The quality of electronic patient records in Finnish primary healthcare needs to be improved

Documentation of comorbidities, lifestyle factors, and asthma management during primary care scheduled asthma contacts

Systematically assessing asthma during follow-up contacts is important to accomplish comprehensive treatment. No previous long-term studies exist on how comorbidities, lifestyle factors, and asthma management details are documented in scheduled asthma contacts in primary health care (PHC). We showed comorbidities and lifestyle factors were poorly documented in PHC in this real-life, 12-year, follow-up study. Documented information on rhinitis was found in 8.9% and BMI, overweight, or obesity in ≤1.5% of the 542 scheduled asthma contacts. Of the 145 patients with scheduled asthma contacts, 6.9% had undergone revision of their inhalation technique; 16.6% had documentation of their asthma action plan. Screening of respiratory symptoms was recorded in 79% but nasal symptoms in only 15.5% of contacts. Lifestyle guidance interventions were found in <1% of contacts. These results, based on documented patient data, indicate a need exists to further improve the assessment and guidance of asthma patients in PHC.

Audit and feedback intervention: An examination of differences in chiropractic record-keeping compliance

Objective : The objective of this study was to investigate the association of a clinical documentation quality improvement program using audit-feedback with clinical compliance to indicators of quality chart documentation. Methods : This was an analysis of differences between adherence to quality indicators of chiropractic record documentation and audit-feedback intervention (feedback report only vs. feedback report with one-on-one educational consultation) at different campuses. Comparisons among groups were analyzed using analysis of variance (ANOVA), Tukey or Dunnett post hoc tests, and Cohen's d effect size estimates. Results : There was a significant increase in the mean percentile compliance in 2 of 5 compliance areas and 1 of 11 compliance objectives. Campus B demonstrated significantly higher levels of compliance relative to campus A and/or campus C in 5 of 5 compliance areas and 7 of 11 compliance objectives. Across-campus comparisons indicated that the compliance area Review (Non-Medicare) Treatment Plan [F(2,18) = 17.537, p < .001] and compliance objective Treatment Plan Goals [F(2,26) = 5.653, p < .001] exhibited the highest practical importance for clinical compliance practice. Conclusions : Feedback of performance improved compliance to indicators of quality health record documentation, especially when baseline adherence is relatively low. Required educational consultations with clinicians combined with audit-feedback were no more effective at increasing compliance to indicators of quality health record documentation than audit-feedback alone.

Electronic discharge summaries in cross-border care in the European Union: How close are we to making it happen?

Introduction

The political drive for cross-border care within the European Union and an increasing focus on integrated care both have implications for electronic health records. The hospital discharge summary is a critical component of systems to ensure quality and continuity of care, and in a cross-border setting would particularly benefit from an electronic version. We have explored the extent to which European Union level policy and practice on electronic health records address issues pertinent to the development and implementation of electronic discharge summaries for patients treated outside their own country.

Methods

We approached the topic by analysing data from two different sources: European Union policy documents on topics relevant to electronic health records and deliverables of European Union-funded electronic health record-focused research and development projects. Elements pertinent to different aspects of interoperability – legal, semantic and technical – were extracted from both sources and their content compared to assess the degree of consistency between policy and implementation targets.

Results

We identified 25 policy documents and 14 European Union-funded projects. Our results show that European legislation is increasingly aligned with projects funded through European Union sources and substantial progress has been accomplished in achieving electronic communication across European health systems. Nevertheless, the achievement of a European level interoperable discharge summary is still a distant goal, while inadequate attention has been paid to the coordination of current discharge summary practices in Member States.

Discussion

If the harmonized European Union patient summary is also to function as an electronic discharge summary, further specific steps are needed that address issues of both content and processes related to communication.

Reasons for encounter and symptom diagnoses: a superior description of patients' problems in contrast to medically unexplained symptoms (MUS)

This is a review of the literature on the role of symptoms in family practice, with a focus on the diagnostic approach in family medicine (FM). We found two, contrasting, approaches to reducing symptoms presented by patients in primary care, especially those which do not immediately allow the definition of a disease-label diagnosis. Years of research into 'medically unexplained symptoms' (MUS) has failed to support an international body of knowledge and cannot convincingly support the philosophy on which the reduction itself is based. This review supports the approach of researching reasons for encounter as they present to the family doctor, without artificial mind-body metaphors. The medical model is shown to be an incomplete reduction of FM, and the concept of MUS fails to improve this situation. A new model based on a substantial paradigm shift is needed. That model should be the biopsychosocial model, reflected in the philosophical concepts of the International Classification of Primary Care and the value of the patient's 'reason for encounter'. There is more to life than medicine may diagnose, and FM should strive to move closer to the lives of our patients than the medical model alone could allow.

Impact of electronic medical record on physician practice in office settings: a systematic review

BACKGROUND

Increased investments are being made for electronic medical records (EMRs) in Canada. There is a need to learn from earlier EMR studies on their impact on physician practice in office settings. To address this need, we conducted a systematic review to examine the impact of EMRs in the physician office, factors that influenced their success, and the lessons learned.

RESULTS

For this review we included publications cited in Medline and CINAHL between 2000 and 2009 on physician office EMRs. Studies were included if they evaluated the impact of EMR on physician practice in office settings. The Clinical Adoption Framework provided a conceptual scheme to make sense of the findings and allow for future comparison/alignment to other Canadian eHealth initiatives.In the final selection, we included 27 controlled and 16 descriptive studies. We examined six areas: prescribing support, disease management, clinical documentation, work practice, preventive care, and patient-physician interaction. Overall, 22/43 studies (51.2%) and 50/109 individual measures (45.9%) showed positive impacts, 18.6% studies and 18.3% measures had negative impacts, while the remaining had no effect. Forty-eight distinct factors were identified that influenced EMR success. Several lessons learned were repeated across studies: (a) having robust EMR features that support clinical use; (b) redesigning EMR-supported work practices for optimal fit; (c) demonstrating value for money; (d) having realistic expectations on implementation; and (e) engaging patients in the process.

CONCLUSIONS

Currently there is limited positive EMR impact in the physician office. To improve EMR success one needs to draw on the lessons from previous studies such as those in this review.

The medico-professional quality of GP consultations assessed by analysing patient records

OBJECTIVE

To assess the medico-professional quality of consultations by analysing textual data from patient records.

DESIGN

Qualitative analyse of textual data.

SETTING

Four primary health care centres using electronic patient records (EPR) in Finland.

SUBJECTS

EPR and paired questionnaires of 175 consultations filled in by GPs and their patients independently.

MAIN OUTCOME MEASURES

Medico-professional quality of consultations, quality of care of acute respiratory infections, and hypertension.

RESULTS

The medico-professional quality of the consultations was quite good. However, 9% of the records could not been assessed at all because of missing or poor documentation and 9% were assessed as poor. The treatment of acute respiratory infections and hypertension is not in line with current care guidelines. Smoking habits or other health behaviour or lifestyle factors were seldom recorded.

CONCLUSIONS

The medico-professional quality of the consultation was quite good. Quality improvement is needed in the treatment of acute respiratory infections and hypertension. User-friendly EPR systems would improve the content of patient records.

The impact of the electronic medical record on structure, process, and outcomes within primary care: a systematic review of the evidence

BACKGROUND

The electronic medical record (EMR)/electronic health record (EHR) is becoming an integral component of many primary-care outpatient practices. Before implementing an EMR/EHR system, primary-care practices should have an understanding of the potential benefits and limitations.

OBJECTIVE

The objective of this study was to systematically review the recent literature around the impact of the EMR/EHR within primary-care outpatient practices.

MATERIALS AND METHODS

Searches of Medline, EMBASE, CINAHL, ABI Inform, and Cochrane Library were conducted to identify articles published between January 1998 and January 2010. The gray literature and reference lists of included articles were also searched. 30 studies met inclusion criteria.

RESULTS AND DISCUSSION

The EMR/EHR appears to have structural and process benefits, but the impact on clinical outcomes is less clear. Using Donabedian's framework, five articles focused on the impact on healthcare structure, 21 explored healthcare process issues, and four focused on health-related outcomes.

Use of Headings and Classifications by Physicians in Medical Narratives of EHRs: An evaluation study in a Finnish hospital

OBJECTIVE

The purpose of this study was to describe and evaluate patient care documentation by hospital physicians in EHRs and especially the use of national headings and classifications in these documentations.

MATERIAL AND METHODS

The initial material consisted of a random sample of 3,481 medical narratives documented in EHRs during the period 2004-2005 in one department of a Finnish central hospital. The final material comprised a subset of 1,974 medical records with a focus on consultation requests and consultation responses by two specialist groups from 871 patients. This electronic documentation was analyzed using deductive content analyses and descriptive statistics.

RESULTS

The physicians documented patient care in EHRs principally as narrative text. The medical narratives recorded by specialists were structured with headings in less than half of the patient cases. Consultation responses in general were more often structured with headings than consultation requests. The use of classifications was otherwise insignificant, but diagnoses were documented as ICD 10 codes in over 50% of consultation responses by both medical specialties.

CONCLUSION

There is an obvious need to improve the structuring of narrative text with national headings and classifications. According to the findings of this study, reason for care, patient history, health status, follow-up care plan and diagnosis are meaningful headings in physicians' documentation. The existing list of headings needs to be analyzed within a consistent unified terminology system as a basis for further development. Adhering to headings and classifications in EHR documentation enables patient data to be shared and aggregated. The secondary use of data is expected to improve care management and quality of care.

Good pregnancy outcome despite intrahepatic cholestasis

OBJECTIVE

Pregnant women complaining of itching are screened for intrahepatic cholestasis (ICP) by laboratory tests in primary healthcare. Cases of ICP are referred to specialist care. In Finland, ICP occurs in 1% of pregnancies. The aim was to study the outcome of deliveries. Design. Retrospective study of ICP pregnancies. Data were collected from the hospital discharge register, patient records, and the labour register.

SETTING

The region of Tampere University Hospital in Finland.

SUBJECTS

Altogether 687 ICP cases from 1969 to 1988 and two controls for each. Main outcome measures. ICP patients were compared with controls in terms of mother's age, pregnancy multiplicity, weeks of gestation at delivery, frequency of induction and Caesarean section, length of ward period, child's weight, Apgar scores, and stillbirth.

RESULTS

For ICP patients, the risk for hospital stay of 10 days or more was eightfold (OR 8.41), for gestational weeks less than 37 at delivery sevenfold (OR 7.02), for induction threefold (OR 3.26), for baby's low weight at birth almost twofold (OR 1.86), and for Caesarean section one and a half fold (OR 1.47). The possibility of the incidence of multiple pregnancy was two and a half fold (OR 2.49, 95%). ICP was not associated with mother's age, the baby's risk of stillbirth, or low Apgar scores.

CONCLUSION

ICP mothers are found and taken care of appropriately, and thus ICP is only a minor risk for mothers and their children.

Three- and four-digit ICD-10 is not a reliable classification system in primary care

OBJECTIVE

The International Classification of Diseases 10th revision (ICD-10) is a standard international diagnostic classification for medical diagnoses. Reliable diagnostic coding is of high medical and epidemiological importance. Coding diagnoses with ICD-10 is the basis of reimbursement in some healthcare systems.

DESIGN

The ICD-10 coding of each case was performed by two raters to investigate the inter-rater agreement. The degree of agreement was assessed using Cohen's kappa. Kappa was divided into two groups: Kappa > or = 0.61 meaning high or satisfactory and kappa < or = 0.6 (incl. < or = 0.000 and 0.000*) meaning low or unsatisfactory.

SUBJECTS

Cross-sectional data were collected from 8877 randomly selected patients. The 209 participating general practitioners used a standardized data collection form. The first of the reasons for encounter was taken into account on new and chronic managed problems.

RESULTS

Kappa values were satisfactory on the chapter level with on average 0.685 (chronic managed problems) and 0.675 (new managed problems). Kappa was unsatisfactory when the three-digit level was used (0.428) and lower for terminal codes (four-digit level) at 0.199 on average (chronic managed problems). For new managed problems the kappa values were at 0.384 (three-digit level) and 0.166 (four-digit level) on average.

CONCLUSION

The ICD-10 is reliable for coding managed problems on the chapter level. Further refinement of ICD-10 with three- and four-digit codes leads to significant coding uncertainties. There is no reliable coding scheme that meets the demands of general practice. The use of coded data for healthcare reimbursement requires a simplification of ICD-10 to provide a realistic picture of morbidity.