Informatics in Primary Care (BCS, The Chartered Institute for IT)
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The provision and impact of online patient access to their electronic health records (EHR) and transactional services on the quality and safety of health care: systematic review protocol
Full text linkBackground Innovators have piloted improvements in communication, changed patterns of practice and patient empowerment from online access to electronic health records (EHR). International studies of online services, such as prescription ordering, online appointment booking and secure communications with primary care, show good uptake of email consultations, accessing test results and booking appointments; when technologies and business process are in place. Online access and transactional services are due to be rolled out across England by 2015; this review seeks to explore the impact of online access to health records and other online services on the quality and safety of primary health care.Objective To assess the factors that may affect the provision of online patient access to their EHR and transactional services, and the impact of such access on the quality and safety of health care.Method Two reviewers independently searched 11 international databases during the period 1999–2012. A range of papers including descriptive studies using qualitative or quantitative methods, hypothesis-testing studies and systematic reviews were included. A detailed eligibility criterion will be used to shape study inclusion .A team of experts will review these papers for eligibility, extract data using a customised extraction form and use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) instrument to determine the quality of the evidence and the strengths of any recommendation. Data will then be descriptively summarised and thematically synthesised. Where feasible, we will perform a quantitative meta-analysis.Prospero (International Prospective Register of Systematic Reviews) registration number: crd42012003091
Clinicians were oblivious to incorrect logging of test dates and the associated risks in an online pathology application: a case study
Full text linkBackground UK primary care physicians receive their laboratory test results electronically. This study reports a computerised physician order entry (CPOE) system error in the pathology test request date that went unnoticed in family practices.Method We conducted a case study using a causation of risk theoretical framework; comprising interviews with clinicians and the manufacturer to explore the identification of and reaction to the error. The primary outcome was the evolution and recognition of and response to the problem. The secondary outcome was to identify other issues with this system noted by users.Results The problem was defined as the incorrect logging of test dates ordered through a CPOE system. The system assigned the test request date to the results, hence a blood test taken after a therapeutic intervention (e.g. an increase in cholesterol-lowering therapy) would appear in the computerised medical record as though it had been tested prior to the increase in treatment. This case demonstrates that: the manufacturers failed to understand family physician workflow; regulation of medical software did not prevent the error; and inherent user trust in technology exacerbated this problem. It took three months before users in two practices independently noted the date errors.Conclusion This case illustrates how users take software on trust and suppliers fail to make provision for risks associated with new software. Resulting errors led to inappropriate prescribing, follow-up, costs and risk. The evaluation of such devices should include utilising risk management processes (RMP) to minimise and manage potential risk
Accelerating the development of an information ecosystem in health care, by stimulating the growth of safe intermediate processing of health information (IPHI)
Full text linkHealth care, in common with many other industries, is generating large amounts of routine data, data that are challenging to process, analyse or curate, so-called ‘big data’. A challenge for health informatics is to make sense of these data. Part of the answer will come from the development of ontologies that support the use of heterogeneous data sources and the development of intermediate processors of health information (IPHI). IPHI will sit between the generators of health data and information, often the providers of health care, and the managers, commissioners, policy makers, researchers, and the pharmaceutical and other healthcare industries. They will create a health ecosystem by processing data in a way that stimulates improved data quality and potentially health care delivery by providers of health care, and by providing greater insights to legitimate users of data. Exemplars are provided of how a health ecosystem might be encouraged and developed to promote patient safety and more efficient health care. These are in the areas of how to integrate data around the unsafe use of alcohol and to explore vaccine safety. A challenge for IPHI is how to ensure that their processing of data is valid, safe and maintains privacy. Development of the healthcare ecosystem and IPHI should be actively encouraged internationally. Governments, regulators and providers of health care should facilitate access to health data and the use of national and international comparisons to monitor standards. However, most importantly, they should pilot new methods of improving quality and safety through the intermediate processing of health data
Pharmacist-generated electronic consults to improve hypertension management in a multisite health centre: pilot study
Full text linkBackground Utilisation of the electronic medical record (EMR) is believed to facilitate timely access to patient information, enhance communication between care team members and further promote clinical decision support.Objective To determine if pharmacist-generated electronic consults (e-consults) improve blood pressure control among patients with uncontrolled hypertension in a multisite health centre.Methods Pharmacists generated hypertension medication e-consults with review by primary care provider (PCP) during the patient appointment. We conducted a retrospective review of consults to determine types of pharmacist recommendations, PCP acceptance rates, and blood pressure changes.Results Pharmacists generated a total of 60 econsults, 41 patients with a systolic blood pressure above their respective goal; e-consults were accepted 46% (n = 19) of the time.Conclusion This pilot project demonstrates a unique way for pharmacists to proactively utilise the EMR when delivering coordinated care within a multisite health centre. In addition, pharmacists were successfully integrated into the planned care approach
Notifications of hospital events to outpatient clinicians using health information exchange: a post-implementation survey
Full text linkBackground The trend towards hospitalist medicine can lead to disjointed patient care. Outpatient clinicians may be unaware of patients’ encounters with a disparate healthcare system. Electronic notifications to outpatient clinicians of patients’ emergency department (ED) visits and inpatient admissions and discharges using health information exchange can inform outpatient clinicians of patients’ hospital-based events.Objective Assess outpatient clinicians’ impressions of a new, secure messaging-based, patient event notification system.Methods Twenty outpatient clinicians receiving notifications of hospital-based events were recruited and 14 agreed to participate. Using a semi-structured interview, clinicians were asked about their use of notifications and the impact on their practices.Results Nine of 14 interviewed clinicians (64%) thought that without notifications, they would have heard about fewer than 10% of ED visits before the patient’s next visit. Nine clinicians (64%) thought that without notifications, they would have heard about fewer than 25% of inpatient admissions and discharges before the patient’s next visit. Six clinicians (43%) reported that they call the inpatient team more often because of notifications. Eight users (57%) thought that notifications improved patient safety by increasing their awareness of the patients’ clinical events and their medication changes. Key themes identified were the importance of workflow integration and a desire for more clinical information in notifications.Conclusions The notification system is perceived by clinicians to be of value. These findings should instigate further message-oriented use of health information exchange and point to refinements that can lead to even greater benefits
Get moving: the practice nurse is watching you!
Full text linkBackground The system informs the nurse about levels of physical activity in the daily living of patients who are using the It’s LiFe! tool. The tool consists of an accelerometer that transfers data to a smartphone, which is subsequently connected to a server. Nurses can monitor patients’ physical activity via a secured website. Physical activity levels are measured in minutes per day compared with pre-set activity goals, which are set in dialogue with the patient.Objective To examine user requirements and to evaluate the usability of the secured website, in order to increase the probability of effective use by nurses.Method The needs and preferences of nurses towards the system were determined through qualitative research. The usability of the system was evaluated in a laboratory situation and during a three-month pilot study.Results A monitoring and feedback system to support patients in their intention to be more active was developed in a systematic way. Automatically generated feedback messages were defined based on the requirements of nurses. The results from the usability tests gave insights into how to improve the structure and quality of the information provided. Nurses were positive about the features and ease of use of the system, but made critical remarks about the time that its use entails.Conclusion The system supports nurses when performing physical activity counselling in a structured and profound way. The opportunity to support self-management of patients in between regular consultations needs further investigation, and adaptation into the clinical workflow of the nurses
Managing and exploiting routinely collected NHS data for research
Full text linkIntroduction Health research using routinely collected National Health Service (NHS) data derived from electronic health records (EHRs) and health service information systems has been growing in both importance and quantity. Wide population coverage and detailed patient-level information allow this data to be applied to a variety of research questions. However, the sensitivity, complexity and scale of such data also hamper researchers from fully exploiting this potential.Objective Here, we establish the current challenges preventing researchers from making optimal use of the data sets at their disposal, on both the legislative and practical levels, and give recommendations as to how these challenges can be overcome.Method A number of projects has recently been launched in the UK to address poor research data management practices. Rapid Organisation of Healthcare Research Data (ROHRD) at Imperial College, London produced a useful prototype that provides local researchers with a one-stop index of available data sets together with relevant metadata.Findings Increased transparency of data sets’ availability and their provenance leads to better utilisation and facilitates compliance with regulatory requirements.Discussion Research data resulting from NHS data is often not utilised fully, or is handled in a haphazard manner that prevents full auditability of the research. Furthermore, lack of informatics and data management skills in research teams act as a barrier to implementing more advanced practices, such as provenance capture and detailed, regularly updated, data management strategies. Only by a concerted effort at the levels of research organisations, funding bodies and publishers, can we achieve full transparency and reproducibility of the research
Impact of the implementation of electronic guidelines for cardiovascular prevention in primary care: study protocol
Full text linkBackground The electronic medical records software of the Catalan Institute of Health has recently incorporated an electronic version of clinical practice guidelines (e-CPGs). This study aims to assess the impact of the implementation of e-CPGs on the diagnosis, treatment, control and management of hypercholesterolaemia, diabetes mellitus type 2 and hypertension.Methods Eligible study participants are those aged 35–74 years assigned to family practitioners (FPs) of the Catalan Institute of Health. Routinely collected data from electronic primary care registries covering 80% of the Catalan population will be analysed using two approaches: (1) a cross-sectional study to describe the characteristics of the sample before e-CPG implementation; (2) a controlled before-and-after study with 1-year follow-up to ascertain the effect of e-CPG implementation. Patients of FPs who regularly use the e-CPGs will constitute the intervention group; the control group will comprise patients assigned to FPs not regularly using the e-CPG. The outcomes are: (1) suspected and confirmed diagnoses, (2) control of clinical variables, (3) requests for tests and (4) proportions of patients with adequate drug prescriptions.Results This protocol should represent a reproducible process to assess the impact of the implementation of e-CPGs. We anticipate reporting results in late 2013.Conclusion This project will assess the effectiveness of e-CPGs to improve clinical decisions and healthcare procedures in the three disorders analysed. The results will shed light on the use of evidence-based medicine to improve clinical practice of FPs
Parents’ knowledge of and opinions about healthcare laws and technology in primary care
Full text linkPurpose Historically, parents have demonstrated poor understanding of adolescent healthcare laws. This study assessed US parents’ current knowledge and opinions about technology facilitated physician–adolescent communication and applicable laws to enhance transition to adult health care.Methods A brief survey in two low-income academic paediatric clinics asked parents about their knowledge of health care and laws, and their opinions about technology facilitated contact between physicians and adolescents.Results Almost all parents (96.7%) have internet access at home, work or via a mobile device. Only 44.1% approved of having a physician directly contact their child about annual examinations, immunisations or to discuss issues of sexuality. Half (55.4%) were aware that adolescents could receive confidential sexuality information and treatment without parents’ permission. Only one-third (32.2%) approved of a specific technology for direct communication.Conclusions Parents are divided about direct physician–adolescent contact. Future plans to engage adolescents to understand their health will require parental education and involvement on the value of physician–adolescent communication
General practitioners’ views on using a prescribing substitution application (ScriptSwitch®)
Full text linkBackground General practitioners (GPs) are increasingly pressured to prescribe cost-effectively, due to rising prescribing expenditure and limited budgets. A computerised prescribing substitution application (ScriptSwitch®) provides ‘pop-ups’ of cost-saving drug switches at the point of prescribing. It has been used by some United Kingdom local health commissioning organisations as part of a medicines management strategy.Objective To explore GPs’ views on using this prescribing substitution application in their day-to-day clinical practice.Methods Qualitative study employing face-to-face semi-structured interviews, undertaken with a convenience sample of eight GPs across five practices within one local health commissioning area in the North of England. Interviews were audio-recorded, transcribed verbatim and thematically analysed.Results Six themes were identified including: (1) GPs’ acceptance, (2) the application’s impact, (3) external control, (4) disruption to workflow, (5) GP willingness to switch and (6) patient willingness to switch.Conclusions Clinician, patient and organisational factors were identified which were assumed by GPs to affect the engagement with the application. Despite general acceptance of the application to enhance cost-effective prescribing, its impact was perceived to be limited within the context of existing cost-effective prescribing initiatives. The application’s perceived lack of ‘learning’—e.g. offering the same switch despite the prescriber repeatedly declining this—devalued users’ confidence in it. With patients varying in amenability and acceptance to drug switches, GPs appear to experience tension between considering individual patient choice and wider practice population prescribing priorities. Giving GPs more control in adapting the application to their own local prescribing priorities may enhance its success