Early cost and safety benefits of an inpatient electronic health record

The Multidisciplinary and Interdisciplinary Teamwork Across Care Settings and Transitions of Care

The increasing complexity of health care and the growing demand for safe, high-quality health care have underscored the crucial need for interdisciplinary teams in health care. As people are living longer, a myriad of complex health care needs arise, necessitating specialized care from various health care professionals. Interdisciplinary teams include a group of health care professionals with various areas of expertise who work together to achieve mutual goals on behalf of a patient and their other significant individuals. Consequently, the role of interdisciplinary teams in health care continues to strengthen, providing more effective responses to the evolving needs of both individuals and health care systems.

Impact of Implementing Electronic Nursing Records on Quality and Safety Indicators in Care

Electronic Health Records (EHR) have been adopted to improve the quality of care. Despite the growing use of health information technology, nursing documentation remains a challenge. In Tunisia, the implementation of the Electronic Medical Record (EMR) system is gaining momentum as part of national initiatives to modernize healthcare. However, nursing documentation is still largely paper-based, and no studies in Tunisia have adressed this topic. This research aims to assess the effect of the Electronic Nursing Record (ENR) on the quality and safety of care indicators (QSCI). This is an interventional study structured in four phases: development, pre-implementation, implementation, and evaluation, integrating the principles of the 'Standards for Reporting Implementation Studies' (StaRI). A list of QSCI was defined and validated through a literature review and Delphi consensus. The impact of the ENR on these indicators was evaluated in a Tunisian university hospital through a quasi-experimental study. Indicators were measured before ENR, one month after, and six months after. Data analyses was conducted using SPSS with statistical tests. Initially, the study led to the identification and validation of seventeen QSCI. Subsequently, a quasi-experimental study was conducted to evaluate the impact of ENR implementation on these indicators. The results revealed a significant improvement in the intervention group (using ENR), particularly in the traceability of vital signs (p < 10⁻3) and infusion administration (p = 0.027). Conversely, the control group (using paper-based documentation) performed better in terms of traceability of inter-team handovers (95.1% compared to 71.9% for the intervention group). The electronic documentation system is seen as a major transformation in healthcare in many hospitals worldwide. Moreover, electronic nursing documentation is crucial for patient safety. Its implementation in our hospital revealed a positive impact of the ENR on certain aspects of care quality while highlighting gaps in inter-team handovers.

Cashing in: cost-benefit analysis framework for digital hospitals

BACKGROUND

For many countries, especially those outside the USA without incentive payments, implementing and maintaining electronic medical records (EMR) is expensive and can be controversial given the large amounts of investment. Evaluating the value of EMR implementation is necessary to understand whether or not, such investment, especially when it comes from the public source, is an efficient allocation of healthcare resources. Nonetheless, most countries have struggled to measure the return on EMR investment due to the lack of appropriate evaluation frameworks.

METHODS

This paper outlines the development of an evidence-based digital health cost-benefit analysis (eHealth-CBA) framework to calculate the total economic value of the EMR implementation over time. A net positive benefit indicates such investment represents improved efficiency, and a net negative is considered a wasteful use of public resources.

RESULTS

We developed a three-stage process that takes into account the complexity of the healthcare system and its stakeholders, the investment appraisal and evaluation practice, and the existing knowledge of EMR implementation. The three stages include (1) literature review, (2) stakeholder consultation, and (3) CBA framework development. The framework maps the impacts of the EMR to the quadruple aim of healthcare and clearly creates a method for value assessment.

CONCLUSIONS

The proposed framework is the first step toward developing a comprehensive evaluation framework for EMRs to inform health decision-makers about the economic value of digital investments rather than just the financial value.

Electronic health record-supported implementation of an evidence-based pathway for perioperative surgical care

OBJECTIVES

Enhanced recovery pathways (ERPs) are evidence-based approaches to improving perioperative surgical care. However, the role of electronic health records (EHRs) in their implementation is unclear. We examine how EHRs facilitate or hinder ERP implementation.

MATERIALS AND METHODS

We conducted interviews with informaticians and clinicians from US hospitals participating in an ERP implementation collaborative. We used inductive thematic analysis to analyze transcripts and categorized hospitals into 3 groups based on process measure adherence. High performers exhibited a minimum 80% adherence to 6 of 9 metrics, high improvers demonstrated significantly better adherence over 12 months, and strivers included all others. We mapped interrelationships between themes using causal loop diagrams.

RESULTS

We interviewed 168 participants from 8 hospitals and found 3 thematic clusters: (1) "EHR difficulties" with the technology itself and contextual factors related to (2) "EHR enablers," and (3) "EHR barriers" in ERP implementation. Although all hospitals experienced issues, high performers and improvers successfully integrated ERPs into EHRs through a dedicated multidisciplinary team with informatics expertise. Strivers, while enacting some fixes, were unable to overcome individual resistance to EHR-supported ERPs.

DISCUSSION AND CONCLUSION

We add to the literature describing the limitations of EHRs' technological capabilities to facilitate clinical workflows. We illustrate how organizational strategies around engaging motivated clinical teams with informatics training and resources, especially with dedicated technical support, moderate the extent of EHRs' support to ERP implementation, causing downstream effects for hospitals to transform technological challenges into care-improving opportunities. Early and consistent involvement of informatics expertise with frontline EHR clinician users benefited the efficiency and effectiveness of ERP implementation and sustainability.

How digital health documentation transforms professional practices in primary healthcare in Denmark: A WPR document analysis

Historically, recordkeeping has been an essential task for health professionals. Today, this mandatory task increasingly takes place as digital documentation. This study critically examines problem constructions in practical documents on digital documentation strategies in Danish municipal healthcare and how these problem constructions imply particular solutions. A document analysis based on the approach presented in Bacchi's "What's the problem represented to be?" was applied. Forty practical documents in the form of guidelines, strategies, and quality control documents were included. The analysis uncovered three problem representations: lack of coherence between health services in a complex healthcare system, lack of assessable data for management and political prioritization, and inefficiency in the healthcare system. The proposed solution is a digitalized and standardized practice that transforms recordkeeping in the municipalities. However, municipal healthcare is at risk of being fragmented due to digital documentation's focus on the organizational management of health with task-oriented practices supplied by an anonymous health professional. We find that digital documentation functions as an organizational micromanagement approach that assigns the health professional a subject position as an employee acting according to the organization's framework rather than the profession's normative framework.

Trends in Adverse Event Rates in Hospitalized Patients, 2010-2019

IMPORTANCE

Patient safety is a US national priority, yet lacks a comprehensive assessment of progress over the past decade.

OBJECTIVE

To determine the change in the rate of adverse events in hospitalized patients.

DESIGN, SETTING, AND PARTICIPANTS

This serial cross-sectional study used data from the Medicare Patient Safety Monitoring System from 2010 to 2019 to assess in-hospital adverse events in patients. The study included 244 542 adult patients hospitalized in 3156 US acute care hospitals across 4 condition groups from 2010 through 2019: acute myocardial infarction (17%), heart failure (17%), pneumonia (21%), and major surgical procedures (22%); and patients hospitalized from 2012 through 2019 for all other conditions (22%).

EXPOSURES

Adults aged 18 years or older hospitalized during each included calendar year.

MAIN OUTCOMES AND MEASURES

Information on adverse events (abstracted from medical records) included 21 measures across 4 adverse event domains: adverse drug events, hospital-acquired infections, adverse events after a procedure, and general adverse events (hospital-acquired pressure ulcers and falls). The outcomes were the total change over time for the observed and risk-adjusted adverse event rates in the subpopulations.

RESULTS

The study sample included 190 286 hospital discharges combined in the 4 condition-based groups of acute myocardial infarction, heart failure, pneumonia, and major surgical procedures (mean age, 68.0 [SD, 15.9] years; 52.6% were female) and 54 256 hospital discharges for the group including all other conditions (mean age, 57.7 [SD, 20.7] years; 59.8% were female) from 3156 acute care hospitals across the US. From 2010 to 2019, the total change was from 218 to 139 adverse events per 1000 discharges for acute myocardial infarction, from 168 to 116 adverse events per 1000 discharges for heart failure, from 195 to 119 adverse events per 1000 discharges for pneumonia, and from 204 to 130 adverse events per 1000 discharges for major surgical procedures. From 2012 to 2019, the rate of adverse events for all other conditions remained unchanged at 70 adverse events per 1000 discharges. After adjustment for patient and hospital characteristics, the annual change represented by relative risk in all adverse events per 1000 discharges was 0.94 (95% CI, 0.93-0.94) for acute myocardial infarction, 0.95 (95% CI, 0.94-0.96) for heart failure, 0.94 (95% CI, 0.93-0.95) for pneumonia, 0.93 (95% CI, 0.92-0.94) for major surgical procedures, and 0.97 (95% CI, 0.96-0.99) for all other conditions. The risk-adjusted adverse event rates declined significantly in all patient groups for adverse drug events, hospital-acquired infections, and general adverse events. For patients in the major surgical procedures group, the risk-adjusted rates of events after a procedure declined significantly.

CONCLUSIONS AND RELEVANCE

In the US between 2010 and 2019, there was a significant decrease in the rates of adverse events abstracted from medical records for patients admitted for acute myocardial infarction, heart failure, pneumonia, and major surgical procedures and there was a significant decrease in the adjusted rates of adverse events between 2012 and 2019 for all other conditions. Further research is needed to understand the extent to which these trends represent a change in patient safety.

American Society for Gastrointestinal Endoscopy guideline on informed consent for GI endoscopic procedures

Informed consent is the cornerstone of the ethical practice of procedures and treatments in medicine. The purpose of this document from the American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee is to provide an update on best practice of the informed consent process and other issues around informed consent and shared decision-making for endoscopic procedures. The principles of informed consent are based on longstanding legal doctrine. Several new concepts and clinical trials addressing the best practice of informed consent will help guide practitioners of the burgeoning field of GI endoscopic procedures. After a literature review and an iterative discussion and voting process by the ASGE Standards of Practice Committee, this document was produced to update our guidance on informed consent for the practicing endoscopist. Because this document was designed by considering the laws and broad practice of endoscopy in the United States, legal requirements may differ by state and region, and it is the responsibility of the endoscopist, practice managers, and other healthcare organizations to be aware of local laws. Our recommendations are designed to improve the informed consent experience for both physicians and patients as they work together to diagnose and treat GI diseases with endoscopy.

Value of the Electronic Medical Record for Hospital Care: Update From the Literature

Background

Electronic records could improve quality and efficiency of health care. National and international bodies propagate this belief worldwide. However, the evidence base concerning the effects and advantages of electronic records is questionable. The outcome of health care systems is influenced by many components, making assertions about specific types of interventions difficult. Moreover, electronic records itself constitute a complex intervention offering several functions with possibly positive as well as negative effects on the outcome of health care systems.

Objective

The aim of this review is to summarize empirical studies about the value of electronic medical records (EMRs) for hospital care published between 2010 and spring 2019.

Methods

The authors adopted their method from a series of literature reviews. The literature search was performed on MEDLINE with “Medical Record System, Computerized” as the essential keyword. The selection process comprised 2 phases looking for a consent of both authors. Starting with 1345 references, 23 were finally included in the review. The evaluation combined a scoring of the studies’ quality, a description of data sources in case of secondary data analyses, and a qualitative assessment of the publications’ conclusions concerning the medical record’s impact on quality and efficiency of health care.

Results

The majority of the studies stemmed from the United States (19/23, 83%). Mostly, the studies used publicly available data (“secondary data studies”; 17/23, 74%). A total of 18 studies analyzed the effect of an EMR on the quality of health care (78%), 16 the effect on the efficiency of health care (70%). The primary data studies achieved a mean score of 4.3 (SD 1.37; theoretical maximum 10); the secondary data studies a mean score of 7.1 (SD 1.26; theoretical maximum 9). From the primary data studies, 2 demonstrated a reduction of costs. There was not one study that failed to demonstrate a positive effect on the quality of health care. Overall, 9/16 respective studies showed a reduction of costs (56%); 14/18 studies showed an increase of health care quality (78%); the remaining 4 studies missed explicit information about the proposed positive effect.

Conclusions

This review revealed a clear evidence about the value of EMRs. In addition to an awesome majority of economic advantages, the review also showed improvements in quality of care by all respective studies. The use of secondary data studies has prevailed over primary data studies in the meantime. Future work could focus on specific aspects of electronic records to guide their implementation and operation.

Examining the acceptance of an integrated Electronic Health Records system: Insights from a repeated cross-sectional design

BACKGROUND AND PURPOSE

Hospital staff's acceptance of an integrated Electronic Health Records system (EHR) is a critical success factor to exploit the benefits EHRs can offer. This study employs a repeated cross-sectional design to differentiate between the enablers and barriers of EHR acceptance prior to EHR implementation and those that arise over time by testing a theoretical model specifically tailored to the EHR context.

METHODS

A repeated cross-sectional design, consisting of one measurement of staff's acceptance before and two after EHR implementation, was employed in a Belgian hospital. To test the theoretical model, partial least squares structural equation modelling (PLS-SEM) was used. Furthermore, partial least squares multigroup analyses (PLS-MGA) and permutation tests were applied to examine whether the relations in the model vary significantly over time.

RESULTS

The formulated model explains up to 80 % of the variance in hospital staff's attitude towards the EHR. The extent to which the EHR leads to administrative simplification outperforms the core technology acceptance variables. Furthermore, support was found for the significant role of implementation factors (i.e. communication quality and training) and prior IT experiences in explaining EHR acceptance. Finally, the results show significant evolutions in path coefficients over time. An important trade-off between effort expectancy and performance expectancy was revealed, meaning effort expectancy is the most important determinant of hospital staff's attitude towards the EHR, but once the EHR has been implemented performance expectancy becomes more important.

CONCLUSIONS

The results of testing the hypothesized model reveal the importance of taking into account hospital staff's perception of the extent to which the EHR generates administrative simplification, a combination of implementation factors, and attitude towards technology in general when assessing the acceptance of an EHR. Moreover, the results highlight the importance of conducting repeated cross-sectional or longitudinal technology acceptance research as relations between core variables vary significantly over time, which implies hospital management and healthcare technology providers should adjust their policy throughout the various implementation stages.

Derivation and Validation of an Automated Search Strategy to Retrospectively Identify Acute Respiratory Distress Patients Per Berlin Definition

Purpose: Acute respiratory distress syndrome (ARDS) is common in critically ill patients and linked with serious consequences. A manual chart review for ARDS diagnosis could be laborious and time-consuming. We developed an automated search strategy to retrospectively identify ARDS patients using the Berlin definition to allow for timely and accurate ARDS detection.

Methods: The automated search strategy was created through sequential steps, with keywords applied to an institutional electronic medical records (EMRs) database. We included all adult patients admitted to the intensive care unit (ICU) at the Mayo Clinic (Rochester, MN) from January 1, 2009 to December 31, 2017. We selected 100 patients at random to be divided into two derivation cohorts and identified 50 patients at random for the validation cohort. The sensitivity and specificity of the automated search strategy were compared with a manual medical record review (gold standard) for data extraction of ARDS patients per Berlin definition.

Results: On the first derivation cohort, the automated search strategy achieved a sensitivity of 91.3%, specificity of 100%, positive predictive value (PPV) of 100%, and negative predictive value (NPV) of 93.1%. On the second derivation cohort, it reached the sensitivity of 90.9%, specificity of 100%, PPV of 100%, and NPV of 93.3%. The strategy performance in the validation cohort had a sensitivity of 94.4%, specificity of 96.9%, PPV of 94.4%, and NPV of 96.9%.

Conclusions: This automated search strategy for ARDS with the Berlin definition is reliable and accurate, and can serve as an efficient alternative to time-consuming manual data review.

A Bespoke Electronic Health Record for Epilepsy Care (EpiToMe): Development and Qualitative Evaluation

BACKGROUND

While electronic health records (EHR) bring various benefits to health care, EHR systems are often criticized as cumbersome to use, failing to fulfill the promise of improved health care delivery with little more than a means of meeting regulatory and billing requirements. EHR has also been recognized as one of the contributing factors for physician burnout.

OBJECTIVE

Specialty-specific EHR systems have been suggested as an alternative approach that can potentially address challenges associated with general-purpose EHRs. We introduce the Epilepsy Tracking and optimized Management engine (EpiToMe), an exemplar bespoke EHR system for epilepsy care. EpiToMe uses an agile, physician-centered development strategy to optimize clinical workflow and patient care documentation. We present the design and implementation of EpiToMe and report the initial feedback on its utility for physician burnout.

METHODS

Using collaborative, asynchronous data capturing interfaces anchored to a domain ontology, EpiToMe distributes reporting and documentation workload among technicians, clinical fellows, and attending physicians. Results of documentation are transmitted to the parent EHR to meet patient care requirements with a push of a button. An HL7 (version 2.3) messaging engine exchanges information between EpiToMe and the parent EHR to optimize clinical workflow tasks without redundant data entry. EpiToMe also provides live, interactive patient tracking interfaces to ease the burden of care management.

RESULTS

Since February 2019, 15,417 electroencephalogram reports, 2635 Epilepsy Monitoring Unit daily reports, and 1369 Epilepsy Monitoring Unit phase reports have been completed in EpiToMe for 6593 unique patients. A 10-question survey was completed by 11 (among 16 invited) senior clinical attending physicians. Consensus was found that EpiToMe eased the burden of care documentation for patient management, a contributing factor to physician burnout.

CONCLUSIONS

EpiToMe offers an exemplar bespoke EHR system developed using a physician-centered design and latest advancements in information technology. The bespoke approach has the potential to ease the burden of care management in epilepsy. This approach is applicable to other clinical specialties.

Health systems' use of enterprise health information exchange vs single electronic health record vendor environments and unplanned readmissions

OBJECTIVE

Enterprise health information exchange (HIE) and a single electronic health record (EHR) vendor solution are 2 information exchange approaches to improve performance and increase the quality of care. This study sought to determine the association between adoption of enterprise HIE vs a single vendor environment and changes in unplanned readmissions.

MATERIALS AND METHODS

The association between unplanned 30-day readmissions among adult patients and adoption of enterprise HIE or a single vendor environment was measured in a panel of 211 system-member hospitals from 2010 through 2014 using fixed-effects regression models. Sample hospitals were members of health systems in 7 states. Enterprise HIE was defined as self-reported ability to exchange information with other members of the same health system who used different EHR vendors. A single EHR vendor environment reported exchanging information with other health system members, but all using the same EHR vendor.

RESULTS

Enterprise HIE adoption was more common among the study sample than EHR (75% vs 24%). However, adoption of a single EHR vendor environment was associated with a 0.8% reduction in the probability of a readmission within 30 days of discharge. The estimated impact of adopting an enterprise HIE strategy on readmissions was smaller and not statically significant.

CONCLUSION

Reductions in the probability of an unplanned readmission after a hospital adopts a single vendor environment suggests that HIE technologies can better support the aim of higher quality care. Additionally, health systems may benefit more from a single vendor environment approach than attempting to foster exchange across multiple EHR vendors.

Development of standard indicators to assess use of electronic health record systems implemented in low-and medium-income countries

Background

Electronic Health Record Systems (EHRs) are being rolled out nationally in many low- and middle-income countries (LMICs) yet assessing actual system usage remains a challenge. We employed a nominal group technique (NGT) process to systematically develop high-quality indicators for evaluating actual usage of EHRs in LMICs.

Methods

An initial set of 14 candidate indicators were developed by the study team adapting the Human Immunodeficiency Virus (HIV) Monitoring, Evaluation, and Reporting indicators format. A multidisciplinary team of 10 experts was convened in a two-day NGT workshop in Kenya to systematically evaluate, rate (using Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) criteria), prioritize, refine, and identify new indicators. NGT steps included introduction to candidate indicators, silent indicator ranking, round-robin indicator rating, and silent generation of new indicators. 5-point Likert scale was used in rating the candidate indicators against the SMART components.

Results

Candidate indicators were rated highly on SMART criteria (4.05/5). NGT participants settled on 15 final indicators, categorized as system use (4); data quality (3), system interoperability (3), and reporting (5). Data entry statistics, systems uptime, and EHRs variable concordance indicators were rated highest.

Conclusion

This study describes a systematic approach to develop and validate quality indicators for determining EHRs use and provides LMICs with a multidimensional tool for assessing success of EHRs implementations.

Effects of Electronic Health Record Implementation and Barriers to Adoption and Use: A Scoping Review and Qualitative Analysis of the Content

Despite the great advances in the field of electronic health records (EHRs) over the past 25 years, implementation and adoption challenges persist, and the benefits realized remain below expectations. This scoping review aimed to present current knowledge about the effects of EHR implementation and the barriers to EHR adoption and use. A literature search was conducted in PubMed, Web of Science, IEEE Xplore Digital Library and ACM Digital Library for studies published between January 2005 and May 2020. In total, 7641 studies were identified of which 142 met the criteria and attained the consensus of all researchers on inclusion. Most studies (n = 91) were published between 2017 and 2019 and 81 studies had the United States as the country of origin. Both positive and negative effects of EHR implementation were identified, relating to clinical work, data and information, patient care and economic impact. Resource constraints, poor/insufficient training and technical/educational support for users, as well as poor literacy and skills in technology were the identified barriers to adoption and use that occurred frequently. Although this review did not conduct a quality analysis of the included papers, the lack of uniformity in the use of EHR definitions and detailed contextual information concerning the study settings could be observed.

Economic Value of Data and Analytics for Health Care Providers: Hermeneutic Systematic Literature Review

BACKGROUND

The benefits of data and analytics for health care systems and single providers is an increasingly investigated field in digital health literature. Electronic health records (EHR), for example, can improve quality of care. Emerging analytics tools based on artificial intelligence show the potential to assist physicians in day-to-day workflows. Yet, single health care providers also need information regarding the economic impact when deciding on potential adoption of these tools.

OBJECTIVE

This paper examines the question of whether data and analytics provide economic advantages or disadvantages for health care providers. The goal is to provide a comprehensive overview including a variety of technologies beyond computer-based patient records. Ultimately, findings are also intended to determine whether economic barriers for adoption by providers could exist.

METHODS

A systematic literature search of the PubMed and Google Scholar online databases was conducted, following the hermeneutic methodology that encourages iterative search and interpretation cycles. After applying inclusion and exclusion criteria to 165 initially identified studies, 50 were included for qualitative synthesis and topic-based clustering.

RESULTS

The review identified 5 major technology categories, namely EHRs (n=30), computerized clinical decision support (n=8), advanced analytics (n=5), business analytics (n=5), and telemedicine (n=2). Overall, 62% (31/50) of the reviewed studies indicated a positive economic impact for providers either via direct cost or revenue effects or via indirect efficiency or productivity improvements. When differentiating between categories, however, an ambiguous picture emerged for EHR, whereas analytics technologies like computerized clinical decision support and advanced analytics predominantly showed economic benefits.

CONCLUSIONS

The research question of whether data and analytics create economic benefits for health care providers cannot be answered uniformly. The results indicate ambiguous effects for EHRs, here representing data, and mainly positive effects for the significantly less studied analytics field. The mixed results regarding EHRs can create an economic barrier for adoption by providers. This barrier can translate into a bottleneck to positive economic effects of analytics technologies relying on EHR data. Ultimately, more research on economic effects of technologies other than EHRs is needed to generate a more reliable evidence base.

The effect of different classification of hospitals on medical expenditure from perspective of classification of hospitals framework: evidence from China

Background

Different classification of hospitals (COH) have an important impact on medical expenditures in China. The objective of this study is to examine the impact of COH on medical expenditures with the hope of providing insights into appropriate care and resource allocation.

Methods

From the perspective of COH framework, using the Urban Employee Basic Medical Insurance (UEBMI) data of Chengdu City from 2011 to 2015, with sample size of 488,623 hospitalized patients, our study empirically analyzed the effect of COH on medical expenditure by multivariate regression modeling.

Results

The average medical expenditure was 5468.86 Yuan (CNY), the average expenditure of drug, diagnostic testing, medical consumables, nursing care, bed, surgery and blood expenditures were 1980.06 Yuan (CNY), 1536.27 Yuan (CNY), 500.01 Yuan (CNY), 166.23 Yuan (CNY), 221.98 Yuan (CNY), 983.18 Yuan (CNY) and 1733.21 Yuan (CNY) respectively. Patients included in the analysis were mainly elderly, with an average age of 86.65 years old. Female and male gender were split evenly. The influence of COH on total medical expenditures was significantly negative (p < 0.001). The reimbursement ratio of UEBMI had a significantly positive (p < 0.001) effect on various types of medical expenditures, indicating that the higher the reimbursement ratio was, the higher the medical expenditures would be.

Conclusions

COH influenced medical expenditures significantly. In consideration of reducing medical expenditures, the government should not only start from the supply side of healthcare services, but also focus on addressing the demand side.

Access to an Electronic Health Record: A Polish National Survey

In Poland, as in many countries around the world, e-health services are becoming more and more popular. Obligatory e-sick leave was implemented, followed by e-prescriptions and e-referrals. Therefore, it is worth considering the introduction of a complete electronic health record (EHR) that can be accessed by doctors and patients. The main aim of the study is to find out whether patients want to have access to their EHRs and if they would agree to pay for such a service. The research was based on three surveys conducted among 1000 Polish adults in 2007, 2012, and 2018. The sample collection was carried out by the national opinion poll agency, with the use of computer-assisted telephone interviews. Over 60% of respondents were interested in the possibility of accessing EHRs in general, and almost 50% of them were ready to pay for it. Nevertheless, when analyzing all the year-on-year trends, they were subject to a gradual decrease. The youngest age group was the one most interested in EHRs, while the group comprising respondents in middle age was the one most willing to pay for it. There is still great potential in implementing EHRs on a bigger scale.

Machine learning in data abstraction: A computable phenotype for sepsis and septic shock diagnosis in the intensive care unit

BACKGROUND

With the recent change in the definition (Sepsis-3 Definition) of sepsis and septic shock, an electronic search algorithm was required to identify the cases for data automation. This supervised machine learning method would help screen a large amount of electronic medical records (EMR) for efficient research purposes.

AIM

To develop and validate a computable phenotype via supervised machine learning method for retrospectively identifying sepsis and septic shock in critical care patients.

METHODS

A supervised machine learning method was developed based on culture orders, Sequential Organ Failure Assessment (SOFA) scores, serum lactate levels and vasopressor use in the intensive care units (ICUs). The computable phenotype was derived from a retrospective analysis of a random cohort of 100 patients admitted to the medical ICU. This was then validated in an independent cohort of 100 patients. We compared the results from computable phenotype to a gold standard by manual review of EMR by 2 blinded reviewers. Disagreement was resolved by a critical care clinician. A SOFA score ≥ 2 during the ICU stay with a culture 72 h before or after the time of admission was identified. Sepsis versions as V1 was defined as blood cultures with SOFA ≥ 2 and Sepsis V2 was defined as any culture with SOFA score ≥ 2. A serum lactate level ≥ 2 mmol/L from 24 h before admission till their stay in the ICU and vasopressor use with Sepsis-1 and-2 were identified as Septic Shock-V1 and-V2 respectively.

RESULTS

In the derivation subset of 100 random patients, the final machine learning strategy achieved a sensitivity-specificity of 100% and 84% for Sepsis-1, 100% and 95% for Sepsis-2, 78% and 80% for Septic Shock-1, and 80% and 90% for Septic Shock-2. An overall percent of agreement between two blinded reviewers had a k = 0.86 and 0.90 for Sepsis 2 and Septic shock 2 respectively. In validation of the algorithm through a separate 100 random patient subset, the reported sensitivity and specificity for all 4 diagnoses were 100%-100% each.

CONCLUSION

Supervised machine learning for identification of sepsis and septic shock is reliable and an efficient alternative to manual chart review.

Digital health for COPD care: the current state of play

Chronic obstructive pulmonary disease (COPD) imposes a huge burden to our healthcare systems and societies. To alleviate the burden, digital health-"the use of digital technologies for health"-has been recognized as a potential solution for improving COPD care at scale. The aim of this review is to provide an overview of digital health interventions in COPD care. We accordingly reviewed recent and emerging evidence on digital transformation approaches for COPD care focusing on (I) self-management, (II) in-hospital care, (III) post-discharge care, (IV) hospital-at-home, (V) ambient environment, and (VI) public health surveillance. The emerging approaches included digital-technology-enabled homecare programs, electronic records, big data analytics, and environment-monitoring applications. The digital health approaches of telemonitoring, telehealth and mHealth support the self-management, post-discharge care, and hospital-at-home strategy, with prospective effects on reducing acute COPD exacerbations and hospitalizations. Electronic records and classification tools have been implemented; and their effectiveness needs to be further evaluated in future studies. Air pollution concentrations in the ambient environment are associated with declined lung functions and increased risks for hospitalization and mortality. In all the digital transformation approaches, clinical evidence on reducing mortality, the ultimate goal of digital health intervention, is often inconsistent or insufficient. Digital health transformation provides great opportunities for clinical innovations and discovery of new intervention strategies. Further research remains needed for achieving reliable improvements in clinical outcomes and cost-benefits in future studies.

Measuring electronic communication networks in virtual care teams using electronic health records access-log data

OBJECTIVE

To develop methods for measuring electronic communication networks in virtual care teams using electronic health records (EHR) access-log data.

METHODS

For a convenient sample of 100 surgical colorectal cancer patients, we used time-stamped EHR access-log data extracted from an academic medical center's EHR system to construct communication networks among healthcare professionals (HCPs) in each patient's virtual care team. We measured communication linkages between HCPs using the inverse of the average time between access events in which the source HCPs sent information to and the destination HCPs retrieved information from the EHR system. Social network analysis was used to examine and visualize communication network structures, identify principal care teams, and detect meaningful structural differences across networks. We conducted a non-parametric multivariate analysis of variance (MANOVA) to test the association between care teams' communication network structures and patients' cancer stage and site.

RESULTS

The 100 communication networks showed substantial variations in size and structures. Principal care teams, the subset of HCPs who formed the core of the communication networks, had higher proportions of nurses, physicians, and pharmacists and a lower proportion of laboratory medical technologists than the overall networks. The distributions of conditional uniform graph quantiles suggested that our network-construction technique captured meaningful underlying structures that were different from random unstructured networks. MANOVA results found that the networks' topologies were associated with patients' cancer stage and site.

CONCLUSIONS

This study demonstrates that it is feasible to use EHR access-log data to measure and examine communication networks in virtual care teams. The proposed methods captured salient communication patterns in care teams that were associated with patients' clinical differences.

Barriers to obtaining prostate multi-parametric magnetic resonance imaging in African-American men on active surveillance for prostate cancer

Purpose

Magnetic resonance imaging is playing an ever‐bigger role in the management of prostate cancer. This study investigated barriers to obtaining multi‐parametric MRI (mpMRI) in African‐American men on active surveillance for prostate cancer in comparison to white men affected by the same type of cancer.

Materials and Methods

Retrospective review of prostate mpMRI orders from August 2015 to October 2017 at a single health organization treating a diverse population was performed. Data was extracted from the electronic medical records and cancellations were examined based on the documented reason for mpMRI cancellation, race, median zip code household income, and distance from healthcare facility.

Results

Out of 793 prostate mpMRI orders, 201 (25%) went unscanned. Access to care issues accounted for 46% of unscanned orders. Patient cancellations were the most common, followed by difficulty contacting patients, and insurance denials. African‐American patients disproportionately went unscanned because institution staff were unable to contact patients (29% vs 10% in white men, P = 0.0015). Median zip code household income was significantly different between racial groups but did not vary between indication for cancellation.

Conclusions

African‐American prostate cancer patients' access to mpMRI is hindered more by barriers to care than White patients. Urology providers must consider these issues before using prostate mpMRI within their active surveillance pathways.

Physician Use of Electronic Health Records: Survey Study Assessing Factors Associated With Provider Reported Satisfaction and Perceived Patient Impact

BACKGROUND

The effect electronic health record (EHR) implementation has on physician satisfaction and patient care remains unclear. A better understanding of physician perceptions of EHRs and factors that influence those perceptions is needed to improve the physician and patient experience when using EHRs.

OBJECTIVE

The objective of this study was to determine provider and clinical practice factors associated with physician EHR satisfaction and perception of patient impact.

METHODS

We surveyed a random sample of physicians, including residents and fellows, at a US quaternary care academic hospital from February to March 2016. The survey assessed provider demographics, clinical practice factors (ie, attending, fellow, or resident), and overall EHR experience. The primary outcomes assessed were provider satisfaction and provider perceptions of impact to patient care. Responses on the satisfaction and patient impact questions were recorded on a continuous scale initially anchored at neutral (scale range 0 to 100: 0 defined as "extremely negatively" and 100 as "extremely positively"). Independent variables assessed included demographic and clinical practice factors, including perceived efficiency in using the EHR. One-way analysis of variance or the Kruskal-Wallis test was used for bivariate comparisons, and linear regression was used for multivariable modeling.

RESULTS

Of 157 physicians, 111 (70.7%) completed the survey; 51.4% (57/111) of the respondents were attending physicians, and of those, 71.9% (41/57) reported a >50% clinical full-time-equivalency and half reported supervising residents >50% of the time. A total of 50.5% (56/111) of the respondents were primary care practitioners, previous EHR experience was evenly distributed, and 12.6% (14/111) of the total sample were EHR super-users. Responses to how our current EHR affects satisfaction were rated above the neutral survey anchor point (mean 58 [SD 22]), as were their perceptions as to how the EHR impacts the patient (mean 61 [SD 18]). In bivariate comparisons, only physician age, clinical role (resident, fellow, or attending), and perceived efficiency were associated with EHR satisfaction. In the linear regression models, physicians with higher reported perceived efficiency reported higher overall satisfaction and patient impact after controlling for other variables in the model.

CONCLUSIONS

Physician satisfaction with EHRs and their perception of its impact on clinical care were generally positive, but physician characteristics, greater age, and attending level were associated with worse EHR satisfaction. Perceived efficiency is the factor most associated with physician satisfaction with EHRs when controlling for other factors. Understanding physician perceptions of EHRs may allow targeting of technology resources to ensure efficiency and satisfaction with EHR system use during clinical care.

SEWA: A framework for sociotechnical analysis of electronic health record system workarounds

OBJECTIVE

To develop a conceptual framework, SEWA, to address challenges of studying workarounds emerging from Electronic Health Record (EHR) system usage.

MATERIALS AND METHODS

SEWA is based on direct observations and follow-up interviews with physicians, nurses and clerks using their EHR at a large academic hospital. SEWA was developed by an iterative process: each new version was reviewed by experts (case study participants, hospital management, EHR developers) and refined accordingly till deemed final.

RESULTS

SEWA defines the work system and its five components constituting the context in which EHR workarounds are created. It also contains 15 rationales for creating EHR workarounds. Furthermore, four attributes are included that define EHR workarounds: cascadedness, anticipatedness, avoidability, and repetitiveness. Finally, SEWA lists the possible effects of workarounds on outcomes of clinical processes in terms of scope and impact.

DISCUSSION

SEWA provides a grounded foundation for performing sociotechnical analyses of EHR workarounds based on components of the work system. SEWA can likewise be supportive in planning redesign efforts of the work system. Finally, workarounds are subject to gradual change caused by e.g. changes in one's knowledge of the EHR, hospital policies, care directives, and system updates. Snapshots of SEWA can be taken over time and compared to gain insights into the evolution of workarounds.

CONCLUSION

Given the absence of a sociotechnical framework to study EHR workarounds, SEWA could aid researchers and practitioners to identify, analyze and resolve workarounds, and thereby contribute to improved patient safety, effectiveness of care and efficiency of care.

The Usability of Electronic Medical Record Systems Implemented in Sub-Saharan Africa: A Literature Review of the Evidence

BACKGROUND

Electronic medical record (EMR) systems hold the exciting promise of accurate, real-time access to patient health care data and great potential to improve the quality of patient care through decision support to clinicians. This review evaluated the usability of EMR systems implemented in sub-Saharan Africa based on a usability evaluation criterion developed by the Healthcare Information and Management Systems Society (HIMSS).

OBJECTIVE

This review aimed to evaluate EMR system implementations in sub-Saharan Africa against a well-defined evaluation methodology and assess their usability based on a defined set of metrics. In addition, the review aimed to identify the extent to which usability has been an enabling or hindering factor in the implementation of EMR systems in sub-Saharan Africa.

METHODS

Five key metrics for evaluating EMR system usability were developed based on the methodology proposed by HIMSS. These were efficiency, effectiveness, ease of learning, cognitive load, and user satisfaction. A 5-point rating system was developed for the review. EMR systems in 19 reviewed publications were scored based on this rating system. It awarded 5 points per metric to any EMR system that was identified as excellent, 4 points for good, 3 points for fair, 2 points for poor, and 1 point for bad. In addition, each of the 5 key metrics carried a maximum weighted score of 20. The percentage scores for each metric were then computed from the weighted scores from which the final overall usability score was derived.

RESULTS

In possibly contributing to the usability of implemented EMR systems, ease of learning obtained the highest percentage score of 71% (SD 1.09) followed by cognitive load in second place with a score of 68% (SD 1.62). Effectiveness followed closely in third place at 67% (SD 1.47) and efficiency was in fourth place at 64% (SD 1.04). User satisfaction came in last at 63% (SD 1.70). The overall usability score for all systems was calculated to be 66%.

CONCLUSIONS

The usability of EMR systems implemented in sub-Saharan Africa has been good with ease of learning possibly being the biggest positive contributor to this rating. Cognitive load and effectiveness have also possibly positively influenced the usability of EMR systems, whereas efficiency and user satisfaction have perhaps contributed least to positively influencing EMR system usability.

Reducing Test Utilization in Hospital Settings: A Narrative Review

Background

Studies addressing the appropriateness of laboratory testing have revealed approximately 20% overutilization. We conducted a narrative review to (1) describe current interventions aimed at reducing unnecessary laboratory testing, specifically in hospital settings, and (2) provide estimates of their efficacy in reducing test order volume and improving patient-related clinical outcomes.

Methods

The PubMed, Embase, Scopus, Web of Science, and Canadian Agency for Drugs and Technologies in Health-Health Technology Assessment databases were searched for studies describing the effects of interventions aimed at reducing unnecessary laboratory tests. Data on test order volume and clinical outcomes were extracted by one reviewer, while uncertainties were discussed with two other reviewers. Because of the heterogeneity of interventions and outcomes, no meta-analysis was performed.

Results

Eighty-four studies were included. Interventions were categorized into educational, (computerized) provider order entry [(C)POE], audit and feedback, or other interventions. Nearly all studies reported a reduction in test order volume. Only 15 assessed sustainability up to two years. Patient-related clinical outcomes were reported in 45 studies, two of which found negative effects.

Conclusions

Interventions from all categories have the potential to reduce unnecessary laboratory testing, although long-term sustainability is questionable. Owing to the heterogeneity of the interventions studied, it is difficult to conclude which approach was most successful, and for which tests. Most studies had methodological limitations, such as the absence of a control arm. Therefore, well-designed, controlled trials using clearly described interventions and relevant clinical outcomes are needed.

Do Electronic Medical Records Improve Advance Directive Documentation? A Systematic Review

BACKGROUND

Documentation rates of advance directives (ADs) remain low. Using electronic medical records (EMRs) could help, but a synthesis of evidence is currently lacking.

OBJECTIVES

To evaluate the evidence for using EMRs in documenting ADs and its implications for overcoming challenges associated with their use.

DESIGN

Systematic review of articles in English, published from inception of databases to December 2017.

DATA SOURCES

PubMed, PsycINFO, EMBASE, and CINAHL.

METHODS/MEASUREMENTS

Four databases were searched from inception to December 2017. Randomized and nonrandomized quantitative studies examining the effects of EMRs on creation, storage, or use of ADs were included. All featured an advance care planning process. Evidence was evaluated using the Cochrane Collaboration's risk assessment tool.

RESULTS

Fifteen studies were included: 1 randomized controlled trial, 1 randomized pilot, 4 pre-post studies, 4 cross-sectional studies, 1 retrospective cohort study, 1 historical control study, 1 retrospective observational study, 1 retrospective review, and 1 evaluation of an EMR feature. Seven studies showed that EMR-based reminders, AD templates, and decision aids can improve AD documentation rates. Three demonstrated that EMR search functions, decision aids, and automatic identification software can help identify patients who have or need ADs according to certain criteria. Five showed EMRs can create documentation challenges, including locating ADs, and making some patients more likely than others to have an AD. Most studies had an unclear or high risk of bias.

CONCLUSIONS

Limited evidence suggests EMRs could be used to help address AD documentation challenges but may also create additional problems. Stronger evidence is needed to more conclusively determine how EMR may assist in population approaches to improving AD documentation.

Implementation of electronic charting is not associated with significant change in physician productivity in an academic emergency department

Objectives

To compare physician productivity and billing before and after implementation of electronic charting in an academic emergency department (ED).

Materials and methods

This retrospective, blinded, observational study compared the 6 months pre-implementation (January to June 2012) with the 6 months post-implementation 1 year later (January to June 2013). Thirty-one ED physicians were recruited, with each physician acting as his/her own control in a before-after design. Productivity was measured via total number of encounters and “productivity index” defined as worked relative value units divided by the clinical full-time equivalent. Values for charges, encounters, and productivity index were determined during each study period and separately for procedures, observational stays, and critical care.

Results

No differences were found for total productivity index per month (758 [623-876] pre-group vs. 756 [673-886] post-group; P = 0.30). There was, however, a 9% decrease in total encounters per month (138 [101-163] pre-group vs. 125 [99-159] post-group; P = 0.01). Significant decreases were seen across all observation stay categories. Conversely, significant increases were seen across all critical care categories. There was no difference in total charges per month.

Discussion

This is one of few studies to demonstrate minimal disruption in physician productivity after transitioning to electronic documentation. The reasons for these findings are likely multi-factorial.

Conclusion

In this study, implementation of electronic charting was not associated with decreases in productivity or billing for total ED care, but may be associated with increases for critical care and decreases for observational stays.

Two-year longitudinal assessment of physicians' perceptions after replacement of a longstanding homegrown electronic health record: does a J-curve of satisfaction really exist?

This report describes a 2-year prospective, longitudinal survey of attending physicians in 3 clinical areas (family medicine, general pediatrics, internal medicine) who experienced a transition from a homegrown electronic health record (EHR) to a vendor EHR. Participants were already highly familiar with using EHRs. Data were collected 1 month before and 3, 6, 13, and 25 months post implementation. Our primary goal was to determine if perceptions followed a J-curve pattern in which they initially dropped but eventually surpassed baseline measures. A J-curve was not found for any measures, including workflow, safety, communication, and satisfaction. Only the reminders and alerts measure dropped and then returned to baseline (U-curve); a few remained flatlined. Most dropped and remained below baseline (L-curve). The only measure that remained above baseline was documenting in the exam room with the patient. This study adds to the literature about current controversies surrounding EHR adoption and physician satisfaction.

Workarounds Emerging From Electronic Health Record System Usage: Consequences for Patient Safety, Effectiveness of Care, and Efficiency of Care

BACKGROUND

Health care providers resort to informal temporary practices known as workarounds for handling exceptions to normal workflow unintendedly imposed by electronic health record systems (EHRs). Although workarounds may seem favorable at first sight, they are generally suboptimal and may jeopardize patient safety, effectiveness of care, and efficiency of care.

OBJECTIVE

Research into the scope and impact of EHR workarounds on patient care processes is scarce. This paper provides insight into the effects of EHR workarounds on organizational workflows and outcomes of care services by identifying EHR workarounds and determining their rationales, scope, and impact on health care providers' workflows, patient safety, effectiveness of care, and efficiency of care. Knowing the rationale of a workaround provides valuable clues about the source of origin of each workaround and how each workaround could most effectively be resolved. Knowing the scope and impact a workaround has on EHR-related safety, effectiveness, and efficiency provides insight into how to address related concerns.

METHODS

Direct observations and follow-up semistructured interviews with 31 physicians, 13 nurses, and 3 clerks and qualitative bottom-up coding techniques was used to identify, analyze, and classify EHR workarounds. The research was conducted within 3 specialties and settings at a large university hospital. Rationales were associated with work system components (persons, technology and tools, tasks, organization, and physical environment) of the Systems Engineering Initiative for Patient Safety (SEIPS) framework to reveal their source of origin as well as to determine the scope and the impact of each EHR workaround from a structure-process-outcome perspective.

RESULTS

A total of 15 rationales for EHR workarounds were identified of which 5 were associated with persons, 4 with technology and tools, 4 with the organization, and 2 with the tasks. Three of these 15 rationales for EHR workarounds have not been identified in prior research: data migration policy, enforced data entry, and task interference.

CONCLUSIONS

EHR workaround rationales associated with different SEIPS work system components demand a different approach to be resolved. Persons-related workarounds may most effectively be resolved through personal training, organization-related workarounds through reviewing organizational policy and regulations, tasks-related workarounds through process redesign, and technology- and tools-related workarounds through EHR redesign efforts. Furthermore, insights gained from knowing a workaround's degree of influence as well as impact on patient safety, effectiveness of care, and efficiency of care can inform design and redesign of EHRs to further align EHR design with work contexts, subsequently leading to better organization and (safe) provision of care. In doing so, a research team in collaboration with all stakeholders could use the SEIPS framework to reflect on the current and potential future configurations of the work system to prevent unfavorable workarounds from occurring and how a redesign of the EHR would impact interactions between the work system components.

Exploring Workarounds Related to Electronic Health Record System Usage: A Study Protocol

Background

Health care providers resort to informal temporary practices known as workarounds for handling exceptions to normal workflow that are unintentionally imposed by electronic health record (EHR) systems. Although workarounds may seem favorable at first sight, they are generally suboptimal and may jeopardize patient safety, effectiveness, and efficiency of care. Identifying workarounds and understanding their motivations, scope, and impact is pivotal to support the design of user-friendly EHRs and achieve closer alignment between EHRs and work contexts.

Objective

We propose a study protocol to identify EHR workarounds and subsequently determine their scope and impact on health care providers’ workflows, patient safety, effectiveness, and efficiency of care. First, knowing whether a workaround solely affects the health care provider who devised it, or whether its effects extends beyond the EHR user to the work context of other health care providers, is key to accurately assessing its degree of influence on the overall patient care workflow. Second, knowing whether the consequence of an EHR workaround is favorable or unfavorable provides insights into how to address EHR-related safety, effectiveness, and efficiency concerns. Knowledge of both perspectives can provide input on optimizing EHR designs.

Methods

In the study, a combination of direct observations, semistructured interviews, and qualitative coding techniques will be used to identify, analyze, and classify EHR workarounds. The research project will be conducted within three distinct pediatric care processes and settings at a large university hospital.

Results

Data was collected using the described approach from January 2016 to March 2017. Data analysis is underway and is expected to be completed in May 2017. We aim to report the results of this study in a follow-up publication.

Conclusions

This study protocol provides a grounded framework to explore EHR workarounds from a holistic and integral perspective. Insights from this study can inform the design and redesign of EHRs to further align with work contexts of healthcare professionals, and subsequently lead to better organization and safer provision of care.

Nursing Student Experiences Regarding Safe Use of Electronic Health Records: A Pilot Study of the Safety and Assurance Factors for EHR Resilience Guides

Previous research has linked improper electronic health record configuration and use with adverse patient events. In response to this problem, the US Office of the National Coordinator for Health Information Technology developed the Safety and Assurance Factors for EHR Resilience guides to evaluate electronic health records for optimal use and safety features. During the course of their education, nursing students are exposed to a variety of clinical practice settings and electronic health records. This descriptive study evaluated 108 undergraduate and 51 graduate nursing students' ratings of electronic health record features and safe practices, as well as what they learned from utilizing the computerized provider order entry and clinician communication Safety and Assurance Factors for EHR Resilience guide checklists. More than 80% of the undergraduate and 70% of the graduate students reported that they experienced user problems with electronic health records in the past. More than 50% of the students felt that electronic health records contribute to adverse patient outcomes. Students reported that many of the features assessed were not fully implemented in their electronic health record. These findings highlight areas where electronic health records can be improved to optimize patient safety. The majority of students reported that utilizing the Safety and Assurance Factors for EHR Resilience guides increased their understanding of electronic health record features.

Medication Errors Despite Using Electronic Health Records: The Value of a Clinical Pharmacist Service in Reducing Discharge-Related Medication Errors

BACKGROUND

Medication errors continue to exist despite the use of electronic health records and electronic prescribing; patient-centered medication reconciliation is important to decrease errors.

OBJECTIVE

To identify whether a team-based approach with a pharmacist performing medication management and discharge medication reconciliation will reduce discharge-related medication errors in an academic tertiary care hospital already using an electronic health record and computerized physician order entry.

DESIGN

Prospective nonrandomized controlled trial.

PATIENTS

All patients were admitted to 2 of the 6 medicine teams from August 1, 2012, through October 31, 2012.

INTERVENTION

On the intervention team, a pharmacist assisted with medication management, medication reconciliation, and medication education upon discharge. Although the physicians on the control team had access to a pharmacist, they rarely collaborated with the pharmacist. The numbers of discharge-related medication discrepancies on the intervention and control teams were compared.

RESULTS

Collaboration with a pharmacist reduced discharge-related medication errors. The percentage of patients without medication errors within 72 hours of discharge was 93.8% on the intervention team compared with 40.2% on the control team (P < .0001).

CONCLUSION

Pharmacist's involvement in the patient care team improved patient safety by decreasing discharge medication errors caused by using electronic health records and computerized physician order entry.

Development of Electronic Medical Record-Based “Rounds Report” Results in Improved Resident Efficiency, More Time for Direct Patient Care and Education, and Less Resident Duty Hour Violations

Surgeons frequently report frustration and loss of efficiency with electronic medical record (EMR) systems. Together, surgery residents and a programmer at Augusta University created a rounds report (RR) summarizing 24 hours of vitals, intake/output, labs, and other values for each inpatient that were previously transcribed by hand. The objective of this study was to evaluate the RR's effect on surgery residents. Surgery residents were queried to assess the RR's impact. Outcome measures were time spent preparing for rounds, direct patient care time, educational activity time, rates of incorrect/incomplete data on rounds, and rate of duty hour violations. Hospital wide, 17,200 RRs were generated in the 1-month study. Twenty-three surgery residents participated. Time spent preparing for rounds decreased per floor patient (15.6 ± 3.0 vs 6.0 ± 1.2, P < 0.0001) and per intensive care unit patient (19.9 ± 2.9 vs 7.5 ± 1.2 P < 0.0001). The work day spent in direct patient care increased from 45.1 ± 5.6 to 54.0 ± 5.7 per cent ( P = 0.0044). Educational activity time increased from 35.2 ± 5.4 to 54.7 ± 7.1 minutes per resident per day ( P = 0.0004). Reported duty hour violations decreased 58 per cent ( P < 0.0001). American Board of Surgery in Training exam scores trended up, and estimates of departmental annual financial savings range from $66,598 to $273,141 per year. Significant improvements occur with surgeon designed EMR tools like the RR. Hospitals and EMR companies should pair interested surgeons with health information technology developers to facilitate EMR enhancements. Improvements like RRs can have broad ranging, multidisciplinary impact and should be standard in all EMRs used for inpatient care at academic medical centers.

Reading and Writing: Qualitative Analysis of Pharmacists' Use of the EHR when Preparing for Team Rounds

In the collaborative hospital environment, pharmacists are important members of the healthcare team, yet compared to physicians and nurses, little is known about pharmacists' information needs or how they interact with the electronic health record (EHR). We directly observed seven clinical inpatient pharmacists as they interacted with the EHR preparing for clinical rounds using an eye-tracking camera and contextual inquiry. Pharmacists spent 50% of their time reading information from the EHR, such as notes and medication lists, and 27% of their time copying EHR data onto paper, such as patient history and laboratory results. In an environment where minutes count, the results of this study can help inform the development of CDS tools and/or EHR designs to facilitate the information needs of the pharmacists in providing care for their patients.

Impact of the Electronic Medical Record on Mortality, Length of Stay, and Cost in the Hospital and ICU: A Systematic Review and Metaanalysis

OBJECTIVE

To evaluate effects of health information technology in the inpatient and ICU on mortality, length of stay, and cost. Methodical evaluation of the impact of health information technology on outcomes is essential for institutions to make informed decisions regarding implementation.

DATA SOURCES

EMBASE, Scopus, Medline, the Cochrane Review database, and Web of Science were searched from database inception through July 2013. Manual review of references of identified articles was also completed.

STUDY SELECTION

Selection criteria included a health information technology intervention such as computerized physician order entry, clinical decision support systems, and surveillance systems, an inpatient setting, and endpoints of mortality, length of stay, or cost. Studies were screened by three reviewers. Of the 2,803 studies screened, 45 met selection criteria (1.6%).

DATA EXTRACTION

Data were abstracted on the year, design, intervention type, system used, comparator, sample sizes, and effect on outcomes. Studies were abstracted independently by three reviewers.

DATA SYNTHESIS

There was a significant effect of surveillance systems on in-hospital mortality (odds ratio, 0.85; 95% CI, 0.76-0.94; I=59%). All other quantitative analyses of health information technology interventions effect on mortality and length of stay were not statistically significant. Cost was unable to be quantitatively evaluated. Qualitative synthesis of studies of each outcome demonstrated significant study heterogeneity and small clinical effects.

CONCLUSIONS

Electronic interventions were not shown to have a substantial effect on mortality, length of stay, or cost. This may be due to the small number of studies that were able to be aggregately analyzed due to the heterogeneity of study populations, interventions, and endpoints. Better evidence is needed to identify the most meaningful ways to implement and use health information technology and before a statement of the effect of these systems on patient outcomes can be made.

Development and validation of electronic surveillance tool for acute kidney injury: A retrospective analysis

INTRODUCTION

Timely detection of acute kidney injury (AKI) facilitates prevention of its progress and potentially therapeutic interventions. The study objective is to develop and validate an electronic surveillance tool (AKI sniffer) to detect AKI in 2 independent retrospective cohorts of intensive care unit (ICU) patients. The primary aim is to compare the sensitivity, specificity, and positive and negative predictive values of AKI sniffer performance against a reference standard.

METHODS

This study is conducted in the ICUs of a tertiary care center. The derivation cohort study subjects were Olmsted County, MN, residents admitted to all Mayo Clinic ICUs from July 1, 2010, through December 31, 2010, and the validation cohort study subjects were all patients admitted to a Mayo Clinic, Rochester, campus medical/surgical ICU on January 12, 2010, through March 23, 2010. All included records were reviewed by 2 independent investigators who adjudicated AKI using the Acute Kidney Injury Network criteria; disagreements were resolved by a third reviewer. This constituted the reference standard. An electronic algorithm was developed; its precision and reliability were assessed in comparison with the reference standard in 2 separate cohorts, derivation and validation.

RESULTS

Of 1466 screened patients, a total of 944 patients were included in the study: 482 for derivation and 462 for validation. Compared with the reference standard in the validation cohort, the sensitivity and specificity of the AKI sniffer were 88% and 96%, respectively. The Cohen κ (95% confidence interval) agreement between the electronic and the reference standard was 0.84 (0.78-0.89) and 0.85 (0.80-0.90) in the derivation and validation cohorts.

CONCLUSION

Acute kidney injury can reliably and accurately be detected electronically in ICU patients. The presented method is applicable for both clinical (decision support) and research (enrollment for clinical trials) settings. Prospective validation is required.

The impact of adopting EHRs: how losing connectivity affects clinical reasoning

CONTEXT

As electronic health records (EHRs) are adopted by teaching hospitals, educators must examine how this change impacts trainee development.

OBJECTIVES

We investigate this influence by studying clinician experiences of a hospital's move from paper charts to an EHR. We ask: how does each chart modality present conceptions of time and data interconnections? How do these conceptions affect clinical reasoning?

METHODS

This two-phase, longitudinal study employed constructivist grounded theory. Data were collected at a paediatric teaching hospital before (Phase 1), during and after (Phase 2) the transition from a paper chart to an EHR system. Data collection consisted of field observations (146 hours involving 300 health care providers, 22 patients and 32 patient family members), think-aloud (n = 13) and think-after (n = 11) sessions, interviews (n = 39) and document retrieval (n = 392). Theories of rhetorical genre studies and visual rhetoric informed analysis.

RESULTS

In the paper flowsheet, clinicians recorded and viewed patient data in chronologically organised displays that emphasised data interconnections. In the EHR flowsheet, clinicians viewed and recorded individual data points that were largely chronologically and contextually isolated. Clinicians reported that this change resulted in: (i) not knowing the patient's evolving status; (ii) increased cognitive workload, and (iii) loss of clinical reasoning support mechanisms.

CONCLUSIONS

Understanding how patient data are interconnected is essential to clinical reasoning. The use of EHRs supports this goal because the EHR is a tool for collecting dispersed data; however, these collections often deconstruct data interconnections. Where the paper flowsheet emphasises chronology and interconnectedness, the EHR flowsheet emphasises individual data values that are largely independent of time and other patient data. To prepare trainees to work with EHRs, the ways of thinking and acting that were implicitly learned through the use of paper charts must be made explicit. To support clinical reasoning, medical educators should provide lessons in connectivity – the chronologically framed data interconnections upon which clinicians rely to provide patient care.

Pediatric aspects of inpatient health information technology systems

In the past 3 years, the Health Information Technology for Economic and Clinical Health Act accelerated the adoption of electronic health records (EHRs) with providers and hospitals, who can claim incentive monies related to meaningful use. Despite the increase in adoption of commercial EHRs in pediatric settings, there has been little support for EHR tools and functionalities that promote pediatric quality improvement and patient safety, and children remain at higher risk than adults for medical errors in inpatient environments. Health information technology (HIT) tailored to the needs of pediatric health care providers can improve care by reducing the likelihood of errors through information assurance and minimizing the harm that results from errors. This technical report outlines pediatric-specific concepts, child health needs and their data elements, and required functionalities in inpatient clinical information systems that may be missing in adult-oriented HIT systems with negative consequences for pediatric inpatient care. It is imperative that inpatient (and outpatient) HIT systems be adapted to improve their ability to properly support safe health care delivery for children.

Interoperability after deployment: persistent challenges and regional strategies in Denmark

QUALITY PROBLEM OR ISSUE

The European Union has identified Denmark as one of the countries who have the potential to provide leadership and inspiration for other countries in eHealth implementation and adoption. However, Denmark has historically struggled to facilitate data exchange between their public hospitals' electronic health records (EHRs). Furthermore, state-led projects failed to adequately address the challenges of interoperability after deployment.

CHOICE OF SOLUTION

Changes in the organizational setup and division of responsibilities concerning the future of eHealth implementations in hospitals took place, which granted the Danish regions the full responsibility for all hospital systems, specifically the consolidation of EHRs to one system per region.

IMPLEMENTATION

The regions reduced the number of different EHRs to six systems by 2014. Additionally, the first version of the National Health Record was launched to provide health care practitioners with an overview of a patient's data stored in all EHRs across the regions and within the various health sectors.

EVALUATION

The governance of national eHealth implementation plays a crucial role in the development and diffusion of interoperable technologies. Changes in the organizational setup and redistribution of responsibilities between the Danish regions and the state play a pivotal role in producing viable and coherent solutions in a timely manner.

LESSONS LEARNED

Interoperability initiatives are best managed on a regional level or by the authorities responsible for the provision of local health care services. Cross-regional communication is essential during the initial phases of planning in order to set a common goal for countrywide harmonization, coherence and collaboration.

Impact of Implementing an Electronic Health Record on Surgical Resident Work Flow, Duty Hours, and Operative Experience

Our objective was to assess the effect of implementing an electronic health record (EHR) on surgical resident work flow, duty hours, and operative experience at a large teaching hospital. In May 2012, an EHR was put into effect at our institution replacing paper documentation and orders. Resident time to complete patient documentation, average duty hours, and operative experience before EHR and afterward (at 1, 4, 6, 8, and 24 weeks) were surveyed. We obtained 100 per cent response rate from 15 surgical residents at all time intervals. The average time spent documenting before EHR was 9 ± 2 minutes per patient document and at Weeks 1, 4, 6, 8, and 24 after EHR implementation was 22 ± 10, 15 ± 7, 15 ± 7, 14 ± 8, and 12 ± 4 minutes, respectively. Repeated measures analysis of variance demonstrated a difference among the means ( P < 0.0001). Discharge summary and operative note remained significantly longer to complete at Week 24 compared with paper documentation ( P < 0.05). Average resident work hours and operative cases per week before EHR were 77 ± 5 hours and 12 ± 5 cases, respectively, which were similar at all time points after EHR implementation ( P > 0.05). At 24 weeks after EHR, 74 per cent of residents felt their risk of performing a medical error using electronic documentation and order entry was higher compared with paper charting and orders. Transition to EHR led to a significant doubling in resident time spent performing documentation for each patient. It improved over 6 months after implementation but never reached the pre-EHR baseline for operative notes and discharge summaries. Average resident work hours and case logs remained similar during this transition.

Contemporary health care economics: an overview

Economic evaluations provide a decision-making framework in which outcomes (benefits) and costs are assessed for various alternative options. Although the interest in complete and partial economic evaluations has increased over the past 2 decades, the quality of studies has been marginal due to methodological challenges or incomplete cost determination. This paper provides an overview of the main types of complete and partial economic evaluations, reviews key methodological elements to be considered for any economic evaluation, and reviews concepts of cost determination. The goal is to provide the clinician neurosurgeon with the knowledge and tools needed to appraise published economic evaluations and to direct high-quality health economic evaluations.

Meaningful Use Status and Participation in Health Information Exchange Among New York State Hospitals: A Longitudinal Assessment

BACKGROUND

Billions of dollars is being utilized to promote electronic health record (EHR) adoption and electronic health information exchange (HIE). Monitoring trends over time is critical to understanding the success of policies initiatives. New York State is a leader in state-based initiatives promoting health information technology (HIT), and its experiences can provide valuable lessons to inform ongoing state and federal efforts.

METHODS

All hospitals in New York State were previously surveyed in 2009 to determine rates of EHR adoption, preparedness to meet meaningful use criteria, and participation in HIE. A follow-up survey was conducted from November 2012 through February 2013 to evaluate progress over time.

RESULTS

Responses were received from 129 of 210 hospitals (61% response rate). Some 98% of responding hospitals (n = 126) had implemented or begun implementing an EHR-greater than a fourfold increase in three years. Nearly three-quarters had already attested to Stage 1 meaningful use for Medicaid (74.8%, n = 86) and Medicare (70.8%, n = 85), although only 10.7% (n = 13) anticipated it would be easy to achieve Stage 2 meaningful use. Seventy-nine percent of respondents (n = 92) reported exchanging electronic patient-level clinical data with other partners, and 89.9% (n = 116) reported participation in regional arrangements to share data. Lack of architecture and cost remain major barriers to achieving robust HIE.

DISCUSSION

Although much progress has been made since 2009, careful attention must be paid to helping hospitals meet the stricter Stage 2 meaningful use requirements and to supporting robust HIE to help fulfill HIT's promise of achieving higher-quality, lower-cost health care.