Informatics in Primary Care (BCS, The Chartered Institute for IT)
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The feasibility of using UML to compare the impact of different brands of computer system on the clinical consultation
Get PDFBackground UK general practice is universally computerised, with computers used in the consulting room at the point of care. Practices use a range of different brands of computer system, which have developed organically to meet the needs of general practitioners and health service managers. Unified Modelling Language (UML) is a standard modelling and specification notation widely used in software engineering.
Objective To examine the feasibility of UML notation to compare the impact of different brands of general practice computer system on the clinical consultation.
Method Multi-channel video recordings of simulated consultation sessions were recorded on three different clinical computer systems in common use (EMIS, iSOFT Synergy and IPS Vision). User action recorder software recorded time logs of keyboard and mouse use, and pattern recognition software captured non-verbal communication. The outputs of these were used to create UML class and sequence diagrams for each consultation. We compared 'definition of the presenting problem' and 'prescribing', as these tasks were present in all the consultations analysed.
Results Class diagrams identified the entities involved in the clinical consultation. Sequence diagrams identified common elements of the consultation (such as prescribing) and enabled comparisons to be made between the different brands of computer system. The clinician and computer system interaction varied greatly between the different brands.
Conclusions UML sequence diagrams are useful in identifying common tasks in the clinical consultation, and for contrasting the impact of the different brands of computer system on the clinical consultation. Further research is needed to see if patterns demonstrated in this pilot study are consistently displayed
Readiness for electronic health records: comparison of characteristics of practices in a collaborative with the remainder of Massachusetts
Get PDFObjective The Massachusetts e-Health Collaborative (MAeHC) is implementing electronic health records (EHRs) in physicians' offices throughout three diverse communities. This study's objective was to assess the degree to which these practices are representative of physicians' practices statewide.
Design We surveyed all MAeHC physicians (n=464) and compared their responses to those of a contemporaneously surveyed statewide random sample (n=1884).
Measurements The survey questionnaire assessed practice characteristics related to EHR adoption, prevailing office culture related to quality and safety, attitudes toward health information technology (HIT) and perceptions of medical practice.
Results A total of 355 MAeHC physicians (77%) and 1345 physicians from the statewide sample (71%) completed the survey. MAeHC practices resembled practices throughout Massachusetts in terms of practice size, physician age and gender, prevailing financial incentives for quality performance and HIT adoption and available resources for practice expansion. MAeHC practices were more likely to be located in rural areas (9.5% vs 4.4%, P=0.004). Physicians in both samples responded similarly to six of seven self-assessments of the office practice environment for quality and safety. Internet connections were more prevalent among MAeHC practices than across the state (96% vs 83%, P<0.001), but similar proportions of MAeHC physicians (83%) and statewide physicians (86%) used the internet daily (P=0.19).
Conclusion MAeHC is implementing EHRs and health information exchange among communities with physicians and practices that appear generally representative of Massachusetts. The lessons learned from this pilot project should be applicable statewide and to other states with large numbers of physicians in small office practices
Adoption of information technology in primary care physician offices in New Zealand and Denmark, part 4: benefits comparisons
Get PDFThis is the fourth in a series of five papers about the use of computing technology in general practitioner (GP) practices in Denmark and New Zealand. This paper looks at the reasons why physicians use computers with a particular emphasis on the benefits gained from automated medication prescriptions. It includes an assessment of the growth of key applications in New Zealand as well as a comparative summary of the success factors in both countries
Developing a decision support system for tobacco use counselling using primary care physicians
Get PDFBackground Clinical decision support systems (CDSS) have the potential to improve adherence to guidelines, but only if they are designed to work in the complex environment of ambulatory clinics as otherwise physicians may not use them.
Objective To gain input from primary care physicians in designing a CDSS for smoking cessation to ensure that the design is appropriate to a clinical environment before attempts to test this CDSS in a clinical trial. This approach is of general interest to those designing similar systems.
Design and approach We employed an iterative ethnographic process that used multiple evaluation methods to understand physician preferences and workflow integration. Using results from our prior survey of physicians and clinic managers, we developed a prototype CDSS, validated content and design with an expert panel, and then subjected it to usability testing by physicians, followed by iterative design changes based on their feedback. We then performed clinical testing with individual patients, and conducted field tests of the CDSS in two primary care clinics during which four physicians used it for routine patient visits.
Results The CDSS prototype was substantially modified through these cycles of usability and clinical testing, including removing a potentially fatal design flaw. During field tests in primary care clinics, physicians incorporated the final CDSS prototype into their workflow, and used it to assist in smoking cessation interventions up to eight times daily.
Conclusions A multi-method evaluation process utilising primary care physicians proved useful for developing a CDSS that was acceptable to physicians and patients, and feasible to use in their clinical environment
Two nations achieve a high level of primary care information technology (IT) interoperability: an introduction to a series comparing Denmark and New Zealand's IT and health care
Get PDFImproving information management in primary care: the proof is in the pudding
Get PDFGeneralists in both the USA and UK have been at the forefront of improving information management skills, defined here as the abilities required to locate and utilise synthesised information for patient care that is accessible, current, relevant and valid.1 Over the past decade, a variety of interventions designed to improve knowledge and skills relative to information management has been implemented. The goals of training are for learners to demonstrate long-term retention of knowledge and skills gained and to be able to transfer this learning from the context of training into different situations and contexts, such as those encountered in the workplace. Thus, to conclude that learning has taken place, it is essential to study performance after learners have acquired knowledge and skills to see how well those have been retained and generalised.
The current study builds on previous work conducted by the authors that described and evaluated an intervention designed to improve information management knowledge, skills and use of Web based resources by participants from generalist primary care practices. This cross-over study found that both groups of participants - those who received training initially and those who received training later - showed the same improvements when assessed 15 months and three months, respectively, after training. Given the definition of learning as 'relatively permanent', we wondered if these improvements would last.
Participants in the original three phases of the study completed questionnaires during each phase; for the current study they were asked to complete a fourth questionnaire administered 27 and 15 months, respectively, after their original training. All variables showed non-significant differences between participants' scores at the end of the original study, where learning was assessed as having occurred, and the current administration of the questionnaire. Demonstrated long-term retention of knowledge and skills and generalisation to the workplace show that the goals of training have been met
The Single Shared Electronic Patient Record (SSEPR): problems with functionality and governance
Get PDFMeasuring the impact of different brands of computer systems on the clinical consultation: a pilot study
Get PDFBackground UK general practitioners largely conduct computer-mediated consultations. Although historically there were many small general practice (GP) computer suppliers there are now around five widely used electronic patient record (EPR) systems. A new method has been developed for assessing the impact of the computer on doctor_patient interaction through detailed observation of the consultation and computer use.
Objective To pilot the latest version of a method to measure the difference in coding and prescribing times on two different brands of general practice EPR system.
Method We compared two GP EPR systems by observing use in real life consultations. Three video cameras recorded the consultation and screen capture software recorded computer activity.We piloted semi-automated user action recording (UAR) software to record mouse and keyboard use, to overcome limitations in manual measurement. Six trained raters analysed the videos using data capture software to measure the doctor_patient_computer interactions; we used interclass correlation coefficients (ICC) to measure reliability.
Results Raters demonstrated high inter-rater reliability for verbal interactions and prescribing (ICC 0.74 to 0.99), but for measures of computer use they were not reliable. We used UAR to capture computer use and found it more reliable.Coded data entry time varied between the systems: 6.8 compared with 11.5 seconds (P = 0.006). However, the EPR with the shortest coding time had a longer prescribing time: 27.5 compared with 23.7 seconds (P = 0.64).
Conclusion This methodological development improves the reliability of our method for measuring the impact of different computer systems on the GP consultation. UAR added more objectivity to the observationof doctor_computer interactions. If larger studies were to reproduce the differences between computer systems demonstrated in this pilot it might be possible to make objective comparisons between systems
Designing healthcare information technology to catalyse change in clinical care
Get PDFThe gap between best practice and actual patient care continues to be a pervasive problem in our healthcare system. Efforts to improve on this knowledge_performance gap have included computerised disease management programs designed to improve guideline adherence. However, current computerised reminder and decision support interventions directed at changing physician behaviour have had only a limited and variable effect on clinical outcomes. Further, immediate pay-for-performance financial pressures on institutions have created an environmentwhere disease management systems are often created under duress, appended to existing clinical systems and poorly integrated into the existing workflow, potentially limiting their realworld effectiveness. The authors present a review of disease management as well as a conceptual framework to guide the development of more effective health information technology (HIT) tools for translating clinical information into clinical action
