Informatics in Primary Care (BCS, The Chartered Institute for IT)
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Feasibility study and methodology to create a quality-evaluated database of primary care data
Get PDFObjectives To build and test a model for the collection of computerised retrospective primary care data from the UK, and to assess its quality for use in medical and pharmaceutical research.
Design Collection and evaluation of sampled retrospective general practice data recording.
Setting General practices, using the Vision practice management software in the UK.
Main outcome measures Quality indicators of completeness of data recording.
Results Initial audit of 236 practices indicated good recording of prescribing in all practices and a high level of completeness of recording of clinical information in many of the practices.
Conclusions In the group of practices studied, levels of recording were generally assessed to be of sufficient quality to enable a database of quality-evaluated, anonymised primary care records to be created
Current state of information technology use in a US primary care practice-based research network
Get PDFObjectives To examine the current levels of information technology (IT) use in a primary care practicebased research network (PBRN) in order to inform future development of its infrastructure.
Participants Every primary care practitioner who is a member of the Kentucky Ambulatory Network (KAN), as well as the office managers of each practice. Practitioners included family practitioners, general practitioners, nurse practitioners and physician assistants.
Methods A cross-sectional study using two survey instruments: one for office managers and one for practitioners. The office manager survey included questions related to the current state of IT within the practice, plans for enhancement and general IT issues from the perspective of managing a practice. The practitioner survey was designed to measure current IT use and attitudes of primary care practitioners.
Results Response rates for the surveys were 46% (n=68) for the office managers and 51% (n=116) for practitioners. All but one practice had internet access; however, 43% had only dial-up service. Only 21% of practitioners use an electronic medical record (EMR), with dollar cost being the barrier reported most frequently (58%). More than half of the office managers were either ‘somewhat interested’ (45%) or ‘very interested’ (17%) in a low-cost, standardised EMR that was, at the time, to be sponsored by the American Academy of Family Physicians. For practitioners, 71% were either ‘somewhat’ or ‘very’ interested in such a system. Responses to other IT issues are reported.
Conclusion While interest in enabling information technologies was high in KAN, adoption was variable, with use of several key technologies reported as low.The results suggest that research in this network that would be dependent on or enhanced by IT might be impeded and, generally, greater attention should be given to enhancing the IT infrastructure in primary care
Comprehensive computerised primary care records are an essential component of any national health information strategy: report from an international consensus conference
Get PDFIn many countries, primary care informatics has developed to the point that it is recognised as an important enabler of quality improvement; this has not occurred to date in the United States.
With this conference, we aimed to build an international consensus as to whether primary care has unique characteristics that require an informatics subspecialty; and, if so, to establish the role of an international audience of 53 health informaticians, mostly working in primary care.
There was consensus among the participants that primary care has many unique characteristics that justify the existence of an informatics subspecialty: primary care informatics (PCI). The conference identified principles and practical examples of: (1) the effective deployment of information technology to underpin the provision of records, communication and access to information; (2) the need to harness the extensive knowledge base about the practice of PCI; and (3) the contribution of the primary care informatics in improving patient care, and to enable its recognition in the national strategy.
The conference was organised by the primary care informatics working groups of AMIA, EFMI, IMIA and Wonca and took place at Medinfo 2004 in San Francisco. It consisted of two plenary lectures, two small-group work sessions and a panel discussion to summarise the day. It was attended by experimental work and theory that underpins the science of PCI. These principles and examples of their practical application were largely derived from the extensive knowledge base which has been built up in countries that have developed PCI over the last one to two decades
Barriers to proliferation of electronic medical records
Get PDFBackground Error reduction, quality improvement and lowering of cost can all be achieved through electronic integration of healthcare providers. Proliferation of standard electronic health records/ electronic medical records (EHR/EMR) software is an essential precursor of this integration. Proliferation of EHR/EMR software has not occurred in the United States.
Objective To characterise users and non-users of EHR/EMR software, identify potential barriers to proliferation, examine the extent of standardisation across reported EHR/EMR and suggest possible solutions to identified barriers.
Methods We performed a secondary analysis of member survey data collected by the American Academy of Family Physicians (AAFP) in January 2003. The purpose of the survey was to measure interest in an AAFP-sponsored EHR/EMR service. We examined demographic and purchasing data from the survey by gender, population density, region and age. We also counted the number of different software vendors reported by users of an EHR/EMR to assess the number of users with unique software.
Results Of the 35 554 members contacted, 5517 (15.5%) responded.Of those responding, 1297 (23.5%) reported use of an EHR/EMR. Of the members responding, 81% reported interest in EHR/EMR software and 61% reported cost as a major reason for not purchasing it. At least 264 different EHR/ EMR software programs are currently in use. On average, the percentage of respondents with the same EHR/EMR software is 0.4%.
Discussion The number of AAFP members with unique EHR/EMR software is very large. Fragmentation, caused by the use of hundreds of unique systems, is a major barrier to proliferation of these systems. Many of the barriers to proliferation could be mitigated through the tools and techniques available through Free and Open Source Software (FOSS)
Estimating impacts on safety caused by the introduction of electronic medical records in primary care
Get PDFContext Primary care is a highly complex environment in which multiple safety problems have been identified. Each primary care practice can be viewed as a complex adaptive system with its own unique characteristics. The introduction of an electronic medical record (EMR) into such a system represents a significant perturbation that can have multiple unpredictable effects. From a safety standpoint this can mean reduction in some vulnerabilities and increase in others, as well as the introduction of new vulnerabilities that did not exist under the old system.
Objective To estimate the impacts of a new EMR on various aspects of practice function using a Failure Modes and Effects Analysis (FMEA) approach based on the concept of hazard adapted from safety engineering.
Setting/participants Academic rural primary care practice with 32 staff.
Design At baseline, a survey instrument (Perceived Hazard Questionnaire) was used to elicit staff (physicians, nurses and administrative) perceptions of frequency and severity of multiple different primary care errors in 12 different domains in the practice. For each error, a Hazard score was calculated based on the product of frequency and severity. The Hazard scores thus derived were used to prioritise the safety problems within the practice. One year later, after partial implementation of an EMR, the survey was repeated.
Main outcome measures Comparison is made between priorities identified by physicians, nursing and administrative staff before and after EMR implementation.
Results At baseline, a high concordance between priorities identified by physicians, nursing and administrative staff was recorded. This concordance halved after partial implementation of the EMR. The staff perceived decreased hazard in nurse– physician and physician–chart interactions but hazard increased in the already high-hazard domains of physician–patient interaction in the assessment stage and nurse–chart interactions, apart from three other domains.
Conclusions This FMEA-like approach identified changes in practice hazards apparently related to EMR implementation. This in turn can help in targeting pre-existing and new vulnerabilities in primary care practices
Integrating clinical information in NHS Scotland: the role of Scottish Care Information Store
Get PDFA key plank in NHS Scotland’s information management and technology (IM&T) eHealth Strategy is the web-based system known as Scottish Care Information (SCI) Store, which gives primary and secondary care clinicians access to core clinical information. There is one SCI Store in each of the 15 NHS Board areas. At present all GP practices in 11 of these areas have access to SCI Stores for test results. Work is underway to augment the Stores with clinical letters and GP summary data. Strategically, SCI Store is seen as the ubiquitous element in our eHealth Strategy which will allow information to be shared across Scotland in a secure and reliable way
Lessons from the implementation of a near patient anticoagulant monitoring service in primary care
Get PDFObjective To evaluate the implementation of a primary care, nurse-led, near patient anticoagulant monitoring service.
Design Action research workshops, supported by questionnaires and clinical audit, to define the strengths and weaknesses of the service and the effectiveness of the computerised decision support system used to set the dosage of anticoagulant and time interval to the next appointment.
Setting 13 general practices that implemented anticoagulant monitoring in a primary care organisation in south east England.
Participants 18 practice nurses, 72% of whom had over 20 years’ clinical experience; the universitybased investigators and managers from the primary care organisation.
Main outcome measure The nurses felt that the patients preferred the practice-based service, finding it more personal and accessible. However, circumstances arose where the nurse’s intuition had to override the software’s advice. The nurses found it stressful when they were unclear whether their decision making represented acceptable variation or dangerous practice. An audit tool was developed to measure the extent to which there was variation from the software’s recommendation, and patterns of variation emerged. Most evident was that nurses responded to uncertainty by practising cautiously, shortening the interval until the next visit and slightly reducing the recommended dose of warfarin.
Conclusions The group, by sharing their experiences through a structured series of workshops, developed an understanding of when it might be appropriate to vary from the decision support software’s recommendations and how this could be audited. The technological solution modelled on hospital practice proved hard to implement in primary care
Email consultations in general practice
Get PDFBackground Email is an established method of communication in business, leisure and education but not yet health care.
Aim To evaluate an email service enabling communication between patients and their general practice regarding repeat prescriptions, appointment booking and clinical enquiries.
Design Qualitative analysis of interactions and an electronic user survey.
Setting An urban practice in Dundee, Scotland.
Participants 150 patients aged 24 to 85.
Methods We set up a practice facility to allow our patients to use email to book appointments, order repeat prescriptions and consult their general practitioner (GP).
Results Patient satisfaction with the service was very high. Patients specifically commended the practice for setting up a facility to allow communication outside standard working hours and for the ease of ordering repeat prescriptions. Patients were pleased to have a means of seeking their doctor’s comment or opinion without bothering him or her by making and attending a formal face-to-face consultation. Email dialogue was polite, factual, but less formal than standard letters. Staff did not experience any perceptible rise in workload.
Conclusions Use of an email consultation facility worked well within an urban practice, was deemed helpful by patients, and resulted in no apparent increase in GP workload. Our results suggest that there may be an unmet need amongst patients for clinical email services, and that such services may have positive outcomes for patients and practices
Making interactive decision support for patients a reality
Get PDFInteractive decision support applications might help patients to make difficult decisions about their health care. They lie in the context of traditional decision aids, which are known to have effects on a number of patient outcomes, including knowledge and decisional conflict. The problem of restricted uptake with decision aids may be addressed by interactive applications, particularly if associated with health information websites. We suggest that there may be an impact on the doctor–patient relationship and that this presents a number of opportunities. However, there are ethical challenges such as information bias and commercialisation