Positive effects of electronic patient records on three clinical activities

The Effect of the Electronic Health Record on Interprofessional Practice: A Systematic Review

BACKGROUND

 Interprofessional practice and teamwork are critical components to patient care in a complex hospital environment. The implementation of electronic health records (EHRs) in the hospital environment has brought major change to clinical practice for clinicians which could impact interprofessional practice.

OBJECTIVES

 The aim of the study is to identify, describe, and evaluate studies on the effect of an EHR or modification/enhancement to an EHR on interprofessional practice in a hospital setting.

METHODS

 Seven databases were searched including PubMed, Scopus, Web of Science, CINAHL, Cochrane, EMBASE, and ACM Digital Library until November 2021. Subject heading and title/abstract searches were undertaken for three search concepts: "interprofessional" and "electronic health records" and "hospital, personnel." No date limits were applied. The search generated 5,400 publications and after duplicates were removed, 3,255 remained for title/abstract screening. Seventeen studies met the inclusion criteria and were included in this review. Risk of bias was quantified using the Quality Assessment Tool for Studies with Diverse Designs. A narrative synthesis of the findings was completed based on type of intervention and outcome measures which included: communication, coordination, collaboration, and teamwork.

RESULTS

 The majority of publications were observational studies and of low research quality. Most studies reported on outcomes of communication and coordination, with few studies investigating collaboration or teamwork. Studies investigating the EHR demonstrated mostly negative or no effects on interprofessional practice (23/31 outcomes; 74%) in comparison to studies investigating EHR enhancements which showed more positive results (20/28 outcomes; 71%). Common concepts identified throughout the studies demonstrated mixed results: sharing of information, visibility of information, closed-loop feedback, decision support, and workflow disruption.

CONCLUSION

 There were mixed effects of the EHR and EHR enhancements on all outcomes of interprofessional practice, however, EHR enhancements demonstrated more positive effects than the EHR alone. Few EHR studies investigated the effect on teamwork and collaboration.

A survey of ambulance clinicians' perceptions of recording and communicating patient information electronically

Objective:

Ambulance services are evolving from use of paper-based recording of patient information to electronic platforms and the impact of this change has yet to be fully explored. The aim of this study is to explore how the introduction of a system permitting electronic information capture and its subsequent sharing were perceived by the ambulance clinicians using it.

Methods:

An online questionnaire was designed based upon the technology acceptance model and distributed throughout one ambulance service in the south east of England. Closed-ended questions with Likert scales were used to collect data from patient-facing staff who use an online community falls and diabetic referral platform or an electronic messaging system to update GPs following a patient encounter.

Results:

There were 273 responses from ambulance clinicians. Most participants agreed that they used tablet computers and smartphones to make their life easier (85% and 86%, respectively). Most participants felt that referring patients to a community falls or diabetic team electronically was an efficient use of their time (81% and 81%, respectively) and many believed that these systems improved the communication of confidential patient information. GP summaries were perceived as increasing time spent on scene but most participants (89%) believed they enabled collaborative working. Overall, collecting and sharing patient information electronically was perceived by most participants as beneficial to their practice.

Conclusion:

In this study, the ability to electronically refer patients to community services and share patient encounters with the GP was predominantly perceived as both safe for patients and an effective use of the participants’ clinical time. However, there is often still a need to communicate to GPs in real time, demonstrating that technology could complement, rather than replace, how clinicians communicate.

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.

Cognitive Maps to Visualise Clinical Cases in Handovers

Background: Clinical handovers at changes of shifts are typical scenarios of time restricted and information intensive communication, which are highly cognitively demanding. The currently available applications supporting handovers typically present complex information in a textual checklist-like manner. This presentation style has been criticised for not meeting the specific user requirements.

Objectives: We, therefore, aimed at developing a concept for visualising the overview of a clinical case that serves as an alternative way to checklist-like presentations in clinical handovers. We also aimed at implementing this concept in a handoverEHR in order to support the pre-handover phase, the actual handover, and the post-handover phase as well as at evaluating its usability and attractiveness.

Results: We developed and implemented a concept that draws on Tolman’s pioneering work on cognitive maps that we designed in accordance with Gestalt principles. These maps provide a pictorial overview of a clinical case. The application to build, manipulate, and store the cognitive maps was integrated into an openEHR based handover record that extends conventional records with handover specific information. Usability (n = 28) and attractiveness (n = 26) testing with experienced clinicians resulted in good ratings for suitability for the task as well as for attractiveness and pragmatism.

Conclusion: We propose cognitive maps to represent and visualise the clinical case in situations where there is limited time to present complex information.

Does adoption of electronic health records improve organizational performances of hospital surgical units? Results from the French e-SI (PREPS-SIPS) study

BACKGROUND

Electronic health records (EHR) are increasingly being adopted by healthcare systems worldwide. In France, the "Hôpital numérique 2012-2017" program was implemented as part of a strategic plan to modernize health information technology (HIT), including promotion of widespread EHR use. With significant upfront investment costs as well as ongoing operational expenses, it is important to assess this system in terms of its ability to result in improvements in hospital performances. The aim of this study was to evaluate the impact of EHR use on the organizational performances of acute care hospital surgical units throughout France.

METHODS

This retrospective study was based on data derived from three national databases for year the 2012: IPAQSS (Indicators of improvement in the quality and the management of healthcare, "IPAQSS"), Hospi-Diag (French hospital performance indicators), and the national accreditation database. National data and methodological support were provided by the French Ministry of Health (DGOS) and the French National Authority for Health (HAS). Multivariate linear models were used to assess four organizational performance indicators: the occupancy rate of surgical inpatient beds, operating room utilization, the activity per surgeon, and the activity per both nurse anesthetist and anesthesiologist which were dependent variables. Several independent variables were taken into account, including the degree of EHR use.

RESULTS

The models revealed a significant positive impact of EHR use on operating room utilization and bed occupancy rates for surgical inpatient units. No significant association was found between the activity per surgeon or the activity per nurse anesthetist and anesthesiologist with EHR use. All four organizational performance indicators were impacted by the type of hospital, the geographical region, and the severity of the pathologies.

CONCLUSION

We were able to verify the purported potential benefits of EHR use on the organizational performances of surgical units in French hospitals.

Electronic versus paper records: documentation of pressure ulcer data

BACKGROUND

The documentation of patient data on health records is a vital component of the care process. Accurate and complete recording of this data is a necessary practice. The adoption of electronic health records to improve the quality of nursing documentation is on the rise.

OBJECTIVES

This study compares the accuracy and completeness of pressure ulcer data documentation between electronic and paper records.

DESIGN

A descriptive, comparative design with a retrospective review of patient records. Settings and sample: Two hospitals were chosen purposefully, one using electronic recording of patient data and the other using paper records.

METHODS

In the first phase, all hospitalised patients aged 18 years and over were inspected for pressure ulcers. In the second phase, the files of patients with pressure ulcers were audited.

RESULTS

Of the 52 patients with ulcers found in the hospital that used an electronic system, 43 of their records documented the pressure ulcers (83%). Of the 55 patients with pressure ulcers in the hospital using paper records, 39 files had corresponding documentation of the presence of a pressure ulcer (71%).

CONCLUSION

In terms of accuracy and completeness, more comprehensive documentation practice was found on the electronic health records compared with paper records. However, both types of systems have shortcomings in the practice of pressure ulcer data documentation.

Citation analysis of the prognosis of Haux et al. for the year 2013

In 2002, Haux, Ammenwerth, Herzog, and Knaup published a prognosis about health care in the information society. In contrast to other prognoses, they underpinned their 30 theses with 71 quantitative statements that could be easily checked. A citation analysis was performed to assess the perception of this work in the medical informatics community. The ISI Web of Science was used for the citation search. From 55 hits, 38 articles were finally included in the metadata analysis, 33 articles in the qualitative analysis. The most prominent statement citing the paper of Haux et al. was identified in each article, divided into statements about the present and those about the future. Each statement was tagged with one keyword out of a convenient list. One article provided a statement about the present and the future. Most of the references were published in English as journal articles between 2006 and 2009. The majority of the first authors were from Europe. Twenty-two articles offered a statement about the present, 12 about the future. There was a shift from the present emphasis on electronic medical records and information and communication technologies to challenges in the future because of an aging population and the advent of personalized medicine. The citing papers seemed to be representative of medical informatics in terms of journals and the authors' countries of origin. The statements relating the citing literature with the paper of Haux et al. corresponded well with current notions about medical informatics. However, there was no debate about the concrete theses and prognoses offered in the cited paper. Therefore, the medical informatics community needs to rethink its own citation strategy.

Mental workload as a key factor in clinical decision making

The decision making process is central to the practice of a clinician and has traditionally been described in terms of the hypothetico-deductive model. More recently, models adapted from cognitive psychology, such as the dual process and script theories have proved useful in explaining patterns of practice not consistent with purely cognitive based practice. The purpose of this paper is to introduce the concept of mental workload as a key determinant of the type of cognitive processing used by clinicians. Published research appears to be consistent with 'schemata' based cognition as the principle mode of working for those engaged in complex tasks under time pressure. Although conscious processing of factual data is also used, it may be the primary mode of cognition only in situations where time pressure is not a factor. Further research on the decision making process should be based on outcomes which are not dependant on conscious recall of past actions or events and include a measure of mental workload. This further appears to support the concept of the patient, within the clinical environment, as the most effective learning resource.

Can we make postoperative patient handovers safer? A systematic review of the literature

Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.

Measurement of mental workload in clinical medicine: a review study

Background:

Measures of mental workload are now commonly used in industries to identify sources of error and to improve performance.

Objectives:

This study aimed to review the evidence for the use of this technique within medicine.

Patients and Methods:

We used search engines and the internet to identify experimental studies that included a measure of mental workload in medical practitioners or trainees/students. Studies that aimed to measure mental “stress” as a disorder, or “productivity” were excluded. Each abstract and then the full paper were appraised prior to inclusion.

Results:

Thirty-three studies were identified that matched the inclusion criteria. Although these covered a variety of settings, common methods were identifiable. The results support the concept of mental workload measurement as an important factor in medical performance.

Conclusions:

The limited number of studies and the variety of definitions and measurement techniques used in these studies, make direct comparisons difficult. However, the utility of this methodology in medical education appears to have been established, and guidelines for further research methods are proposed.

That's nice, but what does IT do? Evaluating the impact of bar coded medication administration by measuring changes in the process of care

Health information technology (IT) is widely endorsed as a way to improve key health care outcomes, particularly patient safety. Applying a human factors approach, this paper models more explicitly how health IT might improve or worsen outcomes. The human factors model specifies that health IT transforms the work system, which transforms the process of care, which in turn transforms the outcome of care. This study reports on transformations of the medication administration process that resulted from the implementation of one type of IT: bar coded medication administration (BCMA). Registered nurses at two large pediatric hospitals in the US participated in a survey administered before and after one of the hospitals implemented BCMA. Nurses' perceptions of the administration process changed at the hospital that implemented BCMA, whereas perceptions of nurses at the control hospital did not. BCMA appeared to improve the safety of the processes of matching medications to the medication administration record and checking patient identification. The accuracy, usefulness, and consistency of checking patient identification improved as well. In contrast, nurses' perceptions of the usefulness, time efficiency, and ease of the documentation process decreased post-BCMA. Discussion of survey findings is supplemented by observations and interviews at the hospital that implemented BCMA. By considering the way that IT transforms the work system and the work process a practitioner can better predict the kind of outcomes that the IT might produce. More importantly, the practitioner can achieve or prevent outcomes of interest by using design and redesign aimed at controlling work system and process transformations.

Exploring the usability of the ISO reference terminology model for nursing actions in representing oriental nursing actions

PURPOSE

This study examined the extent to which the ISO reference terminology model for nursing actions represents oriental nursing actions in a computerized nursing documentation system to share data and foster communication between oriental nursing care and conventional nursing care.

METHODS

The narrative nursing notes of 545 patients retrieved from a nursing documentation system in an oriental medicine teaching hospital were analyzed. Among 49,118 entries, 933 were recorded as nursing actions. Each entry was decomposed in a set of single statements. A total of 1209 nursing action statements were derived and mapped to the components of the model. These processes were reviewed and validated by two domain experts and a nursing terminology expert.

RESULTS

All of the oriental nursing actions documented contained a word or phrase that described the Action and Target in the model. The Recipient of Care was expressed explicitly in 1.2% of statements. The most frequently used Action terms were 'administering' (19.7%), 'teaching' (16.5%), and 'explaining' (13.6%). The Target terms that indicated unique oriental nursing concepts included 'Sasang constitution differentiation', 'removal of acupuncture needles', 'herb moxibustion', 'oriental massage', and 'oriental medication'.

CONCLUSION

The findings demonstrate that oriental nursing actions can be represented using the ISO reference terminology model for nursing actions. Further specification of the components of the model will be useful to achieve consistent mapping across different settings. The addition of component qualifiers should also be taken into consideration to describe nursing actions at a more granular level.

Towards a comprehensive electronic patient record to support an innovative individual care concept for premature infants using the openEHR approach

PURPOSE

This paper introduces the modelling of a prototype neonatology electronic patient record (EPR) using openEHR archetypes. The EPR is necessary to support the complex communication tasks of the innovative concept of 'Developmental, Family-Centred, Individual Care of Premature Infants and Newborns' established for the Department of Neonatology at Heidelberg University Hospital.

METHODS

The data to be documented was analysed and modelled using the five step openEHR data modelling approach (odma).

RESULTS

The analysis revealed a total of 1818 items, which could be arranged into 70 clinical concepts. The items and concepts were then mapped to 132 openEHR archetypes. Fifty-eight of these archetypes could be reused either directly or via specialisation from the existing openEHR archetypes. A further 67 archetypes were newly developed. To combine and constrain archetypes for local settings 16 templates were developed.

CONCLUSION

By using the five step openEHR data modelling approach, semantic interoperability, and a reduced need for repeated documentation of the same data can be realised. This is of major importance within the hospital as well as for trans-institutional data exchange.