Electronic health records, adoption, quality of care, legal and privacy issues and their implementation in emergency departments

Is innovative workforce planning software the solution to NHS staffing and cost crisis? An exploration of the locum industry

BACKGROUND

Workforce planning in the British healthcare system (NHS) is associated with significant costs of agency staff employment. The introduction of a novel software (ABG) as a 'people to people economy' (P2PE) platform for temporary staff recruitment offers a potential solution to this problem. Consequently, the focus of this study was twofold - primarily to explore the locum doctor landscape, and secondarily to evaluate the implementation of P2PE in the healthcare industry.

METHODS

Documentary analysis was conducted alongside thirteen semi structured interviews across five informant groups: two industry experts, two healthcare consultants, an executive director, two speciality managers and six doctors.

RESULTS

We found that locum doctors are indispensable to covering workforce shortages, yet existing planning and recruitment practices were found to be inefficient, inconsistent and lacking transparency. Contrarily, mobile-first solutions such as ABG seem to secure higher convenience, better transparency, cost and time efficiency. We also identified factors facilitating the successful diffusion of ABG; these were in line with classically cited characteristics of innovation such as trialability, observability, and scope for local reinvention. Drawing upon the concept of value-based healthcare coupled with the analysis of our findings led to the development of Information Exchange System (IES) model, a comprehensive framework allowing a thorough comparison of recruitment practices in healthcare.

CONCLUSION

IES was used to evaluate ABG and its diffusion against other recruitment methods and ABG was found to outperform its alternatives, thus suggesting its potential to solve the staffing and cost crisis at the chosen hospital.

Efficiency of Emergency Physicians: Insights from an Observational Study using EHR Log Files

OBJECTIVE

With federal mandates and incentives since the turn of this decade, electronic health records (EHR) have been widely adopted and used for clinical care. Over the last several years, we have seen both positive and negative perspectives on its use. Using an analysis of log files of EHR use, we investigated the nature of EHR use and their effect on an emergency department's (ED) throughput and efficiency.

METHODS

EHR logs of time spent by attending physicians on EHR-based activities over a 6-week period (n = 2,304 patients) were collected. For each patient encounter, physician activities in the EHR were categorized into four activities: documentation, review, orders, and navigation. Four ED-based performance metrics were also captured: door-to-provider time, door-to-doctor time, door-to-disposition time, and length of stay (LOS). Association between the four EHR-based activities and corresponding ED performance metrics were evaluated.

RESULTS

We found positive correlations between physician review of patient charts, and door-to-disposition time (r = 0.43, p < 0.05), and with LOS (r = 0.48, p < 0.05). There were no statistically significant associations between any of the other performance metrics and EHR activities.

CONCLUSION

The results highlight that longer time spent on reviewing information on the EHR is potentially associated with decreased ED throughput efficiency. Balancing these competing goals is often a challenge of physicians, and its implications for patient safety is discussed.

Applying advanced analytics to guide emergency department operational decisions: A proof-of-concept study examining the effects of boarding

BACKGROUND

Emergency Department (ED) leaders are increasingly confronted with large amounts of data with the potential to inform and guide operational decisions. Routine use of advanced analytic methods may provide additional insights.

OBJECTIVES

To examine the practical application of available advanced analytic methods to guide operational decision making around patient boarding.

METHODS

Retrospective analysis of the effect of boarding on ED operational metrics from a single site between 1/2015 and 1/2017. Times series were visualized through decompositional techniques accounting for seasonal trends, to determine the effect of boarding on ED performance metrics and to determine the impact of boarding "shocks" to the system on operational metrics over several days.

RESULTS

There were 226,461 visits with the mean (IQR) number of visits per day was 273 (258-291). Decomposition of the boarding count time series illustrated an upward trend in the last 2-3 quarters as well as clear seasonal components. All performance metrics were significantly impacted (p<0.05) by boarding count, except for overall Press Ganey scores (p<0.65). For every additional increase in boarder count, overall length-of-stay (LOS) increased by 1.55min (0.68, 1.50). Smaller effects were seen for waiting room LOS and treat and release LOS. The impulse responses indicate that the boarding shocks are characterized by changes in the performance metrics within the first day that fade out after 4-5days.

CONCLUSION

In this study regarding the use of advanced analytics in daily ED operations, time series analysis provided multiple useful insights into boarding and its impact on performance metrics.

E-health in Switzerland: The laborious adoption of the federal law on electronic health records (EHR) and health information exchange (HIE) networks

Within the framework of a broader e-health strategy launched a decade ago, in 2015 Switzerland passed a new federal law on patients' electronic health records (EHR). The reform requires hospitals to adopt interoperable EHRs to facilitate data sharing and cooperation among healthcare providers, ultimately contributing to improvements in quality of care and efficiency in the health system. Adoption is voluntary for ambulatories and private practices, that may however be pushed towards EHRs by patients. The latter have complete discretion in the choice of the health information to share. Moreover, careful attention is given to data security issues. Despite good intentions, the high institutional and organisational fragmentation of the Swiss healthcare system, as well as the lack of full agreement with stakeholders on some critical points of the reform, slowed the process of adoption of the law. In particular, pilot projects made clear that the participation of ambulatories is doomed to be low unless appropriate incentives are put in place. Moreover, most stakeholders point at the strategy proposed to finance technical implementation and management of EHRs as a major drawback. After two years of intense preparatory work, the law entered into force in April 2017.

From Population Databases to Research and Informed Health Decisions and Policy

Background

In the era of big data, the medical community is inspired to maximize the utilization and processing of the rapidly expanding medical datasets for clinical-related and policy-driven research. This requires a medical database that can be aggregated, interpreted, and integrated at both the individual and population levels. Policymakers seek data as a lever for wise, evidence-based decision-making and information-driven policy. Yet, bridging the gap between data collection, research, and policymaking, is a major challenge.

The model

To bridge this gap, we propose a four-step model: (A) creating a conjoined task force of all relevant parties to declare a national program to promote collaborations; (B) promoting a national digital records project, or at least a network of synchronized and integrated databases, in an accessible transparent manner; (C) creating an interoperative national research environment to enable the analysis of the organized and integrated data and to generate evidence; and (D) utilizing the evidence to improve decision-making, to support a wisely chosen national policy. For the latter purpose, we also developed a novel multidimensional set of criteria to illuminate insights and estimate the risk for future morbidity based on current medical conditions.

Conclusion

Used by policymakers, providers of health plans, caregivers, and health organizations, we presume this model will assist transforming evidence generation to support the design of health policy and programs, as well as improved decision-making about health and health care, at all levels: individual, communal, organizational, and national.

eHealth in integrated care programs for people with multimorbidity in Europe: Insights from the ICARE4EU project

INTRODUCTION

Care for people with multimorbidity requires an integrated approach in order to adequately meet their complex needs. In this respect eHealth could be of help. This paper aims to describe the implementation, as well as benefits and barriers of eHealth applications in integrated care programs targeting people with multimorbidity in European countries, including insights on older people 65+.

METHODS

Within the framework of the ICARE4EU project, in 2014, expert organizations in 24 European countries identified 101 integrated care programs based on selected inclusion criteria. Managers of these programs completed a related on-line questionnaire addressing various aspects including the use of eHealth. In this paper we analyze data from this questionnaire, in addition to qualitative information from six programs which were selected as 'high potential' for their innovative approach and studied in depth through site visits.

RESULTS

Out of 101 programs, 85 adopted eHealth applications, of which 42 focused explicitly on older people. In most cases Electronic Health Records (EHRs), registration databases with patients' data and tools for communication between care providers were implemented. Percentages were slightly higher for programs addressing older people. eHealth improves care integration and management processes. Inadequate funding mechanisms, interoperability and technical support represent major barriers.

CONCLUSION

Findings seems to suggest that eHealth could support integrated care for (older) people with multimorbidity.

The effect of a test ordering software intervention on the prescription of unnecessary laboratory tests - a randomized controlled trial

Background

The way software for electronic health records and laboratory tests ordering systems are designed may influence physicians’ prescription. A randomised controlled trial was performed to measure the impact of a diagnostic and laboratory tests ordering system software modification.

Methods

Participants were family physicians working and prescribing diagnostic and laboratory tests.

The intervention group had a modified software with a basic shortcut menu changes, where some tests were withdrawn or added, and with the implementation of an evidence-based decision support based on United States Preventive Services Task Force (USPSTF) recommendations. This intervention group was compared with usual software (control group).

The outcomes were the number of tests prescribed from those: withdrawn from the basic menu; added to the basic menu; marked with green dots (USPSTF’s grade A and B); and marked with red dots (USPSTF’s grade D).

Results

Comparing the monthly average number of tests prescribed before and after the software modification, from those tests that were withdrawn from the basic menu, the control group prescribed 33.8 tests per 100 consultations before and 30.8 after (p = 0075); the intervention group prescribed 31.3 before and 13.9 after (p < 0001). Comparing the tests prescribed between both groups during the intervention, from those tests that were withdrawn from the basic menu, the intervention group prescribed a monthly average of 14.0 vs. 29.3 tests per 100 consultations in the control group (p < 0.001). From those tests that are USPSTF’s grade A and B, intervention group prescribed 66.8 vs. 74.1 tests per 100 consultations in the control group (p = 0.070). From those tests categorised as USPSTF grade D, the intervention group prescribed an average of 9.8 vs. 11.8 tests per 100 consultations in the control group (p = 0.003).

Conclusions

Removing unnecessary tests from a quick shortcut menu of the diagnosis and laboratory tests ordering system had a significant impact and reduced unnecessary prescription of tests.

The fact that it was not possible to perform the randomization at the family physicians’ level, but only of the computer servers is a limitation of our study. Future research should assess the impact of different tests ordering systems during longer periods.

Trial registration

ISRCTN45427977, May 1^st 2014 (retrospectively registered).

Electronic Health Records and Meaningful Use in Local Health Departments: Updates From the 2015 NACCHO Informatics Assessment Survey

This study provides an updated view using the most recent data to identify the primary storage of clinical data, status of data for meaningful use, and characteristics associated with the implementation of electronic health records in local health departments.

Electronic health records (EHRs) are evolving the scope of operations, practices, and outcomes of population health in the United States. Local health departments (LHDs) need adequate health informatics capacities to handle the quantity and quality of population health data.

Feasibility of extracting data from electronic medical records for research: an international comparative study

BACKGROUND

Electronic medical records (EMR) offer a major potential for secondary use of data for research which can improve the safety, quality and efficiency of healthcare. They also enable the measurement of disease burden at the population level. However, the extent to which this is feasible in different countries is not well known. This study aimed to: 1) assess information governance procedures for extracting data from EMR in 16 countries; and 2) explore the extent of EMR adoption and the quality and consistency of EMR data in 7 countries, using management of diabetes type 2 patients as an exemplar.

METHODS

We included 16 countries from Australia, Asia, the Middle East, and Europe to the Americas. We undertook a multi-method approach including both an online literature review and structured interviews with 59 stakeholders, including 25 physicians, 23 academics, 7 EMR providers, and 4 information commissioners. Data were analysed and synthesised thematically considering the most relevant issues.

RESULTS

We found that procedures for information governance, levels of adoption and data quality varied across the countries studied. The required time and ease of obtaining approval also varies widely. While some countries seem ready for secondary uses of data from EMR, in other countries several barriers were found, including limited experience with using EMR data for research, lack of standard policies and procedures, bureaucracy, confidentiality, data security concerns, technical issues and costs.

CONCLUSIONS

This is the first international comparative study to shed light on the feasibility of extracting EMR data across a number of countries. The study will inform future discussions and development of policies that aim to accelerate the adoption of EMR systems in high and middle income countries and seize the rich potential for secondary use of data arising from the use of EMR solutions.

Factors affecting compliance with use of online healthcare services among adults in Israel

BACKGROUND

The use of online health services (henceforth, OHS) among middle-aged to older adults can make health-related actions more accessible to this population group as well as help reduce the burden on the health system and avoid unnecessary costs. The study's objectives were to examine the responsiveness and willingness of individuals aged 45+ to use different OHS and to characterize the attitudes and main factors influencing that responsiveness.

METHODS

We conducted a telephone survey among a sample of 703 individuals constituting a representative sample of the Israeli population of individuals aged 45+. The research questionnaire integrates the principles of the Adopting Medical Information Technologies model and includes socio-demographic attributes.

RESULTS

The results indicate that 78 % of internet users claimed to use at least one OHS (79 % of the Jewish sector and 66 % of the non-Jewish sector). Nevertheless, 22 % of internet users do not use OHS. Most online use is on Health Maintenance Organizations (HMO) websites to obtain administrative information. Frequency of OHS use increases as the following factors increase: perceived ease of online use; extent of encouragement for online use; perceived reliability of online health services; and extent of advertisement exposure. The study found that OHS use is much more prevalent among wealthy populations. In addition, individuals' attitudes and the extent of their exposure to advertisement influence their use and intention to use OHS.

CONCLUSIONS

A number of recommendations emerge from the study: 1) For OHS use to increase online health websites should be made more accessible to middle aged-older adults individuals and those of different languages and cultures. 2) Programs should be developed to teach HMO staff to encourage patients to use OHS. 3) Media advertising that encourages the use of OHS should be expanded.

eHealth: past and future perspectives

eHealth is an umbrella term incorporating any area that combines healthcare and technology to improve efficiencies and reduce costs. The ultimate goal of eHealth is to rationalize treatment selection to improve patient safety and outcomes. Telemedicine, first used in the 1920s, is the oldest form of eHealth. The introduction of broadband Internet, followed by wireless technologies, has allowed an explosion of mHealth applications within this field. Wearable technologies, such as smartwatches, are now being used for diagnostics and patient monitoring. Challenges remain to develop reusable Clinical Decision Support systems that will streamline the flow of data from clinical laboratories to point of care. This review explores the history of eHealth, and describes some of the remaining integration and implementation challenges.

Healthcare Reimbursement and Quality Improvement: Integration Using the Electronic Medical Record Comment on "Fee-for-Service Payment--an Evil Practice That Must Be Stamped Out?"

Reimbursement for healthcare has utilized a variety of payment mechanisms with varying degrees of effectiveness. Whether these mechanisms are used singly or in combination, it is imperative that the resulting systems remunerate on the basis of the quantity, complexity, and quality of care provided. Expanding the role of the electronic medical record (EMR) to monitor provider practice, patient responsiveness, and functioning of the healthcare organization has the potential to not only enhance the accuracy and efficiency of reimbursement mechanisms but also to improve the quality of medical care.

Exploring the challenges of implementing e-health: a protocol for an update of a systematic review of reviews

INTRODUCTION

There is great potential for e-health to deliver cost-effective, quality healthcare and spending on e-health systems by governments and healthcare systems is increasing worldwide. However, the literature often describes problematic and unsuccessful attempts to implement these new technologies into routine clinical practice. To understand and address the challenges of implementing e-health, a systematic review was conducted in 2009, which identified several conceptual barriers and facilitators to implementation. As technology is rapidly changing and new e-health solutions are constantly evolving to meet the needs of current practice, an update of this review is deemed necessary to understand current challenges to the implementation of e-health. This research aims to identify, summarise and synthesise currently available evidence, by undertaking a systematic review of reviews to explore the barriers and facilitators to implementing e-health across a range of healthcare settings.

METHODS AND ANALYSIS

This is a protocol for an update of a systematic review of reviews. We will search MEDLINE, EMBASE, CINAHL, PSYCINFO and The Cochrane Library for studies published between 2009 and 2014. We will check reference lists of included studies for further studies. Two authors will independently screen the titles and abstracts identified from the search; any discrepancies will be resolved by discussion and consensus. Full-text papers will be obtained and relevant reviews will be selected against inclusion criteria. Eligible reviews have to be based on the implementation of e-health technologies. Data from eligible reviews will be extracted using a data abstraction form. A thematic analysis of barriers and facilitators to e-health implementation will be conducted.

ETHICS AND DISSEMINATION

Ethical approval is not required. The permission of the original authors to update the review was sought and granted.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42015017661.