A study of user requests regarding the fully electronic health record system at Seoul National University Bundang Hospital: Challenges for future electronic health record systems

Participatory Design of a Medication Module in an Electronic Medical Record for Paediatric Palliative Care: A Think-Aloud Approach with Nurses and Physicians

BACKGROUND

Electronic medical records (EMRs) play a key role in improving documentation and quality of care in paediatric palliative care (PPC). Inadequate EMR design can cause incorrect prescription and administration of medications. Due to the fact of complex diseases and the resulting high level of medical complexity, patients in PPC are vulnerable to medication errors. Consequently, involving users in the development process is important. Therefore, the aim of this study was to evaluate the acceptance of a medication module from the perspective of potential users in PPC and to involve them in the development process.

METHODS

A qualitative observational study was conducted with 10 nurses and four physicians using a concurrent think-aloud protocol and semi-structured qualitative interviews. A qualitative content analysis was applied based on a unified theory of acceptance and use of technology.

RESULTS

Requirements from the user's perspective could be identified as possible influences on acceptance and actual use. Requirements were grouped into the categories "performance expectancies" and "effort expectancies".

CONCLUSIONS

The results serve as a basis for further development. Attention should be given to the reduction of display fragmentation, as it decreases cognitive load. Further approaches to evaluation should be taken.

Development of safety and usability guideline for clinical information system

Clinical information systems (CISs) that do not consider usability and safety could lead to harmful events. Therefore, we aimed to develop a safety and usability guideline of CISs that is comprehensive for both users and developers. And the guideline was categorized to apply actual clinical workflow and work environment.The guideline components were extracted through a systematic review of the articles published between 2000 and 2015, and existing CIS safety and/or usability design guidelines. The guideline components were categorized according to clinical workflow and types of user interface (UI). The contents of the guideline were evaluated and validated by experts with 3 specialties: medical informatics, patient safety, and human engineering.Total 1276 guideline components were extracted through article and guideline review. Of these, 464 guideline components were categorized according to 5 divisions of the clinical workflow: "Data identification and selection," "Document entry," "Order entry," "Clinical decision support and alert," and "Management". While 521 guideline components were categorized according to 4 divisions of UI: UIs related to information process steps, "Perception," "Recognition," "Control," and "Feedback". We developed a guideline draft with 219 detailed guidance for clinical task and 70 for UI. Overall appropriateness and comprehensiveness were proven to achieve more than 90% in experts' survey. However, there were significant differences among the groups of specialties in the judgment of appropriateness (P < .001) and comprehensiveness (P = .038).We developed and verified a safety and usability guideline for CIS that qualifies the requirements of both clinical workflows and usability issues. The developed guideline can be a practical tool to enhance the usability and safety of CISs. Further validation is required by applying the guideline for designing the actual CIS.

How well is the electronic health record supporting the clinical tasks of hospital physicians? A survey of physicians at three Norwegian hospitals

Background

The electronic health record is expected to improve the quality and efficiency of health care. Many novel functionalities have been introduced in order to improve medical decision making and communication between health care personnel. There is however limited evidence on whether these new functionalities are useful. The aim of our study was to investigate how well the electronic health record system supports physicians in performing basic clinical tasks.

Methods

Physicians of three prominent Norwegian hospitals participated in the survey. They were asked, in an online questionnaire, how well the hospital’s electronic health record system DIPS supported 49 clinical tasks as well as how satisfied they were with the system in general, including the technical performance. Two hundred and eight of 402 physicians (52%) submitted a completely answered questionnaire.

Results

Seventy-two percent of the physicians had their work interrupted or delayed because the electronic health record hangs or crashes at least once a week, while 22% had experienced this problem daily. Fifty-three percent of the physicians indicated that the electronic health record is cumbersome to use and adds to their workload. The majority of physicians were satisfied with managing tests, e.g., requesting laboratory tests, reading test results and managing radiological investigations and electrocardiograms. Physicians were less satisfied with managing referrals. There was high satisfaction with some of the decision support functionalities available for prescribing drugs. This includes drug interaction alerts and drug allergy warnings, which are displayed automatically. However, physicians were less satisfied with other aspects of prescribing drugs, including getting an overview of the ongoing drug therapy.

Conclusions

In the survey physicians asked for improvements of certain electronic health record functionalities like medication, clinical workflow support including planning and better overviews. In addition, there is apparently a need to focus on system stability, number of logins, reliability and better instructions on available electronic health record features. Considerable development is needed in current electronic health record systems to improve usefulness and satisfaction.

Change in blood pressure variability in patients with acute ischemic stroke and its effect on early neurologic outcome

Background

How short-term blood pressure variability (BPV) is affected in the acute stage of ischemic stroke and whether BPV is associated with early neurologic outcomes remains unclear.

Methods

Patients who admitted for ischemic stroke within 24 h of symptom onset were consecutively identified between January 2010 and January 2015. BP profiles measured in real-time were summarized into short-term, 24-h time intervals, based on standard deviation (SD) and mean of systolic BP (SBP_SD) during the first 3 days. The primary outcome was daily assessment of early neurological deterioration (END). The associations between short-term SBP_SD values and the secular trend for primary outcome were examined.

Results

A total of 2,545 subjects (mean age, 67.1 ± 13.5 years old and median baseline National Institutes of Health Stroke Scale score, 3) arrived at the hospital an average of 6.1 ± 6.6 h after symptom onset. SBP_SD values at day 1 (SD#D1), SD#D2, and SD#D3 were 14.4 ± 5.0, 12.5 ± 4.5, and 12.2 ± 4.6 mmHg, respectively. Multivariable analyses showed that SD#D2 was independently associated with onset of END at day 2 (adjusted odds ratio, 1.08; 95% confidence interval, 1.03–1.13), and SD#D3 was independently associated with END#D3 (1.07, 1.01–1.14), with adjustments for predetermined covariates, SBP_mean, and interactions with daily SBP_SD.

Conclusion

Short-term BPV changed and stabilized from the first day of ischemic stroke. Daily high BPV may be associated with neurological deterioration independent of BPV on the previous day.

Implementation Processes of Hospital Information Management Systems: A Field Study in Turkey

Our aim is to reflect our experience of developing and implementing of an integrated Hospital Information Management System (HIMS), its financing contributions, technical and managerial challenges and key designing and planning factors. Following the strategic planning stage, HIMS was implemented into the hospital. Key issues were observed, total training hours and satisfaction levels of staff were followed year by year. Number of patients, surgeries and total income of the hospital were analysed. Cessation of printing radiology films, paper and manpower earnings were calculated. After the implementation of HIMS, total income of the hospital increased 37% in the first year. Total financial savings (paper printing, radiology films and manpower) as a result of HIMS implementation were approximately US$ 1.34[Formula: see text]million. HIMS prevents losses and leakages of medical materials, medicines and unnecessary processes in healthcare institutions. For an appropriate implementation of HIMS, healthcare managers should lend priority to seven critical design and implementation issues: (1) effective accessibility, (2) interoperability and integration, (3) ease of use (4) improvement of the quality of processes (5) centralised administration, (6) privacy and digital security, (7) precautions against resistance to IT.

Applied Use of Composite Quality Measures for EHR-enabled Practices

Introduction:

The Primary Care Information Project (PCIP) of the New York City Department of Health and Mental Hygiene has been assisting providers to implement health information technology such as electronic health records (EHRs) since its founding in 2005. Currently, all practices affiliated with PCIP are offered technical support services in order to improve the use of the EHR. We studied the performance of clinical practices on EHR-derived Composite Quality Measures (CQMs) over time. Because specific EHR functionalities are important to calculating the quality measures, we hypothesize that performance on each of the CQMs will differ according to the EHR functionalities, and that this can inform the process of developing targeted technical assistance for the practices.

Methods:

We created four CQMs: (1) Screening, (2) Assessment, (3) Control-BP, and (4) Control-Other. Using data from 93 practices, we identified three tertiles of CQM performance (premier, average, and low tiers) for each measure. A scatterplot of CQMs in 2010 versus 2011 was used to examine the individual movement of practices by tier. A dependent t-test compared the change in mean CQMs, and a chi-square test examined the association between the score and performance tier changes.

Results:

Over a one-year period, low tier practices demonstrated the highest gains, average tier practices had modest gains, and premier tier practices had gains in some measures, but losses in others. On the Screening CQM 70 percent of practices remained within the same tier, with 60 percent on Assessment, 52 percent on Control-BP, and 38 percent on Control-Other; the Control-Other group showed the greatest improvement.

Discussion:

By considering EHR functionalities associated with each of the four CQMs, we suggest that technical assistance can be better targeted to low-tier performing practices. In addition, there is still the potential for improvement over time at practices more familiar with key functionalities.

Predictors for assessing electronic messaging between nurses and general practitioners as a useful tool for communication in home health care services: a cross-sectional study

Background

Nurses providing home health care services are dependent on access to patient information and communicating with general practitioners (GPs) to deliver safe and effective health care to patients. Information and communication technology (ICT) systems are viewed as powerful tools for this purpose. In Norway, a standardized electronic messaging (e-messaging) system is currently being established in health care.

Objective

The aim of this study was to explore home health care nurses’ assessments of the utility of the e-messaging system for communicating with GPs and identify elements that influence the assessment of e-messaging as a useful communication tool.

Methods

The data were collected using a self-developed questionnaire based on variables identified by focus group interviews with home health care nurses (n=425) who used e-messaging and existing research. Data were analyzed using logistic regression analyses.

Results

Over two-thirds (425/632, 67.2%) of the home health care nurses returned the questionnaire. A high proportion (388/399, 97.2%) of the home health care nurses who returned the questionnaire found the e-messaging system to be a useful tool for communication with GPs. The odds of reporting that e-messaging was a useful tool were over five times higher (OR 5.1, CI 2.489-10.631, P<.001) if the nurses agreed or strongly agreed that e-messaging was easy to use. The odds of finding e-messaging easy to use were nearly seven times higher (OR 6.9, CI 1.713-27.899, P=.007) if the nurses did not consider the system functionality poor. If the nurses had received training in the use of e-messaging, the odds were over six times higher (OR 6.6, CI 2.515-17.437, P<.001) that they would consider e-messaging easy to use. The odds that a home health care nurse would experience e-messaging as easy to use increased as the full-time equivalent percentage of the nurses increased (OR 1.032, CI 1.001-1.064, P=.045).

Conclusions

This study has shown that technical (ease of use and system functionality), organizational (training), and individual (full-time equivalent percentage) elements had an impact on home health care nurses’ assessments of using e-messaging to communicate with GPs. By identifying these elements, it is easier to determine which interventions are the most important for the development and implementation of ICT systems in home health care services.

Improving cardiovascular outcomes using electronic health records

Improving quality of care through the enhanced use of digital technologies is becoming an increasingly primary focus of the health care industry in general and cardiovascular (CV) medicine in particular. The recent rapid adoption of electronic health records (EHR) has the potential to improve the management of CV disease by removing variability and assuring at least consideration of guideline-recommended care and appropriate use criteria. This can lead to improved cardiac outcomes at all phases of care; beginning with the automated identification of patients who are at increased risk, implementing evidence based medicine for primary CV prevention, using online decision support tools for acute management, and, possibly most importantly, by connecting the health care provider and the patient through open accessibility to their EHR. The widespread use of EHR is the dawn of a new era where evidence based guidelines can be seamlessly translated to patient care and where patients are actively involved in their own health. As transformative as this will be, it is important to recognize that we are currently experiencing only the very earliest potential of the EHR in improving CV outcomes.

CADe system integrated within the electronic health record

The latest technological advances and information support systems for clinics and hospitals produce a wide range of possibilities in the storage and retrieval of an ever-growing amount of clinical information as well as in detection and diagnosis. In this work, an Electronic Health Record (EHR) combined with a Computer Aided Detection (CADe) system for breast cancer diagnosis has been implemented. Our objective is to provide to radiologists a comprehensive working environment that facilitates the integration, the image visualization, and the use of aided tools within the EHR. For this reason, a development methodology based on hardware and software system features in addition to system requirements must be present during the whole development process. This will lead to a complete environment for displaying, editing, and reporting results not only for the patient information but also for their medical images in standardised formats such as DICOM and DICOM-SR. As a result, we obtain a CADe system which helps in detecting breast cancer using mammograms and is completely integrated into an EHR.