Informatics in Primary Care (BCS, The Chartered Institute for IT)
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The Hayes principles: learning from the national pilot of information technology and core generalisable theory in informatics
Get PDFBackground There has been much criticism of the NHS national programme for information technology (IT); it has been an expensive programme and some elements appear to have achieved little. The Hayes report was written as an independent review of health and social care IT in England.
Objective To identify key principles for health IT implementation which may have relevance beyond the critique of NHS IT.
Outcome We elicit ten principles from the Hayes report, which if followed may result in more effective IT implementation in health care. They divide into patient-centred, subsidiarity and strategic principles. The patient-centred principles are: 1) the patient must be at the centre of all information systems; 2) the provision of patient-level operational data should form the foundation - avoid the dataset mentality; 3) store health data as close to the patient as possible; 4) enable the patient to take a more active role with their health data within a trusted doctor_patient relationship.
The subsidiarity principles set out to balance the local and health-system-wide needs: 5) standardise centrally - patients must be able to benefit from interoperability; 6) provide a standard procurement package and an approved process that ensures safety standards and provision of interoperable systems; 7) authorise a range of local suppliers so that health providers can select the system best meeting local needs; 8) allow local migration from legacy systems, as and when improved functionality for patients is available.
And finally the strategic principles: 9) evaluate health IT systems in terms of measureable benefits to patients; 10) strategic planning of systems should reflect strategic goals for the health of patients/the population.
Conclusions Had the Hayes principles been embedded within our approach to health IT, and in particular to medical record implementation, we might have avoided many of the costly mistakes with the UK national programme. However, these principles need application within the modern IT environment. Closeness to the patient must not be interpreted as physical but instead as a virtual patient-centred space; data will be secure within the cloud and we should dump the vault and infrastructure mentality. Health IT should be developed as an adaptive ecosystem
Recording of adverse events in English general practice: analysis of data from electronic patient records
Get PDFBackground Although the majority of patient contact within the UK's National Health Service (NHS) occurs in primary care, relatively little is known about the safety of care in this setting compared to the safety of hospital care. Measurement methods to detect iatrogenic diseases in primary care require extensive development. Routinely collected data have been successfully applied to develop patient safety indicators in secondary care. Given the availability of electronic health data in primary care, we explored the potential to build adverse event screening tools using computerised medical record systems.
Objective To identify the rate and types of adverse events that might be recorded in primary care through routinely collected data. The findings will inform the development of administrative databased indicators to screen for patient harm arising from primary care contact.
Method Descriptive analyses were performed on data extracted from the clinical information management systems (CIMS) at NHS Brent. The data were explored according to age, sex and ethnicity of patients. Potential or actual adverse events were identified by mapping to three Read code chapters.
Results Records from the calendar year 2007 were available for 69 682 registered patients from 25 practices, consisting of 680 866 consultations. A number of adverse events could be detected through terms contained in certain chapters of the Read code system. These events include injuries due to surgical and medical care (0.72 cases of per 1000 consultations) and adverse drug reactions (1.26 reactions per 1000 consultations). Patterns in the rate of harm among patients fromdifferent ethnic groups tended to reflect the proportion of the respective groups in the overall Brent population, with more injuries occurring among patients of white and Asian ethnicities.
Conclusion These findings suggest that there is scope to develop more accurate and reliable means of safety surveillance in general practice using data obtained from electronic patient records
Getting the signal to noise ratio right in the management of diabetes in primary care: time to stratify risk and focus on outcomes rather than process
Get PDFQuality indicators to measure blood pressure management over a time interval
Get PDFBackground Quality indicators are an important part of the primary care landscape, but focus strongly on point-in-time measurements, such as a patient's last blood pressure (BP) measurement. There is a larger space of possible measurements, including ones that more explicitly consider management over an interval of time.
Objective To determine the predictive abilities of five different quality indicators related to poor BP control.
Methods Data from two New Zealand general practices was analysed on five BP control indicators for patients with diagnosed hypertension: 1) last BP high (>150/90 mmHg); 2) last BP high or no BP measurement; 3) two or more consistently high BP measurements for _90 days; 4) a high BP then lapse of >120 days in BP measurement; and 5) antihypertensive medication possession ratio (MPR) of <80%. Probability that a patient would be identified by each indicator for the nine-month evaluation period ending 31 March 2009 was computed for each indicator one quarter, two quarters and three quarters prior to this date. Associations among the five indicators for the evaluation period were also calculated.
Results Positive predictive value (PPV) of indicators for the same indicator nine months later ranged from 27% (last BP high) to 64% (MPR). PPVs among the five measures with respect to the same time period ranged from 9% to 77% (median 33%).
Conclusions Modest PPVs between indicators suggest the importance of considering multiple indicators to incentivise best management across diverse aspects of BP control
Assessing attitudes toward electronic prescribing adoption in primary care: a survey of prescribers and staff
Get PDFBackground Using survey instruments to assess physicians' attitudes toward electronic health record (EHR) adoption has been an ongoing area of research. No instrument has emerged for widespread use.
Objective We used a theoretically-based, 37-question survey instrument to assess attitudes toward electronic (e-) prescribing adoption in the context of an existing EHR. Our objective was to elicit information to informstrategies to maximise adoption.
Methods The instrument assesses attitudes in four domains: finesse, intent to use technology, perceived usefulness and perceived ease of use. Two additional questions ask about computer use at home and self-assessed computer knowledge. We administered the instrument to prescribers and staff at three primary care sites between 2005 and 2007. Each site represented a unique transition from paper-based or partial (Phase 1) to full (Phase 2) e-prescribing use.
Results Fifty-nine prescribers (82% response) and 58 staff (50% response) completed the survey. At the paper-based site, domain scores increased significantly from Phase 1 to Phase 2 for intent to use technology for both prescribers (4.8 to 5; P<0.04) and staff (4 to 5; P<0.03); and for perceived usefulness for staff (3.7 to 4.6; P<0.02). For prescribers, significant associations (P<0.05) were found between computer use at home for professional use and each domain score; and between computer knowledge and three of the four domains. Selfassessed computer knowledge was consistently rated as intermediate, vs novice or expert.
Conclusions Domain scores improved. Prescribers' self-assessment of computer use at home and computer knowledge predicted attitudes toward adoption. This instrument may be useful in tailoring strategies for successful adoption
Commentary on: Creating a diabetes foot reminder-based registry using the electronic medical record
Get PDFDesktop software to identify patients eligible for recruitment into a clinical trial: using SARMA to recruit to the ROAD feasibility trial
Get PDFBackground Recruitment to trials in primary care is often difficult, particularly when practice staff need to identify study participants with acute conditions during consultations. The Scottish Acute Recruitment Management Application (SARMA) system is linked to general practice electronic medical record (EMR) systems and is designed to provide recruitment support to multi-centre trials by screening patients against trial inclusion criteria and alerting practice staff if the patient appears eligible. For patients willing to learn more about the trial, the software allows practice staff to send the patient's contact details to the research team by text message.
Aim To evaluate the ability of the software to support trial recruitment.
Design of study Software evaluation embedded in a randomised controlled trial.
Setting Five general practices in Tayside and Fife, Scotland.
Methods SARMA was used to support recruitment to a feasibility trial (the Response to Oral Agents in Diabetes, or ROAD trial) looking at users of oral therapy in diabetes. The technical performance of the software and its utility as a recruitment tool were evaluated.
Results The software was successfully installed at four of the five general practices and recruited 11 of the 29 participants for ROAD (other methods were letter and direct invitation by a practice nurse) and had a recruitment return of 35% (11 of 31 texts sent led to a recruitment). Screen failures were relatively low (7 of 31 referred). Practice staff members were positive about the system.
Conclusion An automated recruitment tool can support primary care trials in Scotland and has the potential to support recruitment in other jurisdictions. It offers a low-cost supplement to other trial recruitment methods and is likely to have a much lower screen failure rate than blanket approaches such as mailshots and newspaper campaigns
General practitioners' and nurses' experiences of using computerised decision support in screening for diabetic foot disease: implementing Scottish Clinical Information - Diabetes Care in routine clinical practice
Get PDFObjective The Scottish Care Information - Diabetes Collaboration (SCI-DC) developed a computer- based information system to create a shared electronic record for use by all involved in the care of patients with diabetes mellitus. The objectives of this study were to understand primary care practitioners' views towards screening for diabetic foot disease and their experience of the SCI-DC system.
Method We conducted an exploratory study using qualitativemethods. Semi-structured interviews were audiotape-recorded, transcribed and subjected to thematic analysis. Seven practice nurses and six general practitioners (GPs) with special responsibility for diabetes care inNHS Lothian participated.
Results Primary care clinicians reported good systems in place to screen for diabetes-related complications and to refer their patients to specialist care. Foot ulceration was rarely observed; other diabetesrelated conditions were seen as a higher priority. Most had heard of the SCI-DC foot assessment tool, but its failure to integrate with other primary care information technology (IT) systems meant it was not used in these general practices.
Conclusions Adoption of the SCI-DC foot assessment tool in primary care is not perceived as clinically necessary. Although information recorded by specialist services on SCI-DC is helpful, important structural barriers to its implementation mean the potential benefits associated with its use are unlikely to be realised; greater engagement with primary care priorities for diabetes management is needed to assist its successful implementation and adoption
Informing the development of a national diabetes register in Ireland: a literature review of the impact of patient registration on diabetes care
Get PDFBackground Research suggests that a structured approach to diabetes care can lead to improved patient outcomes. In order to enable greater organisation of care, an electronic patient registration system is required. As part of the development of a national disease register in Ireland, we conducted a review of literature relating to the impact of registration systems on processes and outcomes of care.
Objective The aim of the review is to establish the impact of a registration system on patient care and clinical outcomes. The review explores the role played by a patient registration system, particularly in the primary care setting.
Methods The literature review applied a search strategy to six identified databases. Included studies were those based on original research, including a patient registration system and published between 1999 and 2009 in the English language. Studies including only patients with type 2 diabetes or those with both type 1 and type 2 diabetes were included. Some papers did not specify which type of diabetes was included.
Findings In interventions of structured care which used a patient registration system, modest results for clinical outcomes were demonstrated as well as significant improvements in the processes of care. A patient register was a necessary step along the path towards improved patient clinical outcomes, notably glycated haemoglobin (HbA1c), blood pressure and cholesterol measurements.
Conclusions This review suggested that registers are generally assumed to be an essential element of quality improvement interventions rather than an optional addition. A diabetes register is central to the development of a comprehensive diabetes management system in primary care, which can lead to improvements in the processes and outcomes of diabetes care
Using routine data to conduct small area health needs assessment through observing trends in demographics, recording of common mental health problems (CMHPs) and sickness certificates: longitudinal analysis of a northern and London locality
Get PDFBackground Many practices in the UK have computerised information dating back to the 1990s. These health records provide contemporaneous collected longitudinal data for analysis of health trends and their management in primary care over time.
Objective This study examines the trends in common mental health problems (CMHPs), prescription of antidepressant, anxiolytics and hypnotics and medical certificates over four years to highlight the strengths and pitfalls in trends analysis using primary care data.
Method Relevant clinical information for the first six months of each of the calendar years 2004, 2005, 2006 and 2007 were extracted from participating practices in a London locality and in the North.
Results Between 2004 and 2007 recorded episodes ofCMHPsrose from 33 to 45 per thousand adults in the northern site, and from 19 to 22 in the London site. Prescriptions of antidepressants, anxiolytics and hypnotics rose (from 381.4 to 418 per thousand adults) in the northern site but did not increase in the London site. Medical certificates increased steadily (from 32.7 to 61.6 per thousand adults with a CMHP) in the London site but not in the northern. Recorded episodes of CMHPs and prescriptions of antidepressants, anxiolytics or hypnotics are much higher in the northern site than the London site; the rate of medical certificates per thousand adults with CMHPs in the northern site is more than ten times that in the London site.
Conclusions Demographics, diagnostic and prescribing data are of high quality in primary care, and they could be used more to understand local health needs and inform commissioning decisions