Informatics in Primary Care (BCS, The Chartered Institute for IT)
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The benefits and risks of structuring and coding of patient histories in the electronic clinical record: protocol for a systematic review
Get PDFBackground Data in medical records have in part been recorded in structured and coded forms for some decades. However, the patient history is as yet largely recorded in an uncoded format. There is a need to consider the optimal balance of use of free text and coded data in the patient history. This review protocol summarises our plans to identify, critically appraise and synthesise evidence relating to approaches taken to introduce structure and coding within patient histories in electronic health records, and the empirically demonstrated benefits and risks of structuring and coding of patient histories in health records.
Objectives To determine how structured and coded data are being introduced for the recording of patient histories, the benefits observed where structuring and coding have been introduced and the risks encountered when structuring and coding are introduced.
Methods We will search the following databases for evidence of published and unpublished material: CINAHL; EMBASE; Google Scholar; IndMED; LILACS; MEDLINE;NIHR; Paklit and PsycINFO.We will, depending on the study designs employed, use the Cochrane EPOC, Joanna Briggs Institute (JBI) and Newcastle_Ottawa instruments to critically appraise studies. Data synthesis is likely to be undertaken using a narrative approach, although meta-analysis will also be undertaken if appropriate and if the data allow this.
Results This protocol should represent a reproducible approach to reviewing the literature regarding structuring and coding in patient histories. We anticipate that we will be able to report results in early 2011.
Conclusion The review should offer increased clarity and direction on the optimal balance between structuring/coding and free text recording of data relating to the patient history
Views of diagnosis distribution in primary care in 2.5 million encounters in Stockholm: a comparison between ICD-10 and SNOMED CT
Get PDFBackground Primary care (PC) in Sweden provides ambulatory and home health care outside hospitals. Within the County Council of Stockholm, coding of diagnoses in PC is mandatory and is done by general practitioners (GPs) using a Swedish primary care version of the International Statistical Classification of Diseases, version 10 (ICD-10). ICD-10 has amono-hierarchical structure. SNOMED CT is poly-hierarchical and belongs to a new generation of terminology systems with attributes (characteristics) that connect concepts in SNOMED CT and build relationships. Mapping terminologies and classifications has been pointed out as a way to attain additional advantages in describing and documenting healthcare data. A poly-hierarchical system supports the representation and aggregation of healthcare data on the basis of specific medical aspects and various levels of clinical detail.
Objective To describe and compare diagnoses and health problems in KSH97-P/ICD-10 and SNOMED CT using primary care diagnostic data, and to explore and exemplify complementary aggregations of diagnoses and health problems generated from a mapping to SNOMED CT.
Methods We used diagnostic data collected throughout 2006 and coded in electronic patient records (EPRs), and a mapping from KSH97-P/ ICD-10 to SNOMED CT, to aggregate the diagnostic data with SNOMED CT defining hierarchical relationship Is a and selected attribute relationships.
Results The chapter level comparison between ICD-10 and SNOMED CT showed minor differences except for infectious and digestive system disorders. The relationships chosen aggregated the diagnostic data to 2861 concepts, showing a multidimensional view on different medical and specific levels and also including clinically relevant characteristics through attribute relationships.
Conclusions SNOMED CT provides a different view of diagnoses and health problems on a chapter level, and adds significant new views of the clinical data with aggregations generated fromSNOMED CT Is a and attribute relationships. A broader use of SNOMED CT is therefore of importance when describing and developing primary care
Providing patients online access to their primary care computerised medical records: a case study of sharing and caring
Get PDFBackground Healthcare systems are struggling to deliver high quality care and constrain costs as more people live longer with a greater burden of disease. Providing patients with access to their records and with practice specific health information may improve the quality of care.
Objective To describe one practice's experience of providing patients with access to their primary care records.
Subjects and setting Approximately 12 200 patients, registered with a semi-rural practice based on two sites, have been offered online access to their records.
Method A description of strategies used to encourage patients to sign up for access to their records. This includes the development of a practice-based web portal regularly updated with health advice.
Results Six percent of the patients in the practice now have access to their records via an explicit consent process. There are over 100 000 viewings of the practice web portal. There have been no problems as a result of providing access. Further developments include developing a new process for patients unable to provide consent in nursing homes.
Conclusions This case study provides a model of how to set up patient access to electronic records
The NHS Information Technology (IT) and Social Care Review 2009: a synopsis
Get PDFBackground England's National Health Service information technology (NHS IT) has been much criticised in a number of major governmental and non-governmental reports. The author was requested to write a review of NHS IT to help formulate policy.
Objective To identify what had worked and should be continued and what was unhelpful and should be dropped from NHS IT.
Method Iterative process of debate with a committee of experts.
Results The theme areas which emerged were:
the central importance of the record to serving individual patient care, and that this should be top prioritydevelopment of systems should be carried out as close as possible to the front-line clinicians who use themstandards and frameworks are useful centralised functions; whereas imposing detailed technical solutions across large geographical areas is unlikely to succeed and should be abandoned.
Conclusions IT should be seen as a clinical tool in health care, developed to meet the needs of patients and front-line clinicians
Complexity in practice: understanding primary care as a complex adaptive system
Get PDFBackground This series summarises new empirical research on quality improvement through case studies of the implementation of clinical governance arrangements in two primary care organisations (PCOs).
Objective To describe a new socio-technical model for effective quality improvement and clinical governance.
Method The research strategy included a literature review, survey, in-depth interviews, participant observation and purposively sampled case studies, conducted within a social constructionist ontological perspective. This approach contextualises the origins of clinical governance and the trend towards collaborative partnerships and federated models of practice, enabled by developments in primary care informatics.
Results People operating within multidisciplinary networks communicate with each other to determine actions that govern their most relevant concerns. Quality improvement in two PCOs is enabled through social interactions between individuals and groups with complex relationships; and information technology (IT) systems which make some aspects of the quality of care explicit.
Conclusions The results are real-world exemplars of the emergent properties of complex adaptive systems. Improving clinical governance in primary care requires both complex social interactions and underpinning informatics. The socio-technical lessons learned from this research should inform future management approaches
Clinical data extraction and feedback in general practice: a case study from Australian primary care
Get PDFBackground Quality improvement in general practice has increasingly focused on the analysis of its clinical databases to guide its improvement strategies. However, general practitioners (GPs) need to be motivated to extract and review their clinical data, and they need skills to do so. This study examines the initial experience of 15 practices in undertaking clinical data extraction and management and the support they were given by their local division of general practice.
Objectives To explore the uptake of data extraction tools in general practice and understand how divisions of general practice can assist with their uptake.
Method This study was conducted within a single division of general practice within the south-eastern suburbs of metropolitan Melbourne, Australia. Self-selected practiceswere offered a data extraction program ('tool') free of charge, with ongoing division support. Practice representatives, either GPs, practice nurses or other practice staff members, were given instructions on how to extract data using the data extraction tool. This was followed by discussion with division staff regarding which clinical areas might be focused on. Division staff systematically recorded information about the experience of the practices and collated their clinical data.
Results Fifteen practices, representing 69 GPs, participated. The practices chose from the following areas to work on as quality improvement activities: improving data entry; inactivating patient files for those who no longer attended the practice; correcting demographic information; diabetes and coronary heart disease management. The recording of data, according to the extraction tool, was found to be incomplete. For example, one-third of the patients who had HbA1cs recorded were on target, i.e. <7%, but nearly half the patients with diabetes did not have HbA1cs recorded at all. About half the patients with coronary heart disease were not reported as taking aspirin and one-third were not on a statin. Nearly half the patients who had attended their practice in the previous 30 months did not have smoking status recorded.
Conclusion While data extraction programs provide GPs with useful tools for examining their clinical databases and identifying clinical practice issues which could be improved, external support, such as that provided by divisions, is helpful. Technical barriers, such as the failure of extraction tools to recognise some data and the failure to comprehensively enter data, are impediments, but in spite of these considerable interest exists in the use of clinical data to improve practice
The NHS Care Record Service (NHS CRS): recommendations from the literature on successful implementation and adoption
Get PDFThe implementation of the National Health Service's Care Record Service (NHS CRS) is the most ambitious information technology innovation ever undertaken in healthcare. This electronic health record system represents the key component of the National Programme for Information Technology. Its implementation is however proving extremely challenging. Building on a recent systematic review of the eHealth literature, we critically reflect on factors that can facilitate the implementation of the NHS CRS and suggest recommendations for a way forward to facilitate implementation efforts
The cognitive impact of research synopses on physicians: a prospective observational analysis of evidence-based summaries sent by email
Get PDFBackground Effective information transfer in primary care is becoming more difficult as the volume of medical information expands. Emailed research synopses are expected to raise awareness and thereby permit more effective information retrieval.
Objective To identify key factors that influence physicians' self-reported cognitive impact of emailed research synopses.
Method In this prospective observational study, research synopses sent by email between 8 September 2006 and 30 May 2007 were analysed. Seven characteristics of synopses (number of characters, research design, study setting, number of types of patient populations studied, number of comparisons, number of outcomes, and number of results) were analysed. Each synopsis was classified as either positive or negative based on physician-reported impacts. Logistic regression analysis was used to evaluate the association between a negative impact and the synopsis' characteristics.
Results A total of 1960 Canadian physicians submitted 159 442 ratings on 193 synopses. Each synopsis was assessed on average by 826.1 physicians. On average there were 28.3 negative ratings per research synopsis, 146.3 neutral, and 656.2 positive. Out of the seven characteristics analysed, only the number of comparisons (odds ratio (OR) = 0.47, 95% confidence interval (CI) = 0.23_0.93) and the number of results (OR = 0.64, 95% CI = 0.44_0.93) had a statistically significant influence on physician ratings. An increase in the number of comparisons (P = 0.03) or the number of results (P = 0.02) decreased the likelihood of a negative impact.
Conclusions Characteristics of the synopses appear to influence cognitive impact, and there might be lexical patterns specific to these factors. Further research is recommended in order to understand the mechanism for the influence of these characteristics
Identifying barriers to implementing a cardiovascular computerised decision support system (CDSS): a Delphi survey
Get PDFPurpose This paper reports an evaluation of stakeholders' perspectives and recommendations for the dissemination of a cardiovascular computerised decision support system (CDSS) program.
Methods A literature review of dissemination models for health information and decision support aids was undertaken to develop a semi-structured interview protocol outlining a range of dissemination models for distribution. A cross section of eight health professionals and three corporate managers were interviewed to provide as broad a view as possible of eight dissemination models. Data were collected via two questionnaires incorporating the Delphi technique. Perspectives from the corporate managers were collected by telephone interview.
Results Financial incentive was the most highly rated disseminationmethod, followed by joint promotion with a professional body and undergraduate medical education. The lowest average rating was for dividing the program into separate components. Participants provided five other suggestions for dissemination. Suggestions for further exploration include the development of a multi-professional model comprising two or more approaches that is piloted and evaluated.
Conclusion Our results provide beneficial information on the potential dissemination of computer decision support systems to health professionals whose uptake of CDSS has not previously been explored. Whether use of a shared decision aid impacts on the decisions made by health professionals working in a team is, however, less evident