Proliferation of electronic health records among obstetrician-gynecologists

OBJECTIVE

To examine the current use of electronic health records (EHRs) and their key subfunctions among obstetrician-gynecologists and compare this trend with other doctors.

METHODS

In this study, we examined responses to a large statewide study of EHR use among Florida physicians practicing in the ambulatory setting. For assessment purposes, we compared obstetrician-gynecologists with other primary care physicians (PCPs) and surgeons with respect to EHR utilization, the availability of key EHR functions, and time since adoption. In addition, we examined adoption intentions among non-EHR users. To compare differences among groups, the chi-square test was utilized with significance level set at P < .05.

RESULTS

A total of 2428 responses (28.4% response rate), of which 454 were from obstetrician-gynecologists, were available for the current study. EHR use among obstetrician-gynecologists (18.3%) was significantly less (P < .001) than among PCPs (25.7%) and surgeons (20.5%). Among EHR users, obstetrician-gynecologists were significantly less likely than PCPs to have the following desirable EHR functions: problem lists (P < .001), medication lists (P < .001), allergy information (P = .014), electronic prescribing of medications (P = .001), electronic order entry (P = .009), electronically available laboratory results (P = .002), electronic connection to pharmacy information (P = .008), preventative service reminders (P < .001), and patient education material (P = .004). Moreover, obstetrician-gynecologists were significantly more likely to have adopted their system within the last 2 years. However, among nonusers, they were not more likely to indicate the intention to adopt EHR.

CONCLUSION

Compared with peers, obstetrician-gynecologists are less likely to be using EHR in their practice. In addition, their systems tend to have fewer medical error preventing functions and fewer basic functions.

Adoption of electronic health records in primary care pediatric practices

BACKGROUND

Electronic health records may improve care delivery. Although professional organizations and federal agencies encourage widespread adoption, no national data are available regarding the penetration of electronic health records into primary care pediatric practices.

METHODS

We used a national mail survey of 1000 randomly selected primary care pediatricians conducted from August to November 2005.

RESULTS

The response rate was 58%. Overall, 21.3% of respondents had an electronic health record in their practice. The likelihood of having an electronic health record increased with practice size. Those in a practice network were more likely to have an electronic health record than those in other settings. Smaller and independent practices were less likely to be considering implementing an electronic health record. Although most electronic health records include some pediatric-specific functionality such as the ability to record immunizations, many do not offer decision support; only approximately one third included immunization prompts or alerts for abnormal laboratory results. Cost was a barrier for nearly all of those without an electronic health record; half of the respondents questioned whether electronic health records lead to improvement in quality of care, and many could not identify an electronic health record that would meet their practice requirements.

CONCLUSIONS

Electronic health records are concentrated in larger and networked pediatric practices. Smaller and independent pediatric practices, the most common types of practice, are unlikely to adopt electronic health records until the cost of implementing and maintaining the systems decreases, developing standards for interoperability are adopted, and electronic health records are widely perceived to improve quality of care by practicing general pediatricians. The lack of decision support in current electronic health records may limit the ability of these tools to improve care delivery.

Evidence for handheld electronic medical records in improving care: a systematic review

Background

Handheld electronic medical records are expected to improve physician performance and patient care. To confirm this, we performed a systematic review of the evidence assessing the effects of handheld electronic medical records on clinical care.

Methods

To conduct the systematic review, we searched MEDLINE, EMBASE, CINAHL, and the Cochrane library from 1966 through September 2005. We included randomized controlled trials that evaluated effects on practitioner performance or patient outcomes of handheld electronic medical records compared to either paper medical records or desktop electronic medical records. Two reviewers independently reviewed citations, assessed full text articles and abstracted data from the studies.

Results

Two studies met our inclusion criteria. No other randomized controlled studies or non-randomized controlled trials were found that met our inclusion criteria. Both studies were methodologically strong. The studies examined changes in documentation in orthopedic patients with handheld electronic medical records compared to paper charts, and both found an increase in documentation. Other effects noted with handheld electronic medical records were an increase in time to document and an increase in wrong or redundant diagnoses.

Conclusion

Handheld electronic medical records may improve documentation, but as yet, the number of studies is small and the data is restricted to one group of patients and a small group of practitioners. Further study is required to determine the benefits with handheld electronic medical records especially in assessing clinical outcomes.

Internet health information use and e-mail access by parents attending a paediatric emergency department

OBJECTIVES

To document internet access and health related usage patterns by families of children in a large paediatric emergency department (ED), and to discover if parents want the internet to become a tool for transferring medical test results.

METHODS

This was a pre-tested, 21 item, interview conducted with parents at the paediatric ED in Toronto over 3 months. Descriptive statistics and frequency distributions were calculated and variables associated with parents wishing to access results electronically were examined.

RESULTS

In total, 950 parents completed the interview (93%), of whom 87% reported routine internet access, 75% reported having an e-mail account, and 60% accessed their e-mail once or more a day. Over half (56%) reported searching the internet for health related information, with 8.5% of these searching immediately preceding their visit. Nearly three quarters (73%) indicated they would like to receive an e-mail containing the results of tests conducted in the ED; 66% of all respondents and 89% of those with e-mail indicated that they would like their child's primary care provider to receive information electronically.

CONCLUSION

The majority of families have internet access and most want to receive medical information electronically and to send it to the primary provider. The vast use of internet for health related information emphasises the need to guide parents regarding reliable resources online, possibly as part of their ED visit.

Use of electronic medical records in Oman and physician satisfaction

The Electronic Medical Record (EMR) is a computerized record of clinical, demographic and management information. EMR is an enabling technology that allows physicians to utilize quality improvement processes in the practice of medicine. Oman is one of the Middle Eastern Countries that has implemented an integrated electronic hospital information system at government health care institutions. The system was first applied in primary health care centers and then implemented in hospitals. Survey research highlights factors that affect physician satisfaction and utilizing of this new technology in a hospital setting. Outcome survey data suggests areas for improvement. Specific concerns about patient confidentiality are discussed as well as quality improvement in patient care.

Use of computerized medical records in home health and hospice agencies: United States, 2000

OBJECTIVE

The use of information technology (IT), such as computerized medical records (CMR), has been proposed as a method for increasing the efficiency of delivered services, raising the level of the quality of care provided, and decreasing the number of medical errors. Research on IT and CMRs in health care has focused primarily on hospitals and physicians' offices, and there currently exists no nationally representative information for home health and hospice agencies. This report provides the first nationally representative estimates of the prevalence of CMR use in home health and hospice agencies in the United States in 2000.

METHODS

Data are from the 2000 National Home and Hospice Care Survey. Data presented include estimates of home health and hospice agencies that are currently using or planning to use a CMR in the next year. CMR use is also presented by agency characteristics.

RESULTS AND CONCLUSIONS

Approximately 32% of all agencies were using a CMR. Nearly one-third of home health agencies (32.1%), one-fifth of hospice agencies (18.6%), and two-fifths of mixed-type agencies (offering both services) (40.3%) reported using a CMR. Number of current active patients and provision of "high technology" services (e.g., respiratory, intravenous, or enterostomal therapy) were significantly associated with use of CMRs. While 23.0% of agencies with 50 or fewer patients reported use of a CMR, the proportion almost doubled to 44.8%, among agencies with 100 or more patients. Over one-third (34.8%) of agencies that provided high technology services reported using a CMR, compared with one-fifth (20.8%) of agencies that did not provide high technology services. No other agency characteristics were found to have a significant relationship with CMR use.

Epidemiology and treatment of neuropathic pain: The UK primary care perspective

The true incidence of neuropathic pain is unknown, but it is believed to be under-diagnosed and treated inadequately, despite the availability of drugs with proven efficacy. Our objective was to report the epidemiology and drug treatment of neuropathic pain as managed by UK primary care physicians. A descriptive analysis of the epidemiology of incident post-herpetic neuralgia (n=12,386); trigeminal neuralgia (8268); phantom limb pain (451) and painful diabetic neuropathy (4719) and prescription treatment at diagnosis from computerised UK general practice records (GPRD): January 1992 to April 2002. Incidences per 100,000 person years observation of 40 (95% CI 39-41) for post-herpetic neuralgia, 27 (26-27) for trigeminal neuralgia, 1 (1-2) for phantom limb pain and 15 (15-16) for painful diabetic neuropathy are reported, with rates decreasing over time for phantom limb pain and post-herpetic neuralgia and increasing for painful diabetic neuropathy. Drugs were initiated at first diagnosis record for 46-66% of conditions, usually one item, with antidepressants included in 30% of prescriptions, anticonvulsants in 20% and opioid analgesics in 20%. The most commonly prescribed items were the same across conditions; amitriptyline, carbamazepine, coproxamol, codydramol and codeine+paracetamol. Carbamazepine was prescribed to 58% of the trigeminal neuralgia cohort. In 2600 patients followed to stable therapy, there was a median of one to two drug changes. We provide the primary care managed incidence of four neuropathic pain conditions. For commonly prescribed treatments, changes in therapy are less frequent when initial therapy was with antidepressants or anticonvulsants rather than conventional analgesics.

Clinical computing in general dentistry

OBJECTIVE

Measure the adoption and utilization of, opinions about, and attitudes toward clinical computing among general dentists in the United States.

DESIGN

Telephone survey of a random sample of 256 general dentists in active practice in the United States.

MEASUREMENTS

A 39-item telephone interview measuring practice characteristics and information technology infrastructure; clinical information storage; data entry and access; attitudes toward and opinions about clinical computing (features of practice management systems, barriers, advantages, disadvantages, and potential improvements); clinical Internet use; and attitudes toward the National Health Information Infrastructure.

RESULTS

The authors successfully screened 1,039 of 1,159 randomly sampled U.S. general dentists in active practice (89.6% response rate). Two hundred fifty-six (24.6%) respondents had computers at chairside and thus were eligible for this study. The authors successfully interviewed 102 respondents (39.8%). Clinical information associated with administration and billing, such as appointments and treatment plans, was stored predominantly on the computer; other information, such as the medical history and progress notes, primarily resided on paper. Nineteen respondents, or 1.8% of all general dentists, were completely paperless. Auxiliary personnel, such as dental assistants and hygienists, entered most data. Respondents adopted clinical computing to improve office efficiency and operations, support diagnosis and treatment, and enhance patient communication and perception. Barriers included insufficient operational reliability, program limitations, a steep learning curve, cost, and infection control issues.

CONCLUSION

Clinical computing is being increasingly adopted in general dentistry. However, future research must address usefulness and ease of use, workflow support, infection control, integration, and implementation issues.

Qualitative assessment of the International Classification of Functioning, Disability, and Health with respect to the desiderata for controlled medical vocabularies

BACKGROUND

The International Classification of Functioning, Disability, and Health (ICF), a classification system published in 2001 by the World Health Organization (WHO), provides a common language and framework for describing functional status information (FSI) in health records.

METHODS

Informed by ongoing research in coding FSI in patient records, this paper qualitatively assesses the ICF framework with respect to the desiderata for controlled medical vocabularies, an enumerated a list of desirable qualities for controlled medical vocabularies proposed by Cimino [J.J. Cimino, Desiderata for controlled medical vocabularies in the twenty-first century, Meth. Inform. Med. 37 (1998) 394-403].

RESULTS

The ICF satisfies 5 of the 12 desiderata. Five points were not satisfied and two points could not be evaluated.

CONCLUSION

The ICF is a rich source of relevant terms, concepts, and relationships, but it was not developed in consideration of requirements for formal terminologies. Therefore, it could serve as a base from which to develop a formal terminology of functioning and disability. This assessment is a key next step in the development of the ICF as a sensitive, universal measure of functional status.

A computer-based medical record system and personal digital assistants to assess and follow patients with respiratory tract infections visiting a rural Kenyan health centre

Background

Clinical research can be facilitated by the use of informatics tools. We used an existing electronic medical record (EMR) system and personal data assistants (PDAs) to assess the characteristics and outcomes of patients with acute respiratory illnesses (ARIs) visiting a Kenyan rural health center.

Methods

We modified the existing EMR to include details on patients with ARIs. The EMR database was then used to identify patients with ARIs who were prospectively followed up by a research assistant who rode a bicycle to patients' homes and entered data into a PDA.

Results

A total of 2986 clinic visits for 2009 adult patients with respiratory infections were registered in the database between August 2002 and January 2005; 433 patients were selected for outcome assessments. These patients were followed up in the villages and assessed at 7 and 30 days later. Complete follow-up data were obtained on 381 patients (88%) and merged with data from the enrollment visit's electronic medical records and subsequent health center visits to assess duration of illness and complications. Symptoms improved at 7 and 30 days, but a substantial minority of patients had persistent symptoms. Eleven percent of patients sought additional care for their respiratory infection.

Conclusion

EMRs and PDA are useful tools for performing prospective clinical research in resource constrained developing countries.

Electronic medical record use and physician-patient communication: an observational study of Israeli primary care encounters

OBJECTIVES

Within the context of medical care there is no greater reflection of the information revolution than the electronic medical record (EMR). Current estimates suggest that EMR use by Israeli physicians is now so high as to represent an almost fully immersed environment. This study examines the relationships between the extent of electronic medical record use and physician-patient communication within the context of Israeli primary care.

METHODS

Based on videotapes of 3 Israeli primary care physicians and 30 of their patients, the extent of computer use was measured as number of seconds gazing at the computer screen and 3 levels of active keyboarding. Communication dynamics were analyzed through the application of a new Hebrew translation and adaptation of the Roter Interaction Analysis System (RIAS).

RESULTS

Physicians spent close to one-quarter of visit time gazing at the computer screen, and in some cases as much as 42%; heavy keyboarding throughout the visit was evident in 24% of studied visits. Screen gaze and levels of keyboarding were both positively correlated with length of visit (r = .51, p < .001 and F(2,27) = 2.83, p < .08, respectively); however, keyboarding was inversely related to the amount of visit dialogue contributed by the physician (F(2,27) = 4.22, p < .02) or the patient (F(2,27) = 3.85, p < .05). Specific effects of screen gaze were inhibition of physician engagement in psychosocial question asking (r = -.39, p < .02) and emotional responsiveness (r = -.30, p < .10), while keyboarding increased biomedical exchange, including more questions about therapeutic regimen (F(2,27) = 4.78, p < .02) and more patient education and counseling (F(2,27) = 10.38, p < .001), as well as increased patient disclosure of medical information to the physician (F(2,27) =3.40, p < .05). A summary score reflecting overall patient-centered communication during the visit was negatively correlated with both screen gaze and keyboarding (r = -.33, p < .08 and F(2,27) = 3.19, p < .06, respectively).

DISCUSSION

The computer has become a 'party' in the visit that demanded a significant portion of visit time. Gazing at the monitor was inversely related to physician engagement in psychosocial questioning and emotional responsiveness and to patient limited socio-emotional and psychosocial exchange during the visit. Keyboarding activity was inversely related to both physician and patient contribution to the medical dialogue. Patients may regard physicians' engrossment in the tasks of computing as disinterested or disengaged. Increase in visit length associated with EMR use may be attributed to keyboarding and computer gazing.

CONCLUSIONS

This study suggests that the way in which physicians use computers in the examination room can negatively affect patient-centered practice by diminishing dialogue, particularly in the psychosocial and emotional realm. Screen gaze appears particularly disruptive to psychosocial inquiry and emotional responsiveness, suggesting that visual attentiveness to the monitor rather than eye contact with the patient may inhibit sensitive or full patient disclosure.

PRACTICAL IMPLICATIONS

We believe that training can help physicians optimize interpersonal and educationally effective use of the EMR. This training can assist physicians in overcoming the interpersonal distancing, both verbally and non-verbally, with which computer use is associated. Collaborative reading of the EMR can contribute to improved quality of care, enhance the decision-making process, and empower patients to participate in their own care.

[Quality of data transfer in perinatal data -- experience of a centre]

BACKGROUND

A sufficient quality of data transfer from written patient records to electronic data processing is a precondition for a reasonable usage of perinatal data. However the quality of data transfer of the almost 200 characteristics routinely recorded at each delivery is largely unknown.

MATERIALS AND METHODS

The quality of data transfer of 33 characteristics in 350 randomly selected singleton deliveries of the women's clinic of the University of Marburg from 2002 and 2003 has been checked by comparing electronically recorded data with the original written documents.

RESULTS

The quality of data transfer of the tested characteristics turned out to be heterogeneous. Characteristics necessary to calculate quality indicators show a very high data quality when excluding the characteristic attendance of a paediatrician. The quality of data transfer of characteristics denoting time as well as blood gas analysis are heterogeneous. Characteristics with a low quality of data transfer are associated with ambiguous instructions, the fact that the coding obstetrician is not dealing in the first instance with the item being encoded and the characteristics are of no immediate relevance for delivery, as well as difficult application of the software.

CONCLUSION

The quality of data transfer of the characteristics collected in perinatal surveys needs to be validated. The type and amount of data being collected should be reassessed considering improvements of data quality.

[Data collection for quality assurance in neonatology: how do physicians compare to documentation specialists?]

BACKGROUND

The quality of data collected for the German nationwide quality assurance program in neonatology is currently unknown. The aim of this study was to compare the quality of data collected by resident physicians with the quality of similar data collected by a dedicated research nurse.

METHODS

Data for the German national quality assurance program in neonatology, derived from a cohort of 128 premature newborns with a birth weight <1500 g and/or a gestational age of <30 weeks born in the year 2003, were collected by residents taking care on these patients, and separately by a dedicated research nurse for the European Neonatal Network (EuroNeoNet). The data set collected for both networks included 44 common data items. The two data sets were compared, and any disagreement was double-checked using the chart of the baby to clarify which of the data entries was wrong. Furthermore, as data items are not equally important, a weighted analysis of all mistakes was performed.

RESULTS

We found wrong data in 108/128 (84 %) of the data sets collected by the residents, and in 43/128 (34 %) of the data sets collected by the research nurse (p < 0.001). The weighted analysis revealed that residents made more mistakes in 30/44 of collected data items, whereas the research nurse did worse only in 1/44 data items.

CONCLUSION

This study shows that the quality of data obtained by our resident physicians was worse than the quality of data obtained by our dedicated research nurse.

A reporting system for the assessment of chemotherapy toxicity

PURPOSE

Toxicity may distress patients and cause delay or a discontinuance of scheduled chemotherapies. A key issue is to create a reporting system in order to assess toxicities and also evaluate treatments.

METHODS

In the Oncology Unit 3,000 intravenous chemotherapies are administered each year, mostly in the day hospital. In summer 2002, oncologists and pharmacists agreed to assess myelosuppression and gastrointestinal toxicity of grades 3 and 4. Pharmacists designed a form and a database in order to collect toxicity data for every patient. The oncologist records type and grade of toxicity (according to the NCI CTC) on the patient chart before chemotherapy commences. During the validation of computerized prescriptions the pharmacist collects data about possible toxicities of every grade.

RESULTS

From August-October 2002, 675 chemotherapies were administered. Seventy-two patients developed GI toxicity at various grades, nine of grade 3 and two of grade 4. Regimens with fluorouracil, carboplatin, cisplatin and oxaliplatin were highly involved in GI toxicity. Eighty-seven patients developed myelosuppression, two of grade 3 and 33 of grade 4. Regimens with epirubicin, cyclophosphamide, paclitaxel, cisplatin and carboplatin were highly involved in myelosuppression. After the first report, oncologists and pharmacists decided to stop collecting data in order to improve the reporting system and to plan regular meetings.

CONCLUSIONS

A reliable reporting system is a valuable tool for oncologists to manage toxicity and to evaluate chemotherapy regimens. Assessing chemotherapy toxicity is a good opportunity for pharmacists to take part in preventing toxicity and reducing patient's discomfort.

Implementing pediatric growth charts into an electronic health record system

Electronic health record (EHR) systems are increasingly being adopted in pediatric practices; however, requirements for integrated growth charts are poorly described and are not standardized in current systems. The authors integrated growth chart functionality into an EHR system being developed and installed in a multispecialty pediatric clinic in an academic medical center. During a three-year observation period, rates of electronically documented values for weight, stature, and head circumference increased from fewer than ten total per weekday, up to 488 weight values, 293 stature values, and 74 head circumference values (p<0.001 for each measure). By the end of the observation period, users accessed the growth charts an average 175 times per weekday, compared to 127 patient visits per weekday to the sites that most closely monitored pediatric growth. Because EHR systems and integrated growth charts can manipulate data, perform calculations, and adapt to user preferences and patient characteristics, users may expect greater functionality from electronic growth charts than from paper-based growth charts.

Invasive meningococcal disease in Austria 2002: assessment of completeness of notification by comparison of two independent data sources

AIM OF THE STUDY

The notified incidence of meningococcal disease in European countries varies from <1 case per 100,000 inhabitants to approximately 7 cases per 100,000. Assessing the true burden of disease is important for setting priorities in health services and for estimating the benefit of interventions such as vaccination. Completeness and timeliness of reporting is also essential for the early recognition of outbreaks. The objective of this study was to assess the completeness of surveillance data on invasive meningococcal disease in Austria at the National Reference Center for Meningococci for the year 2002.

METHODS

The data stored at the reference center was compared with an independent database containing the main diagnosis documented in the obligatory hospital discharge dataset of all Austrian hospitals (coded in ICD-10 since 2001). All mismatches were reviewed in order to exclude possible errors and identify true cases of meningococcal disease that had not been reported to the reference center. The number of cases not recorded by either data source was estimated using the capture-recapture method.

RESULTS

The first comparison of the two data sources identified 50 cases not registered at the national reference center. Screening of the ICD codes from these 50 patients through the hospitals reduced the number of under-reported cases to 10, of which 6 showed symptoms compatible with meningococcal disease, although microbiological confirmation was missing. Re-evaluation of the case histories of these 6 patients by a clinical expert for meningococcal disease identified them as probable cases. The main reason for correction of the diagnosis in 27 cases was an obvious coding error: these patients had been treated in hospitals for illnesses not related to meningococcal disease. In 72 cases, the two databases were in agreement. Eleven cases of meningococcal disease were notified solely to the national reference center. Addition of the newly recognized cases of invasive meningococcal disease increased the total number of cases from 83 (incidence, 1.03/100,000) to 93 (incidence, 1.16/100,000). Estimation of the "true" number of cases of meningococcal disease, using the capture-recapture method, gave a final total of 95 cases (95% CI, 93-98) and an incidence of 1.18/100,000. The completeness (sensitivity) of the original notification at the national reference center was therefore 87.4% (83 of 95 cases).

CONCLUSION

All probable cases of meningococcal disease, even those (still) lacking microbiological confirmation, should be reported to the public health authorities as soon as possible, in order to ensure the necessary prompt prophylactic action (e.g., chemoprophylaxis).

Drivers of electronic medical record adoption among medical groups

BACKGROUND

Use of electronic medical records (EMRs) in health care organizations can reduce medical errors and improve quality of care through physicians' increased use of evidence-based patient care processes. However, only 20%-25% of physician organizations have adopted EMRs. A study was undertaken to determine the characteristics of primary care medical groups that distinguish EMR adopter from nonadopter organizations.

METHODS

A quantitative nationwide survey was undertaken of all primary care medical groups in the United States with 20 or more physicians; data were collected on 738 medical groups (70% response rate).

RESULTS

Fewer than one-third of the medical groups reported having either patients' medical records or progress notes in an EMR. Large organizations with relatively fewer practice locations were more likely to adopt an EMR.

DISCUSSION

Large medical groups are more likely to have the financial and human resources necessary to overcome barriers to the adoption of an EMR. Knowing the influence of the other organizational characteristics on EMR adoption will help prepare organizational leaders for the complicated process of achieving consensus among physicians and others in medical groups on the expenditure of funds and other resources to acquire an EMR. Financial incentives for all medical groups will help drive EMR adoption, but financial and technical assistance aimed specifically at smaller groups is particularly warranted. Widespread adoption of EMR among medical groups will take time.