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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

PRACTICAL IMPLICATIONS

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

Physicians' use of email with patients: factors influencing electronic communication and adherence to best practices

BACKGROUND

With the public's increased use of the Internet, the use of email as a means of communication between patients and physicians will likely increase. Yet, despite evidence of increased interest by patients, e-mail use by physicians for clinical care has been slow.

OBJECTIVE

To examine the factors associated with physician-patient e-mail, and report on the physicians' adherence to recognized guidelines for e-mail communication.

METHODS

Cross-sectional survey (March-May, 2005) of all primary care physicians (n = 10253), and a 25% stratified, random sample of all ambulatory clinical specialists (n = 3954) in the state of Florida. Physicians were surveyed on email use with patients, adherence to recognized guidelines, and demographics.

RESULTS

The 4203 physicians completed the questionnaire (a 28.2% participation rate). Of these, 689 (16.6%) had personally used e-mail to communicate with patients. Only 120 (2.9%) used e-mail with patients frequently. In univariate analysis, e-mail use correlated with physician age (decreased use: age > 61; P = .014), race (decreased use: Asian background; P < .001), medical training (increased use: family medicine, P = .001; or surgical specialty, P = .007; but not internal medicine, P = .112), practice size (> 50 physicians, P < .001), and geographic location (urban 17.2% vs. rural, 7.9%; P < .001). Multivariate modeling showed that only practice size greater than 50 (OR = 1.94; 95% CI = 1.01-3.79) and Asian-American race (OR = 0.26; 95% CI = 0.14-0.49) were related to e-mail use with patients. Remarkably, only 46 physicians (6.7%) adhered to at least half of the 13 selected guidelines for e-mail communication.

CONCLUSIONS

This large survey of physicians, practicing in ambulatory settings, shows only modest advances in the adoption of e-mail communication, and little adherence to recognized guidelines for e-mail correspondence. Further efforts are required to educate both patients and physicians on the advantages and limitations of e-mail communication, and to remove fiscal and legal barriers to its adoption.

Priorities and strategies for the implementation of integrated informatics and communications technology to improve evidence-based practice

The U.S. health care system is one of the world's most advanced systems. Yet, the health care system suffers from unexplained practice variations, major gaps between evidence and practice, and suboptimal quality. Although information processing, communication, and management are key to health care delivery and considerable evidence links information/communication technology (IT) to improvements in patient safety and quality of care, the health care system has a longstanding gap in its investment. In the Crossing the Quality Chasm and Building a Better Delivery System reports, The Institute of Medicine and National Academy of Engineering identified IT integration as critical to improving health care delivery systems. This paper reviews the state of IT use in the U.S. health care system, its role in facilitating evidence-based practices, and identifies key attributes of an ideal IT infrastructure and issues surrounding IT implementation. We also examine structural, financial, policy-related, cultural, and organizational barriers to IT implementation for evidence-based practice and strategies to overcome them.

Predicting the adoption of electronic health records by physicians: when will health care be paperless?

OBJECTIVES

The purpose of this study was threefold. First, we gathered and synthesized the historic literature regarding electronic health record (EHR) adoption rates among physicians in small practices (ten or fewer members). Next, we constructed models to project estimated future EHR adoption trends and timelines. We then determined the likelihood of achieving universal EHR adoption in the near future and articulate how barriers can be overcome in the small and solo practice medical environment.

DESIGN

This study used EHR adoption data from six previous surveys of small practices to estimate historic market penetration rates. Applying technology diffusion theory, three future adoption scenarios, optimistic, best estimate, and conservative, are empirically derived.

MEASUREMENT

EHR adoption parameters, external and internal coefficients of influence, are estimated using Bass diffusion models.

RESULTS

All three EHR scenarios display the characteristic diffusion S curve that is indicative that the technology is likely to achieve significant market penetration, given enough time. Under current conditions, EHR adoption will reach its maximum market share in 2024 in the small practice setting.

CONCLUSION

The promise of improved care quality and cost control has prompted a call for universal EHR adoption by 2014. The EHR products now available are unlikely to achieve full diffusion in a critical market segment within the time frame being targeted by policy makers.

Prevalence and incidence of adults consulting for shoulder conditions in UK primary care; patterns of diagnosis and referral

OBJECTIVES

To estimate the national prevalence and incidence of adults consulting for a shoulder condition and to investigate patterns of diagnosis, treatment, consultation and referral 3 yr after initial presentation.

METHODS

Prevalence and incidence rates were estimated for 658469 patients aged 18 and over in the year 2000 using a primary care database, the IMS Disease Analyzer-Mediplus UK. A cohort of 9215 incident cases was followed-up prospectively for 3 yr beyond the initial consultation.

RESULTS

The annual prevalence and incidence of people consulting for a shoulder condition was 2.36% [95% confidence interval (CI) 2.32-2.40%] and 1.47% (95% CI 1.44-1.50%), respectively. Prevalence increased linearly with age whilst incidence peaked at around 50 yr then remained static at around 2%. Around half of the incident cases consulted once only, while 13.6% were still consulting with a shoulder problem during the third year of follow-up. During the 3 yr following initial presentation, 22.4% of patients were referred to secondary care, 30.8% were prescribed non-steroidal anti-inflammatory drugs and 10.6% were given an injection by their general practitioner (GP). GPs tended to use a limited number of generalized codes when recording a diagnosis; just five of 426 possible Read codes relating to shoulder conditions accounted for 74.6% of the diagnoses of new cases recorded by GPs.

CONCLUSIONS

The prevalence of people consulting for shoulder problems in primary care is substantially lower than community-based estimates of shoulder pain. Most referrals occur within 3 months of initial presentation, but only a minority of patients are referred to orthopaedic specialists or rheumatologists. GPs may lack confidence in applying precise diagnoses to shoulder conditions.

Physicians And Ambulatory Electronic Health Records

Few U.S. physicians use outpatient electronic health records (EHRs), although it appears that most would like to begin. The main barriers are not technical, because adoption rates in other countries are high. The biggest barrier is reimbursement, because physicians must pay for EHRs, but most of the benefits accrue to payers and purchasers. The lack of interoperability is also pivotal. Others include capital and risk tolerance; physicians' resistance related to time concerns, fears about privacy, system maintenance, the number of vendors in the marketplace, and the transience of vendors. The key initial policy changes will be those addressing financial incentives and interoperability.

The validity of searching routinely collected general practice computer data to identify patients with chronic kidney disease (CKD): a manual review of 500 medical records

BACKGROUND

We conducted a search of 12 practices' routinely collected computer data in three localities across the UK and found that 4.9% of the registered population had an estimated glomerular filtration rate (GFR) of <60 ml/min/1.73 m(2) (equivalent to stages 3-5 CKD). Only 3.6% of these were known to have renal disease. Although UK general practice is computerized, important clinical data might be recorded in letters or free-text computer entries and might therefore be invisible to the standard computer search tools. We therefore manually searched through all the records of patients with stages 3-5 CKD in one practice, to test the validity of the computer generated diagnosis and to see if other relevant information was missed by the computer search.

METHODS

We identified 492 people with stages 3-5 CKD using computer searching and then manually searched their computer records and written notes for any missed data. The dataset included cardiovascular morbidities and risk factors including diabetes; drugs which may impair renal function; known renal disease; and terminal diagnoses and dementia.

RESULTS

The manual searches only added four renal diagnoses to the 36 already identified. Although heart failure and stroke appear to be over-estimated by computer searches, other cardiovascular diagnoses were reliably recorded. Cardiovascular risk factors and drug recording is a strength of general practice computer data. It is complete and contemporary, though most patients had scope to have their cardiovascular risk reduced further. Eighty-four percent had a haemoglobin estimation, and a higher proportion with reduced renal function were anaemic (P<0.001). Testing for proteinuria was less well recorded; negative stick tests were not recorded. Clinical diagnoses of prostatism and bladder outflow problems made these data hard to interpret.

CONCLUSIONS

Automated searching of general practice computer records could provide a reliable and valid way of identifying people with stages 3-5 CKD who could benefit from interventions readily available in primary care.

Identifying patients with chronic kidney disease from general practice computer records

BACKGROUND

Chronic kidney disease (CKD) is an important predictor of end-stage renal disease, as well as a marker of increased mortality. The New Opportunities for Early Renal Intervention by Computerised Assessment (NEOERICA) project aimed to assess whether people with undiagnosed CKD who might benefit from early intervention could be identified from GP computer records.

METHODS

The simplified Modification of Diet in Renal Disease (MDRD) equation was used to estimate glomerular filtration rate (GFR) and determine stage of CKD in patients from 12 practices in Surrey, Kent and Greater Manchester with SCr recorded in their notes. Further data were extracted on associated co-morbidities and potentially modifiable risk factors.

RESULTS

One quarter (25.7%; 28,862/112,215) had an SCr recorded and one in five (18.9%) of them had a GFR <60 ml/min/1.73 m2 (equivalent to Stage 3-5 CKD), representing 4.9% of the population. Only 3.6% of these were recorded as having renal disease. Three-quarters (74.6%; 4075/5449) of those with Stage 3-5 CKD had one or more circulatory diseases; 346 were prescribed potentially nephrotoxic drugs and over 4000 prescriptions were issued for drugs recommended to be used with caution in renal impairment.

CONCLUSIONS

Patients with CKD can be identified by searching GP computer databases; along with associated co-morbidities and treatment. Results revealed a similar rate of Stage 3-5 CKD to that found previously in the USA. The very low rate of recording of renal disease in patients found to have CKD indicates scope for improving detection and early intervention.

Infrastructure requirements for practice-based research networks

BACKGROUND

The practice-based research network (PBRN) is the basic laboratory for primary care research. Although most PBRNs include some common elements, their infrastructures vary widely. We offer suggestions for developing and supporting infrastructures to enhance PBRN research success.

METHODS

Information was compiled based on published articles, the PBRN Resource Center survey of 2003, our PBRN experiences, and discussions with directors and coordinators from other PBRNs.

RESULTS

PBRN research ranges from observational studies, through intervention studies, clinical trials, and quality of care research, to large-scale practice change interventions. Basic infrastructure elements such as a membership roster, a board, a director, a coordinator, a news-sharing function, a means of addressing requirements of institutional review boards and the Health Insurance Portability and Accountability Act, and a network meeting must exist to support these initiatives. Desirable elements such as support staff, electronic medical records, multiuser databases, mentoring and development programs, mock study sections, and research training are costly and difficult to sustain through project grant funds. These infrastructure elements must be selected, configured, and sized according to the PBRN's self-defined research mission. Annual infrastructure costs are estimated to range from $69,700 for a basic network to $287,600 for a moderately complex network.

CONCLUSIONS

Well-designed and properly supported PBRN infrastructures can support a wide range of research of great direct value to patients and society. Increased and more consistent infrastructure support could generate an explosion of pragmatic, generalizable knowledge about currently understudied populations, settings, and health care problems.

Electronic data collection options for practice-based research networks

PURPOSE

We wanted to describe the potential benefits and problems associated with selected electronic methods of collecting data within practice-based research networks (PBRNs).

METHODS

We considered a literature review, discussions with PBRN researchers, industry information, and personal experience. This article presents examples of selected PBRNs' use of electronic data collection.

RESULTS

Collecting research data in the geographically dispersed PBRN environment requires considerable coordination to ensure completeness, accuracy, and timely transmission of the data, as well as a limited burden on the participants. Electronic data collection, particularly at the point of care, offers some potential solutions. Electronic systems allow use of transparent decision algorithms and improved data entry and data integrity. These systems may improve data transfer to the central office as well as tracking systems for monitoring study progress. PBRNs have available to them a wide variety of electronic data collection options, including notebook computers, tablet PCs, personal digital assistants (PDAs), and browser-based systems that operate independent of or over the Internet. Tablet PCs appear particularly advantageous for direct patient data collection in an office environment. PDAs work well for collecting defined data elements at the point of care. Internet-based systems work well for data collection that can be completed after the patient visit, as most primary care offices do not support Internet connectivity in examination rooms.

CONCLUSIONS

When planning to collect data electronically, it is important to match the electronic data collection method to the study design. Focusing an inappropriate electronic data collection method onto users can interfere with accurate data gathering and may also anger PBRN members.

Statin use in the secondary prevention of coronary heart disease in primary care: cohort study and comparison of inclusion and outcome with patients in randomised trials

OBJECTIVE

To compare the social and demographic profiles of patients who receive statin treatment after myocardial infarction and patients included in randomised trials. To estimate the effect of statin use in community based patients on subsequent all cause mortality and cardiovascular recurrence, contrasting effects with trial patients.

DESIGN

Observational cohort study using a record linkage database.

SETTING

Tayside, Scotland (population size and characteristics: about 400,000, mixed urban and rural).

SUBJECTS

4892 patients were discharged from hospital after their first myocardial infarction between January 1993 and December 2001. 2463 (50.3%) were taking statins during an average follow-up of 3.7 years (3.1% in 1993 and 62.9% in 2001).

MAIN OUTCOME MEASURES

All cause mortality and recurrence of cardiovascular events.

RESULTS

319 deaths occurred in the statin treated group (age adjusted rate 4.1 per 100 person years, 95% confidence interval 3.2 to 4.9), and 1200 in the statin untreated group (12.7 per 100 person years, 11.1 to 14.3). More older people and women were represented in the population of patients treated with statins than among those recruited into clinical trials (mean age 67.8 v 59.8; women 39.6% v 16.9%, respectively). The effects of statins in routine clinical practice were consistent with, and similar to, those reported in clinical trials (adjusted hazard ratio for all cause mortality 0.69, 95% confidence interval 0.59 to 0.80; adjusted hazard ratio for cardiovascular recurrence 0.82, 0.71 to 0.95).

CONCLUSIONS

The community effectiveness of statins in those groups that were not well represented in clinical trials was similar to the efficacy of statins in these trials.

Accelerating U.S. EHR adoption: how to get there from here. recommendations based on the 2004 ACMI retreat

Despite growing support for the adoption of electronic health records (EHR) to improve U.S. healthcare delivery, EHR adoption in the United States is slow to date due to a fundamental failure of the healthcare information technology marketplace. Reasons for the slow adoption of healthcare information technology include a misalignment of incentives, limited purchasing power among providers, variability in the viability of EHR products and companies, and limited demonstrated value of EHRs in practice. At the 2004 American College of Medical Informatics (ACMI) Retreat, attendees discussed the current state of EHR adoption in this country and identified steps that could be taken to stimulate adoption. In this paper, based upon the ACMI retreat, and building upon the experiences of the authors developing EHR in academic and commercial settings we identify a set of recommendations to stimulate adoption of EHR, including financial incentives, promotion of EHR standards, enabling policy, and educational, marketing, and supporting activities for both the provider community and healthcare consumers.

Design and implementation of a web-based HL7 message generation and validation system

Health level 7 (HL7) is the standard of electronic data interchange in the health domain. We have developed a web-based message generation and validation system for testing the message format of the data exchange among hospitals and health organizations. Compared with other existing ones, this system has incorporated several novel functions that optimize medical data exchange and helps medical students in learning HL7 messages. When receiving HL7 message from another system with the hypertext transmission protocol or accepting an uploaded HL7 message file, the system shows the validation result through a web browser. In this platform, users may input and edit medical data on-line to test and generate standard HL7 messages. The system supports various data formats and is capable of transforming HL7 messages between the standard delimiter format and the extensible markup language format. This system has been successfully passed our system evaluation among 139 student users for HL7 training. Most of the users agreed that the system is helpful for medical data exchange.

Surfing for health: user evaluation of a health information website. Part one: Background and literature review

The Government in Britain is set on using the Internet to expand the provision of health information to the general public. Concerns over the quality of the health information have preoccupied commentators and organizations rather than the way users interact with health information systems. This report examines the issues surrounding the provision of electronic health information, and describes an evaluation undertaken of a commercial health website-that of Surgerydoor (http://www.surgerydoor.co.uk/), and comprises two parts. Part one outlines the literature on electronic health information evaluation. It discusses quality issues, but also redresses the imbalance by exploring other evaluative perspectives. Part two describes an evaluation of a health information Internet site in terms of its usability and appeal, undertaken as part of a Department of Health funded study on the impact of such systems.

Towards personal health record: current situation, obstacles and trends in implementation of electronic healthcare record in Europe

In this article, we define the electronic healthcare record and present its purpose as a tool for continuity of care. We briefly describe the current situation of usage and focus on the major challenges to wide implementation in Europe and beyond. Finally, we point out trends that show stronger involvement of the patients-citizens in the health care prevention and promotion processes, and discuss the impact on the future development of the electronic healthcare record into personal health records.