- Cook some Orichette pasta or similar small fairly rough textured pasta (you really taste the pasta in this one so important to get something nice)
- meanwhile fry off some good quality bacon (i use three rashers per person). I use smoked back bacon but it's up to you. Leave the fat on if there is a rind until it's cooked, then cut off the rind if you prefer. Chop the bacon into little pieces (I use scissors not a knife)
- add diced avocado to the pan (I use one per person)
- carefully pour in a generous glug of port per person and cook for a minute or so to deglaze the pan (picking up all the bacon juices) and tone down the alcoholic content of the port
Add the bacon avocado and port mix to the pasta and serve to your delighted other half! Expensive but delicious.
Marking place
Easy veggie lasagne
Heat through some Frozen Roasted Veg in a tin of tomatoes. While this is cooking, microwave some frozen spinach and mix with a tub of creme fraiche and grate in some nutmeg.
Layer - tomato/veggies - lasagne sheets - spinach mix - repeat. Finish with spinach layer grate some cheese on top.
Bake for 30mins ish. Yum.
Chicken and chorizo casserole. I think I orginally robbed it off Mums net.
Sooo easy and even my youngest loves it.
Serve with pasta, rice or just bread. Just google on chicken and chorizo. It only takes half an hour and only 5 mins of that is prep.
Tip: Don't overboil or the chicken goes tough (take meat out if you need to reduce and then put back) .
Tip ~2 add butternut squash blitzed to tiny pieces - extra veg that they don't notice and tastes fab.
Creamy broccoli pasta.
Tub of garlic and herb Philadelphia. Tip into a small saucepan, add a glug of hot water and a chicken stock cube. Stir. That makes your sauce. If you're a garlic fiend like me, add more chopped garlic or some really lazy stuff from a jar.
Cook your pasta, add broccoli to the cooking water towards the end. Drain, tip the sauce in. Eat.
Try layering your lasagne with slices of cooked potato - simply gorgeous, a bit cheaper, and fewer calories as well!
Tomato tart - use ready-rolled puff pastry and spread it with either cottage cheese or creme fraiche mixed with a dollop of wholegrain mustard. Cover with any combination of: sliced tomatoes, sliced courgette, ham, salami, lardons, spinach, feta, goats' cheese, any cheese, spring onions - basically anything you need to use up. Sprinkle with salt and pepper. Bake for approx 20 mins on a baking tray, drizzle with balsamic reduction (if you're feeling fancy), et voila.
sharond101 I made the crispy beef tonight, it's beyond delish!! Everyone inhaled it Minute steaks from our butcher were fantastic, proper steak for around £3.50 and fed 4 of us. It's a keeper.
Chocolate Tarts
Fab & very easy recipe found in a sainsburys mag - egg/free & veggie
use 6 or 8 individual ready made all-butter pastry tart (Waitrose/Sainsburys/M&S)
Bring to the boil 150ml single or double cream with 1TBS sugar. Take off heat & throw in 150g chopped up chocolate & leave for a minute then stir gently till melted through. I have used dark choc, milk choc & Divine white choc w strawberries, all equally yum. Pour gently into cases & fridge for at least an hour, ideally two.
Serve, having dusted with icing sugar or cocoa powder.
Juniperdewdropofbrandy Iam delighted you enjoyed it. Here is another two we like,
Thanks for those. Yes we really enjoyed it. Got it written down to take on hols too as we're staying in Britain for Easter.
Fellatio fabulous recipes - any more? <greedy>
Huevos Rancheros with bought bread
great thread...marking place
Sharond101. I also made the crispy beef. Last night and tonight. Tweaked a bit today with less vinegar and corn four but inhaled. Amazing and once you have done the prep (does anyone know how to do julienne?) very quick to make.
I also found it easier to do the beef in batches.
Thanks for the link.
Crutchlow35 Iam so pleased. We do the beef in batches too.
Lamb shanks with stock and mint / mint sauce in the slow cooker. So yummy.
I am going to make the crispy beef as it look yum too.
Toad in the hole
I pop oil and sausages in a pan... Part cook for 10-15 mins..
Then, open a packet of Aunt Bessie's Yorkshire Pudding mix... Pop in jug, add 22ml water, whisk... Then pour over the sausages and continue to cook until done!
Key Lime Pie
250g digestive biscuits
100g butter, melted
405g can Carnation Condensed Milk Light
finely grated zest and juice of 5 large limes
300ml carton double cream
To decorate (optional)
Lime zest
85g half fat crème fraîche
You will also need...
20x30cm rectangular loose-bottomed tart tin or 23cm (9in) round loose-bottomed tart tin.
1. Mix the crushed biscuits with the melted butter in a bowl.
2. Press the crumbs into the base and up the sides of the tin. Chill for 10 minutes.
3. Whisk together the condensed milk and cream, then add the lime juice and zest (watch it magically thicken!). Pour into the tart case and chill or at least 1-2 hours.
4. Remove the pie from the tin and place on a serving plate. Cut into slices and serve with the crème fraîche and lime zest.
This recipe can also be made with lemons replace the 5 limes with 4 lemons.
Where do I find the crunchy beef recipe? Thanks in advance x
Mediterranean vegetables always gets compliments and it easy peasy......
Red onion
Cherry tomatoes
Chop all the above, drizzle with olive oil and roast in the oven.
Put pasta on.
Chop up feta
Drain pasta put in bowls, roasted veg and feta on top, then drizzle with balsamic glaze.
Also just roll home made garlic bread is piece of pie and goes nicely
Christmas hope
I eat this a lot when I am by myself as I hate cooking for one.
1 yellow pepper
1 courgette
1 onion
(all chopped into big chunks)
Uncooked by cleaned prawns (from the freezer section)
Creme Fraiche (optional)
Fry veg in a little olive oil till soft, add prawns till they turn pink. Add pesto and creme fraiche, serve with bread.
Or this one:
Finely slice a fennel bulb and an apple.
Mix with blue cheese and yellow raisins. Drizzle some olive oil and a pinch of salt over it.
I'll have this with a pork chop or some sausages.
For desert I made some Eton Mess the other day and could not believe how easy it was. Dice up strawberries add a couple of tablespoons of juice and some balsamic vinegar (or alcohol). Whip cream with a little sugar. Break shop bought meringues into bowls, spoon over cream and top with strawberries.
I also like Nigella's ice cream cake. Looks so impressive! www.foodnetwork.com/recipes/nigella-lawson/ice-cream-cake-recipe/index.html I don't bother with the sauces and will use whatever chocolate or biscuits I can find in the house.
Another easy Nigella one, I make this for the office and they love it! www.nigella.com/recipes/view/chocolate-pistachio-fudge-96
Great thread.
My easy one:
Mushroom and salmon pasta
Fry an onion. Add packet of sliced mushrooms. Add carton of creme fraiche (half fat works too). Add packet of smoked salmon (either nice slices chopped up or cheap bits depending on how flush you're feeling). Add chopped parsley and squeeze of lemon if you have them.
Mix into pasta.
Super quick easy and delicious.
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New Arrival
Kenu Airframe Portable Car Mount
for Samsung Galaxy Stratosphere IIWelcome to an improved driving experience with Airframe, the world's most portable car mount for smartphones. Just attach Airframe on to any air vent and insert your smartphone.$24.95 -
New Arrival
CasePower EDGE 3000mAh with Lightning and Micro-USB
for Samsung Galaxy Stratosphere IIEDGE 3000 takes portable power to a whole new level with its thin and lightweight design and with an inbuilt Lightning cable.$76.95 -
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Samsung Micro-USB 700mA Travel Charger
for Galaxy Stratosphere IIThe Samsung Micro-USB 700mA Travel Charger plugs directly from an AC wall power source into your phone and provides a standard battery charge whether at home, office or on the road.Now
Was $19.99
You Save $7.04
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BlackBerry Premium Micro-USB 1.8A Charger
for Samsung Galaxy Stratosphere IIThe BlackBerry Premium Micro-USB 1.8A Charger is made for maximum portability. Use it at home, or take it with you to the office, to the airport, or anywhere life takes you!Now
Was $39.99
You Save $18.04
(45% Off) -
Best Selling
Samsung Micro-USB 700mA Travel Charger
for Galaxy Stratosphere IIThe Samsung Micro-USB 700mA Travel Charger plugs into any standard wall outlet, and the compact and durable design makes it convenient to charge your battery while home or on the go.Now
Was $24.99
You Save $9.04
(36% Off)
Enhance the productivity of your Samsung Galaxy Stratosphere II by adding quality accessories. We carry Bluetooth, NFC Tags, Cradles, LLOYD Gear, Screen Protectors, Tools, Stylus, Gaming, Car Kits & Mounts, Speakers, and much more!


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You are Bidding on Six Original Handmade Note Cards!! General Information About Our Note Cards: Six greeting or note cards based on our original artwork Finished Size of each card is 4.625" x 6.25" (A6 size) Cards are white with a 4"x5" image on the front Printed on high quality Epson Premium Matte Paper using dye-based six-color ink Cards are blank inside Includes six envelopes Suitable for framing Copyright, Alpen Designs, 2008. All rights reserved. When you purchase this item, you purchase one print for personal use only and the copyright of this print remains with us. Strictly no reproduction allowed. Thank you. Check out our other items! Check out our ebay store! Please contact us if you have any problems or issues. We want to make sure you are satisfied with your purchase! Thanks! Please check our Frequently Asked Questions page for more detailed information . Powered by eBay Turbo Lister The free listing tool. List your items fast and easy and manage your active items. Powered by eBay Turbo Lister The free listing tool. List your items fast and easy and manage your active items. |
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Love the sound in this one. Rawr! I love to watch men hump pillows, next time you should zoom the cam out a little so we can see your thighs and ass a bit better while you hump it!
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start a home based business Archives | How to make money on the internet. What is Pligg? Pligg is an open source content management system that lets you easily create your own user-powered website. Latest Comments.
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