Informatics in Primary Care (BCS, The Chartered Institute for IT)
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The interpretation of the reasons for encounter ‘cough’ and ‘sadness’ in four international family medicine populations
Full text linkBackground This is a study of the relationships between common reasons for encounter and common diagnoses (episode titles) within episodes of care in family practice populations in four countries.Method Participating family doctors recorded details of all their patient contacts in an EoC structure using the International Classification of Primary Care, including RfEs presented by the patient, and the FDs’ diagnostic labels. The relationships between RfEs and episode titles were studied using Bayesian methods.Results The RfE ‘cough’ is a strong, reliable predictor for the diagnoses ‘cough’, ‘acute bronchitis’, ‘URTI’ and ‘acute laryngitis/tracheitis’ and a less strong, but reliable predictor for ‘sinusitis’, ‘pneumonia’, ‘influenza’, ‘asthma’, ‘other viral diseases’, ‘whooping cough’, ‘chronic bronchitis’, ‘wheezing’ and ‘phlegm’. The absence of cough is a weak but reliable predictor to exclude a diagnosis of ‘cough’, ‘acute bronchitis’ and ‘tracheitis’. Its presence allows strong, reliable exclusion of the diagnoses ‘gastroenteritis’, ‘no disease’ and ‘health promotion/prevention’, and less strong exclusion of ‘adverse effects of medication’. The RfE ‘sadness’ is a strong, reliable predictor for the diagnoses ‘feeling sad/depressed’ and ‘depressive disorder’. It is a less strong, but reliable predictor of a diagnosis of ‘acute stress reaction’. The absence of sadness is a weak but reliable predictor to exclude the symptom diagnosis ‘feeling sad/depressed’. Its presence does not support the exclusion of any diagnosis.Conclusions We describe clinically and statistically significant diagnostic associations observed between the RfEs ‘cough’ and ‘sadness’, presenting as a new problem in family practice, and all the episode titles in ICPC
Technological resources and personnel costs required to implement an automated alert system for ambulatory physicians when patients are discharged from hospitals to home
Full text linkBackground With the adoption of electronic medical records by medical group practices, there are opportunities to improve the quality of care for patients discharged from hospitals. However, there is little guidance for medical groups outside integrated hospital systems to automate the flow of patient information during transitions in care.Objective To describe the technological resources, expertise and time needed to develop an automated system providing information to ambulatory physicians when their patients are discharged from hospitals to home.Development Within a medical group practice, we developed an automated alert system that provides notification of discharges, reminders of the need for follow-up visits, drugs added during inpatient stays, and recommendations for laboratory monitoring of high-risk drugs. We tracked components of the information system required and the time spent by team members. We used USA national averages of hourly wages to estimate personnel costs.Application Critical components of the information system are notifications of hospital discharges through an admission, discharge and transfer registration (ADT) interface, linkage to the group’s scheduling system, access to information on pharmacy dispensing and lab tests, and an interface engine. Total personnel cost was $76,314. Nearly half (47%) was for 614 hours by physicians who developed content, provided overall project management, and reviewed alerts to ensure that only ‘actionable’ alerts would be sent.Conclusion Implementing a system to provide information about hospital discharges requires strong internal informatics expertise, cooperation between facilities and ambulatory providers, development of electronic linkages, and extensive commitment of physician time
Data-modelling and visualisation in chronic kidney disease (CKD): a step towards personalised medicine
Full text linkBackground Personalised medicine involves customising management to meet patients' needs. In chronic kidney disease (CKD) at the population level there is steady decline in renal function with increasing age; and progressiveCKDhas been defined as marked variation from this rate of decline.
Objective To create visualisations of individual patient's renal function and display smoothed trend lines and confidence intervals for their renal function and other important co-variants.
Method Applying advanced pattern recognition techniques developed in biometrics to routinely collected primary care data collected as part of the Quality Improvement in Chronic Kidney Disease (QICKD) trial. We plotted trend lines, using regression, and confidence intervals for individual patients.We also created a visualisation which allowed renal function to be compared with six other covariants: glycated haemoglobin (HbA1c), body mass index (BMI), BP, and therapy. The outputs were reviewed by an expert panel.
Results We successfully extracted and displayed data. We demonstrated that estimated glomerular filtration (eGFR) is a noisy variable, and showed that a large number of people would exceed the 'progressive CKD' criteria. We created a data display that could be readily automated. This display was well received by our expert panel but requires extensive development before testing in a clinical setting.
Conclusions It is feasible to utilise data visualisation methods developed in biometrics to look at CKD data. The criteria for defining 'progressive CKD' need revisiting, as many patients exceed them. Further development work and testing is needed to explore whether this type of data modelling and visualisation might improve patient care
Emergency medicine residents' beliefs about contributing to a Google DocsTM presentation: a survey protocol
Full text linkBackground Web 2.0 collaborative writing technologies have shown positive effects on medical education. One such technology, Google DocsTM, offers collaborative writing applications that improve healthcare students' sharing of information. Since 2008, all graduating residents in emergency medicine in Canada have had access to an online Google DocsTM slideshow designed to help them share summaries of landmark articles in preparation for their Royal College of Physicians and Surgeons of Canada certification exam. A recent evaluation showed that contributions to the presentation were low.
Objective This study will identify the factors that influence residents' decision to contribute or not to contribute to this online collaborative project.
Methods Using the Theory of Planned Behaviour, semistructured interviews will be conducted with 25 graduating emergency medicine residents in Canada. Content from the interviews will be analysed to determine the most important beliefs in relation to the defined behaviour.
Conclusion To our knowledge, this study will be the first to use a theory based framework to identify healthcare trainees' salient beliefs concerning their decision whether to contribute to an online collaborative writing project using Google DocsTM
Evaluation of a prototype health information system using the FITT framework
Full text linkObjectives To demonstrate how the fit between individual, task and technology (FITT) framework1 can be used for health information system evaluation.
Methods We developed a prototype information system with an integrated expert system for headache patients. The FITT framework1 was used to evaluate the prototype health information system.
Results The FITT framework,1 once applied, positively evaluated 199 integrated headache diagnoses, 349 schemes and 698 symptoms. We assessed 528 internet pages to determine to what extent they met the users' expectations. In two study sections, a total of 70 (of 140) participants used the system. In the second section, the intervention group did significantly better (P=0.031) than the control group.
Conclusions The FITT framework1 provided a proper tool for evaluating the prototype health information system and determining which specific set of deltas to focus on in future developments
Feedback and training tool to improve provision of preventive care by physicians using EMRs: a randomised control trial
Full text linkBackground Electronic medical records (EMRs) have the potential to improve the provision of preventive care by allowing general practitioners (GPs) to track and recall eligible patients and record testing for feedback on their service provision.
Objective This study evaluates the effect of an educational intervention and feedback tool designed to teach GPs how to use their EMRs to improve their provision of preventive care.
Methods A randomised controlled trial comparing rates of mammography, Papanicolaou tests, faecal occult blood tests and albumin creatinine ratios one-year pre- and post-intervention was conducted. Nine primary care practices (PCPs) representing over 30 000 patients were paired by practice size and experience of GPs, and randomly allocated to intervention or control groups. Physicians at the four intervention practices received a two-hour feedback session on their current level of preventive care and training to generate eligible patient lists for preventive services from their EMR database.
Results One-year post-intervention results provided no evidence of a difference. The intervention was not a significant predictor of the one-year post-intervention test rates for any of the four tests. On average, the intervention practices increased postintervention test rates on all tests by 16.8%, and control practices increased by 22.3%.
Conclusion The non-significant results may be due to a variety of reasons, including the level of intensity of the educational intervention, the cointervention of a government programme which provided incentives to GPs meeting specific targets for preventive care testing or the level of recording of tests performed in the EMR
SNOMED is coming, and more about using and interacting with technology in primary care
Full text linkComplex adaptive systems (CAS): an overview of key elements, characteristics and application to management theory
Full text linkObjective To identify key elements and characteristics of complex adaptive systems (CAS) relevant to implementing clinical governance, drawing on lessons from quality improvement programmes and the use of informatics in primary care.
Method The research strategy includes a literature review to develop theoretical models of clinical governance of quality improvement in primary care organisations (PCOs) and a survey of PCOs.
Results Complex adaptive system theories are a valuable tool to help make sense of natural phenomena, which include human responses to problem solving within the sampled PCOs. The research commenced with a survey; 76% (n16) of respondents preferred to support the implementation of clinical governance initiatives guided by outputs from general practice electronic health records. There was considerable variation in the way in which consultation data was captured, recorded and organised. Incentivised information sharing led to consensus on coding policies and models of data recording ahead of national contractual requirements. Informatics was acknowledged as a mechanism to link electronic health record outputs, quality improvement and resources. Investment in informatics was identified as a development priority in order to embed clinical governance principles in practice.
Conclusions Complex adaptive system theory usefully describes evolutionary change processes, providing insight into how the origins of quality assurance were predicated on rational reductionism and linearity. New forms of governance do not neutralise previous models, but add further dimensions to them. Clinical governance models have moved from deterministic and 'objective' factors to incorporate cultural aspects with feedback about quality enabled by informatics. The socio-technical lessons highlighted should inform healthcare management
Using primary care prescribing data to improve GP awareness of antidepressant adherence issues
Full text linkBackground Adherence to antidepressant therapy remains a major issue worldwide. Most people with depression are treated in a general practice setting, but many stop taking antidepressants before completing a six-month course as recommended by guidelines.
Objectives To determine antidepressant adherence rates as indicated in primary care prescribing data and pharmacy dispensing data; to demonstrate commonly occurring patterns related to non-adherence, using a prescription visualisation tool we have developed; and to determine whether prescribing data is a good predictor of dispensing based adherence.
Methods We analysed general practice electronic prescribing data for the year ending 31 December 2006 and linked pharmacy dispensing records by National Health Index. We calculated medication adherence for patients starting antidepressants using a six-month evaluation period and a gap-based adherence measure. Patients with a gap of more than 15 days in antidepressant therapy were considered non-adherent. Using a prescription visualisation tool,we described common modes of non-adherence.
Results Out of 2713 patients, 153 satisfied our inclusion criteria. Thirty-nine percent of patients showed poor adherence based on prescribing and 68% showed poor adherence on dispensing. Prescribing based non-adherence had a positive predictive value of 98% (95% CI 92%_99%) and negative predictive value of 51% (CI 47%_52%) for dispensing based non-adherence. Three broad categories of non-adherence were identified: 1) failure to return for re-prescription, 2) failure to maintain adherence despite initial attempts and 3) failure to return for re-prescription in a timely manner.
Conclusions Prescribing data identifies substantial adherence issues in antidepressant therapy. Clinicians should consider adherence issues as part of the overall treatment regime and discuss such issues during consultations
Non-face-to-face consultations and communications in primary care: the role and perspective of general practice managers in Scotland
Full text linkBackground Practice managers play an important role in the organisation and delivery of primary care, including uptake and implementation of technologies. Little is currently known about practice managers' attitudes to the use of information and communication technologies, such as email or text messaging, to communicate or consult with patients.
Objectives To investigate practice managers' attitudes to non-face-to-face consultation/communication technologies in the routine delivery of primary care and their role in the introduction and normalisation of these technologies.
Methods We carried out a mixed-methods study in Scotland, UK. We invited all practice managers in Scotland to take part in a postal questionnaire survey. A maximum variation sample of 20 survey respondents participated subsequently in in-depth qualitative interviews.
Results Practice managers supported the use of new technologies for routine tasks to manage workload and maximise convenience for patients, but a range of contextual factors such as practice list size, practice deprivation area and geographical location affected whether managers would pursue the introduction of these technologies in the immediate future. The most common objections were medico-legal concerns and lack of perceived patient demand.
Conclusion Practice managers are likely to play a central role in the introduction of new consultation/ communication technologies within general practice. They hold varying views on the appropriateness of these technologies, influenced by a complex mix of contextual characteristics.Managers from areas in which the ethos of the practice prioritises personalised care in service delivery are less enthusiastic about the adoption of remote consultation/ communication technologies