Does feedback improve the quality of computerized medical records in primary care?

Interventions to improve the use of EMRs in primary health care: a systematic review and meta-analysis

Background

Electronic medical record (EMR) adoption in primary care has grown exponentially since their introduction in the 1970s. However, without their proper use benefits cannot be achieved. This includes: 1) the complete and safe documentation of patient information; 2) improved coordination of care; 3) reduced errors and 4) more involved patients. The use of EMRs is defined by practitioners using EMRs and their features to perform daily practice functions.

Objective

The purpose of this systematic review was to identify interventions aimed at improving EMR use in primary healthcare settings.

Methods

Ten online databases were searched to identify studies conducted in primary healthcare settings aimed at implementing interventions to observe the use of EMRs and directly measure the use of EMR functions or outcomes effected by the use of EMR functions.

Results

Of 2098 identified studies, 12 were included in the review. Results showed that interventions focused on the use of EMR functions, including referrals, electronic communication, reminders, use of clinical decision support systems and workflow management support functions, were five times more likely to show improvements in EMR use compared with controls. Interventions focused on data quality were five and a half times more likely to show improvements in EMR use compared with controls.

Conclusions

Individuals in primary healthcare settings aiming to improve EMR use would benefit from implementing interventions focused on EMR feature add-ons such as clinical decision support systems and customised referral templates, and provisions of educational materials, or financial incentives targeted at improving the use of EMR functions and data quality.

Rule-Based Data Quality Assessment and Monitoring System in Healthcare Facilities

Measuring and managing data quality in healthcare has remained largely uncharted territory with few notable exceptions. A rules-based approach to data error identification was explored through compilation of over 6,000 data quality rules used with healthcare data. The rules were categorized based on topic and logic yielding twenty-two rule templates and associated knowledge tables used by the rule templates. This work provides a scalable framework with which data quality rules can be organized, shared among facilities and reused. The ten most frequent data quality problems based on the initial rules results are identified. While there is significant additional work to be done in this area, the exploration of the rule template and associated knowledge tables approach here shows rules-based data quality assessment and monitoring to be possible and scalable.

Applying Persuasive Design Techniques to Influence Data-Entry Behaviors in Primary Care: Repeated Measures Evaluation Using Statistical Process Control

Background

Persuasive design is an approach that seeks to change the behaviors of users. In primary care, clinician behaviors and attitudes are important precursors to structured data entry, and there is an impact on overall data quality. We hypothesized that persuasive design changes data-entry behaviors in clinicians and thus improves data quality.

Objective

The objective of this study was to use persuasive design principles to change clinician data-entry behaviors in a primary care environment and to increase data quality of data held in a family health team’s reporting system.

Methods

We used the persuasive systems design framework to describe the persuasion context. Afterward, we designed and implemented new features into a summary screen that leveraged several persuasive design principles. We tested the influence of the new features by measuring its impact on 3 data quality measures (same-day entry, record completeness, and data validity). We also measured the impacts of the new features with a paired pre-post t test and generated XmR charts to contextualize the results. Survey responses were also collected from users.

Results

A total of 53 users used the updated system that incorporated the new features over the course of 8 weeks. Based on a pre-post analysis, the new summary screen successfully encouraged users to enter more of their data on the same day as their encounter. On average, the percentage of same-day entries rose by 10.3% for each user (P<.001). During the first month of the postimplementation period, users compensated by sacrificing aspects of data completeness before returning to normal in the second month. Improvements to record validity were marginal over the study period (P=.05). Statistical process control techniques allowed us to study the XmR charts to contextualize our results and understand trends throughout the study period.

Conclusions

By conducting a detailed systems analysis and introducing new persuasive design elements into a data-entry system, we demonstrated that it was possible to change data-entry behavior and influence data quality in a reporting system. The results show that using persuasive design concepts may be effective in influencing data-entry behaviors in clinicians. There may be opportunities to continue improving this approach, and further work is required to perfect and test additional designs. Persuasive design is a viable approach to encourage clinician user change and could support better data capture in the field of medical informatics.

Assessing primary care data quality

Purpose The purpose of this paper is to assess National Medical Care Survey data quality. Design/methodology/approach Data completeness and representativeness were computed for all observations while other data quality measures were assessed using a 10 per cent sample from the National Medical Care Survey database; i.e., 12,569 primary care records from 189 public and private practices were included in the analysis. Findings Data field completion ranged from 69 to 100 per cent. Error rates for data transfer from paper to web-based application varied between 0.5 and 6.1 per cent. Error rates arising from diagnosis and clinical process coding were higher than medication coding. Data fields that involved free text entry were more prone to errors than those involving selection from menus. The authors found that completeness, accuracy, coding reliability and representativeness were generally good, while data timeliness needs to be improved. Research limitations/implications Only data entered into a web-based application were examined. Data omissions and errors in the original questionnaires were not covered. Practical implications Results from this study provided informative and practicable approaches to improve primary health care data completeness and accuracy especially in developing nations where resources are limited. Originality/value Primary care data quality studies in developing nations are limited. Understanding errors and missing data enables researchers and health service administrators to prevent quality-related problems in primary care data.

Enhanced Safety Surveillance of Seasonal Quadrivalent Influenza Vaccines in English Primary Care: Interim Analysis

Introduction

The European Medicines Agency (EMA) requires vaccine manufacturers to conduct enhanced safety surveillance (ESS) of seasonal influenza vaccines including a near real-time evaluation of collected data. The objective was to identify whether the use of passive surveillance or active surveillance provides different results of reported adverse events of interest (AEIs) by specified age strata and AEI type. We report the weekly incidence rates of AEIs within 7 days following seasonal influenza vaccination using passive and active surveillance.

Methods

AEIs were collected within 7 days of vaccination from ten general practices predominantly administering inactivated quadrivalent influenza vaccine (IIV4, Fluarix Tetra, GSK). Vaccinees completed an adverse drug reaction (ADR) card. ADR card and medically attended AEIs data were recorded in practice electronic health records. We report the outcome of the first 5 weeks of safety surveillance (September 12, 2016–October 16, 2016); in an exploratory analysis, rates of AEI for IIV4 are compared to those passively reported through a sentinel network.

Results

Practices vaccinated 13.1% (12,864/98,091) of their registered population; 5.6% (95% CI 5.20–6.00) of them reported AEIs, none serious. The most frequent were respiratory 2.60% (95% CI 2.33–2.88), musculoskeletal 1.82% (95% CI 1.59–2.05) and neurological 1.05% (95% CI 0.88–1.23). AEIs were more frequently reported for adults than for children; 5.91% (95% CI 5.49–6.34) compared to 1.49% (95% CI 0.69–2.29); 47.18% of the adults reported AEI using the ADR card, none were returned for subjects < 18 years old. The frequency of AEIs reporting was higher, 6.88% (95% CI 6.35–7.42) vs. 3.30% (95% CI 2.68–3.96, 100/3028, p < 0.000), through ESS than passive surveillance.

Conclusion

The ESS did not reveal any safety signal and we demonstrated the feasibility of conducting ESS following EMA recommendations. The use of a customised ADR card led to a doubling of AEIs reports over passive surveillance in adults.

Funding

GlaxoSmithKline Biologicals SA, Wavre, Belgium.

Electronic supplementary material

The online version of this article (10.1007/s12325-018-0747-4) contains supplementary material, which is available to authorized users.

An Exploratory Case Study to Understand Primary Care Users and Their Data Quality Tradeoffs

Primary care data is an important part of the evolving healthcare ecosystem. Generally, users in primary care are expected to provide excellent patient care and record high-quality data. In practice, users must balance sets of priorities regarding care and data. The goal of this study was to understand data quality tradeoffs between timeliness, validity, completeness, and use among primary care users. As a case study, data quality measures and metrics are developed through a focus group session with managers. After calculating and extracting measurements of data quality from six years of historic data, each measure was modeled with logit binomial regression to show correlations, characterize tradeoffs, and investigate data quality interactions. Measures and correlations for completeness, use, and timeliness were calculated for 196,967 patient encounters. Based on the analysis, there was a positive relationship between validity and completeness, and a negative relationship between timeliness and use. Use of data and reductions in entry delay were positively associated with completeness and validity. Our results suggest that if users are not provided with sufficient time to record data as part of their regular workflow, they will prioritize spending available time with patients. As a measurement of a primary care system's effectiveness, the negative correlation between use and timeliness points to a self-reinforcing relationship that provides users with little external value. In the future, additional data can be generated from comparable organizations to test several new hypotheses about primary care users.

Improving the quality of EHR recording in primary care: a data quality feedback tool

OBJECTIVE

Electronic health record (EHR) data are used to exchange information among health care providers. For this purpose, the quality of the data is essential. We developed a data quality feedback tool that evaluates differences in EHR data quality among practices and software packages as part of a larger intervention.

METHODS

The tool was applied in 92 practices in the Netherlands using different software packages. Practices received data quality feedback in 2010 and 2012.

RESULTS

We observed large differences in the quality of recording. For example, the percentage of episodes of care that had a meaningful diagnostic code ranged from 30% to 100%. Differences were highly related to the software package. A year after the first measurement, the quality of recording had improved significantly and differences decreased, with 67% of the physicians indicating that they had actively changed their recording habits based on the results of the first measurement. About 80% found the feedback helpful in pinpointing recording problems. One of the software vendors made changes in functionality as a result of the feedback.

CONCLUSIONS

Our EHR data quality feedback tool is capable of highlighting differences among practices and software packages. As such, it also stimulates improvements. As substantial variability in recording is related to the software package, our study strengthens the evidence that data quality can be improved substantially by standardizing the functionalities of EHR software packages.

Impact of pneumococcal conjugate vaccines on childhood otitis media in the United Kingdom

BACKGROUND

Studies have demonstrated a reduction for otitis media (OM) following the introduction of seven-valent pneumococcal conjugate vaccine (PCV7), but this has not been evaluated in the United Kingdom (UK). Moreover, there are limited data on any additional impact of PCV13 introduction in 2010.

METHODS

We conducted an observational cohort study to investigate the trends in OM incidence and associated antibiotic prescriptions in children aged <10 year-olds during 2002-2012 using a national primary care database. Three time-periods were defined to estimate monthly incidence: pre-PCV7 (January 2002-August 2006), post-PCV7 (September 2007-March 2010), and post-PCV13 (April 2011-December 2012).

RESULTS

Overall annual OM incidence declined by 51.3% from 135.8 episodes/1000 person-years in 2002 to 66.1 episodes/1000 person-years in 2012; antibiotic prescription rates for OM declined by 72.9% from 57.9 prescriptions/1000 person-years to 15.7 prescriptions/1000 person-years, respectively. PCV7 introduction was associated with significant decline in OM rates across all age-groups (21.8%; 95% CI, 20.2-23.4), including <2 year-olds (19.8%; 95% CI, 16.0-23.5%); 2-4 year-olds (23.0%; 95% CI, 20.4-25.4%) and 5-9 year-olds (20.2%; 95% CI, 17.6-22.7%). There was an additional significant reduction in OM (18.5%; 95% CI, 16.7-20.2%) and associated antibiotic prescribing (12.2%; 95% CI, 8.6-15.6%) after the introduction of PCV13 across all age-groups.

CONCLUSION

The introduction of PCV7 was associated with a 22% significant reductions in OM in children aged <10 year-olds with an additional 19% reductions after PCV13 introduction. These declines are equivalent to 592,000 and 15,700 fewer consultations and OM-related hospitalizations, respectively, in England and Wales every year. Although the continuing decline in OM rates in our study suggests that further reduction may continue to occur, it is important to monitor long-term trends in all pneumococcal diseases, including OM and pneumonia, because of increasing replacement of non-vaccine pneumococcal serotypes in carriage and disease.

From patient care to research: a validation study examining the factors contributing to data quality in a primary care electronic medical record database

Background

Electronic Medical Records (EMRs) are increasingly used in the provision of primary care and have been compiled into databases which can be utilized for surveillance, research and informing practice. The primary purpose of these records is for the provision of individual patient care; validation and examination of underlying limitations is crucial for use for research and data quality improvement. This study examines and describes the validity of chronic disease case definition algorithms and factors affecting data quality in a primary care EMR database.

Methods

A retrospective chart audit of an age stratified random sample was used to validate and examine diagnostic algorithms applied to EMR data from the Manitoba Primary Care Research Network (MaPCReN), part of the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). The presence of diabetes, hypertension, depression, osteoarthritis and chronic obstructive pulmonary disease (COPD) was determined by review of the medical record and compared to algorithm identified cases to identify discrepancies and describe the underlying contributing factors.

Results

The algorithm for diabetes had high sensitivity, specificity and positive predictive value (PPV) with all scores being over 90%. Specificities of the algorithms were greater than 90% for all conditions except for hypertension at 79.2%. The largest deficits in algorithm performance included poor PPV for COPD at 36.7% and limited sensitivity for COPD, depression and osteoarthritis at 72.0%, 73.3% and 63.2% respectively. Main sources of discrepancy included missing coding, alternative coding, inappropriate diagnosis detection based on medications used for alternate indications, inappropriate exclusion due to comorbidity and loss of data.

Conclusions

Comparison to medical chart review shows that at MaPCReN the CPCSSN case finding algorithms are valid with a few limitations. This study provides the basis for the validated data to be utilized for research and informs users of its limitations. Analysis of underlying discrepancies provides the ability to improve algorithm performance and facilitate improved data quality.

Risk of mortality in patients with psoriatic arthritis, rheumatoid arthritis and psoriasis: a longitudinal cohort study

BACKGROUND

There are conflicting reports in the literature of the mortality risk among patients with psoriatic arthritis (PsA). The objective of this study was to examine the risk of mortality in patients with PsA compared with matched controls, patients with psoriasis and those with rheumatoid arthritis (RA).

METHODS

A longitudinal cohort study was performed in a large UK medical record database, The Health Improvement Network, among patients with PsA, rheumatoid arthritis (RA) or psoriasis with data from 1994 to 2010. Unexposed controls were matched on practice and start date within the practice for each patient with PsA. Cox proportional hazards models were used to calculate the relative hazards for death.

RESULTS

Patients with PsA (N=8706), RA (N=41 752), psoriasis (N=138 424) and unexposed controls (N=82 258) were identified; 1 442 357 person-years were observed during which 21 825 deaths occurred. Compared with population controls, patients with PsA did not have an increased risk of mortality after adjusting for age and sex (disease-modifying antirheumatic drug (DMARD) users: HR 0.94, 95% CI 0.80 to 1.10; DMARD non-users: HR 1.06, 95% CI 0.94 to 1.19) whereas patients with RA had increased mortality (DMARD users: HR 1.59, 95% CI 1.52 to 1.66; DMARD non-users: HR 1.54, 95% CI 1.47 to 1.60). Patients with psoriasis who had not been prescribed a DMARD had a small increased risk of mortality (HR 1.08, 95% CI 1.04 to 1.12) while those who had been prescribed a DMARD, indicating severe psoriasis, were at increased risk (HR 1.75, 95% CI 1.56 to 1.95).

CONCLUSIONS

Patients with RA and psoriasis have increased mortality compared with the general population but patients with PsA do not have a significantly increased risk of mortality.

Educational interventions to improve the meaningful use of Electronic Health Records: a review of the literature: BEME Guide No. 29

BACKGROUND

Electronic health records (EHRs) are increasingly available and this was expected to reduce healthcare costs and medical errors. This promise has not been realized because healthcare professionals are unable to use EHRs in a manner that contributes to significant improvements in care, i.e. meaningful. Policymakers now acknowledge that training healthcare professionals in meaningful use is essential for successful EHR implementation. To help educators and policymakers design evidence based educational interventions (i.e. interventions that involve educational activities but no practical lessons) and training (i.e. interventions that involve practical components), we summarized all evidence regarding the efficacy of different educational interventions to improve meaningful use of EHRs.

METHODS

We used a predefined search filter to search eight databases for studies that considered an educational intervention to promote meaningful use of EHRs by healthcare professionals.

RESULTS

Seven of the 4507 reviewed articles met the in- and exclusion criteria.

CONCLUSIONS

These studies suggest that a combination of classroom training, computer-based training and feedback is most effective to improve meaningful use. In addition, the training should be tailored to the needs of the trainees and they should be able to practice in their own time. However, the evidence is very limited and we recommend that governments, hospitals and other policymakers invest more in the development of evidence based educational interventions to improve meaningful use of EHRs.

Prevalence and treatment patterns of psoriatic arthritis in the UK

OBJECTIVES

The objectives of this study were to determine the prevalence of PsA in The Health Improvement Network (THIN), a large population-based medical records database in the UK, to examine factors associated with prevalent PsA among patients with psoriasis and to describe the use of DMARDs in patients with PsA.

METHODS

Two cohorts were derived from THIN to examine the prevalence of PsA in a cross-sectional study among all patients aged 18-90 years and among a subcohort of 4900 psoriasis patients aged 45-65 years. Prescription codes were used to describe therapies after the diagnosis of PsA. Associations for prevalent PsA among psoriasis patients were assessed using logistic regression analysis.

RESULTS

Among 4.8 million patients in THIN between the ages of 18 and 90 years, 9045 patients had at least one medical code for PsA, giving an overall prevalence of 0.19% (95% CI 0.19%, 0.19%). Of those patients, 45.9% with PsA have been prescribed DMARDs. Among the 4064 confirmed psoriasis patients, the prevalence of PsA was 8.6% (95% CI 7.7%, 9.5%). PsA was more prevalent among patients with severe psoriasis [odds ratio (OR) 3.34; 95% CI 2.40, 4.65], obesity (OR 1.77; 95% CI 1.30, 2.41) and duration of psoriasis for ≥10 years (OR 7.42; 95% CI 3.86, 14.25) in the fully adjusted model.

CONCLUSION

The prevalence of PsA in THIN is consistent with previous population-based estimates. Limitations include a definition of PsA based on a diagnostic code rather than Classification Criteria for Psoriatic Arthritis (CASPAR) criteria. Given the large population of PsA patients, THIN is an important resource for the study of PsA.

Collecting and sharing data for population health: a new paradigm

Health information technology (IT) has great potential to transform health care and inform population health goals in clinical research, quality measurement, and public safety. To fully realize the benefits of health IT for population health, we must focus on new models that maximize efficiency, encourage rapid learning, and protect patients' privacy. In this paper we explore the advantages of a networked model for analyzing population health information, providing several examples. Although broadening the use of networked models is challenging, the societal benefits of a networked model merit continued exploration and the development of workable solutions.

Disparities in testing for renal function in UK primary care: cross-sectional study

BACKGROUND

In the UK, explicit quality standards for chronic disease management, including for diabetes and chronic kidney disease (CKD), are set out National Service Frameworks and pay-for-performance indicators. These conditions are common with a prevalence of 4% and 5.4%, respectively. CKD is largely asymptomatic, detected following renal function testing and important because associated with increased mortality and morbidity, especially in people with diabetes and proteinuria.

OBJECTIVES

To investigate who has their renal function tested and any association with age, sex, ethnicity and diabetes.

METHOD

A cross-sectional survey in a primary care research network in south-west London (n = 220 721). The following data were extracted from routine data: age, gender, ethnicity, latest serum creatinine, diagnosis of diabetes and recording of proteinuria. We used logistic regression to explore any association in testing for CKD.

RESULTS

People (82.1%) with diabetes had renal function and proteinuria tested; the proportion was much smaller (<0.5%) in those without. Women were more likely to have a creatinine test than men (28% versus 24%, P < 0.05), but this association was modified by age, ethnicity and presence of diabetes. People >75 years and with diabetes were most likely to have been tested. Black [adjusted odds ratio (AOR) 2.1, 95% confidence interval (CI) 2.0-2.2] and south Asian (AOR 1.65, 95% CI 1.56-1.75) patients were more likely to be tested than whites. Those where ethnicity was not stated were the only group not tested more than whites.

CONCLUSIONS

Quality improvement initiatives and equity audits, which include CKD should take account of disparities in renal function testing.

Dose variations associated with formulations of NSAID prescriptions for children: a descriptive analysis of electronic health records in the UK

BACKGROUND

NSAIDs, particularly ibuprofen, are commonly prescribed for children but there is limited published research on real-life prescribed doses for this class of drugs.

OBJECTIVE

The aim of the study was to investigate if variations in NSAID doses prescribed to children can be explained by patient age, indication, dosage form, type of NSAID or year of prescription.

STUDY DESIGN

Recorded daily doses for drugs within the 'Anti-rheumatics, non-steroidal plain' anatomical classification were studied. First prescriptions of a distinct NSAID substance within 13-month time periods in a patient's history were included. To enable grouping and comparison of NSAIDs, doses were analysed as prescribed daily doses (PDDs) relative to the adult defined daily dose, stated as the relative PDD (rPDD) in this study. Multiple regression analysis was performed with the rPDD as the response variable, and age, indication, dosage form, NSAID substance and year of prescription as the explanatory variables.

SETTING

Prescriptions from the Intercontinental Medical Statistics (IMS) Health Disease Analyzer database containing electronic health records of general practitioners in the UK issued from 1988 to December 2005.

PATIENTS

Data for children aged 2-11 years with NSAID prescriptions including daily dose information.

RESULTS

A total of 21 473 first prescriptions for 19 695 patients were studied. The vast majority of prescriptions were for ibuprofen (n = 20 855), which were therefore analysed separately. The other NSAID prescriptions were grouped (n = 618), containing diclofenac, indometacin, mefenamic acid, naproxen and piroxicam ('NSAID group'). The rPDD varied considerably with dosage form in both the ibuprofen and NSAID groups. In particular, tablets/capsules were prescribed at higher doses than liquid dosage forms. In the NSAID group, naproxen was prescribed at noticeably higher doses. The rPDD varied only slightly with age in both groups. Prescriptions indicated for rheumatic disease were associated with lower doses than other indications in the NSAID group. The rPDD was not influenced by year of prescription.

CONCLUSIONS

This study shows a correlation between higher prescribed NSAID doses and tablet/capsule formulation, and highlights the need for careful choice of dose formulation when prescribing medicines for children.

Pneumonia following antipsychotic prescriptions in electronic health records: a patient safety concern?

BACKGROUND

In screening the Intercontinental Medical Statistics (IMS) Health Disease Analyzer database of GP records from the UK, an increased registration of pneumonia subsequent to the prescription of some antipsychotic medicines was identified.

AIM

To investigate the temporal pattern between antipsychotic prescriptions and pneumonia with respect to age, type of pneumonia and other chest infections, and antipsychotic class.

DESIGN OF STUDY

Self-controlled cohort analysis.

SETTING

Electronic health records from the UK IMS Health Disease Analyzer database.

METHOD

Three groups of pneumonia-related International Classification of Diseases (ICD)-10 terms and prescriptions of atypical and conventional antipsychotic medicines were studied. Separate analyses were carried out for patients aged 65 years. The observed rate of pneumonia terms registered in different time periods in connection to antipsychotic prescriptions was contrasted to the overall rate of pneumonia terms relative to prescriptions of other drugs in the same dataset.

RESULTS

In patients aged ≥ 65 years, an increased registration of a group of terms defined as 'acute chest infections', after atypical antipsychotic prescriptions, was identified. The corresponding increase after conventional antipsychotic prescriptions was much smaller. Bronchopneumonia had a striking increase after both atypical and conventional antipsychotic prescriptions, and was commonly recorded with fatal outcome. Few registrations of hypostatic pneumonia were noted. Patients aged <65 years did not have a higher rate of acute chest infections after receiving antipsychotic prescriptions.

CONCLUSION

The consistent pattern of an increased rate of chest infections after atypical antipsychotic prescriptions in older people seen in this outpatient study, together with the higher risk shown in a previous study on hospitalised patients, suggests a causal relationship. This is of importance since bronchopneumonia seems highly linked to fatal outcome. In the absence of a mechanism, further investigation of the role of antipsychotics in older people is needed.

The QICKD study protocol: a cluster randomised trial to compare quality improvement interventions to lower systolic BP in chronic kidney disease (CKD) in primary care

Background

Chronic kidney disease (CKD) is a relatively newly recognised but common long-term condition affecting 5 to 10% of the population. Effective management of CKD, with emphasis on strict blood pressure (BP) control, reduces cardiovascular risk and slows the progression of CKD. There is currently an unprecedented rise in referral to specialist renal services, which are often located in tertiary centres, inconvenient for patients, and wasteful of resources. National and international CKD guidelines include quality targets for primary care. However, there have been no rigorous evaluations of strategies to implement these guidelines. This study aims to test whether quality improvement interventions improve primary care management of elevated BP in CKD, reduce cardiovascular risk, and slow renal disease progression

Design

Cluster randomised controlled trial (CRT)

Methods

This three-armed CRT compares two well-established quality improvement interventions with usual practice. The two interventions comprise: provision of clinical practice guidelines with prompts and audit-based education.

The study population will be all individuals with CKD from general practices in eight localities across England. Randomisation will take place at the level of the general practices. The intended sample (three arms of 25 practices) powers the study to detect a 3 mmHg difference in systolic BP between the different quality improvement interventions. An additional 10 practices per arm will receive a questionnaire to measure any change in confidence in managing CKD. Follow up will take place over two years. Outcomes will be measured using anonymised routinely collected data extracted from practice computer systems. Our primary outcome measure will be reduction of systolic BP in people with CKD and hypertension at two years. Secondary outcomes will include biomedical outcomes and markers of quality, including practitioner confidence in managing CKD.

A small group of practices (n = 4) will take part in an in-depth process evaluation. We will use time series data to examine the natural history of CKD in the community. Finally, we will conduct an economic evaluation based on a comparison of the cost effectiveness of each intervention.

Clinical Trials Registration

ISRCTN56023731. ClinicalTrials.gov identifier.

The barriers to clinical coding in general practice: A literature review

Clinical coding is variable in UK general practice. The reasons for this remain undefined. This review explains why there are no readily available alternatives to recording structured clinical data and reviews the barriers to recording structured clinical data. Methods used included a literature review of bibliographic databases, university health informatics departments, and national and international medical informatics associations. The results show that the current state of development of computers and data processing means there is no practical alternative to coding data. The identified barriers to clinical coding are: the limitations of the coding systems and terminologies and the skill gap in their use; recording structured data in the consultation takes time and is distracting; the level of motivation of primary care professionals; and the priority within the organization. A taxonomy is proposed to describe the barriers to clinical coding. This can be used to identify barriers to coding and facilitate the development of strategies to overcome them.

The strategic management of data quality in healthcare

This research extends and tests principles to establish good practice and overcome practical barriers in the strategic management of data quality. The research explores the issues that define and control data quality in national health data collections and the mechanisms and frameworks that can be developed to achieve and sustain good data quality. The aim is to make the strategic management of data quality, and the prevention of persistent errors, everyday, `institutionalized' activities. Using action research methodology and a combination of interpretive and positivist data collection and analysis methods, this research provides the health informatics community with an understanding of the issues related to developing and implementing programmes to improve data quality. Healthcare is a complex system that is highly political and culturally diverse, and applied health informatics research is essential to improve outcomes and performance.

Using registries in general practice to estimate countrywide morbidity in The Netherlands

OBJECTIVE

Examining the possibility of using data from registries in general practice in order to present morbidity figures concerning a broad range of major diseases for the Dutch population.

STUDY DESIGN

Qualitative and quantitative analysis of registered diagnoses.

METHODS

Quantitative data from six registries were obtained. In addition, information about the registration process was obtained and discussed with representatives of the registries. Subjects for discussion were the general characteristics of the registries and disease-specific rules.

RESULTS

Some important differences exist in the characteristics of the registries and the disease-specific coding rules for computing incidence and prevalence. However, for most diseases the rules of two or more registries corresponded with each other, so that a selection of registries that measured the occurrence of a particular disease in a similar way could be made. Nevertheless, for some age categories rather large differences between registries were observed. The best estimates for the whole country were calculated as the average incidence and prevalence of the selected registries.

CONCLUSIONS

Data that were originally obtained during patient care can be made usable for public health policy purposes. To further improve the quality of data and to increase the usefulness of these data for public health policy purposes, more efforts are required.

The use of routinely collected computer data for research in primary care: opportunities and challenges

INTRODUCTION

Routinely collected primary care data has underpinned research that has helped define primary care as a specialty. In the early years of the discipline, data were collected manually, but digital data collection now makes large volumes of data readily available. Primary care informatics is emerging as an academic discipline for the scientific study of how to harness these data. This paper reviews how data are stored in primary care computer systems; current use of large primary care research databases; and, the opportunities and challenges for using routinely collected primary care data in research.

OPPORTUNITIES

(1) Growing volumes of routinely recorded data. (2) Improving data quality. (3) Technological progress enabling large datasets to be processed. (4) The potential to link clinical data in family practice with other data including genetic databases. (5) An established body of know-how within the international health informatics community.

CHALLENGES

(1) Research methods for working with large primary care datasets are limited. (2) How to infer meaning from data. (3) Pace of change in medicine and technology. (4) Integrating systems where there is often no reliable unique identifier and between health (person-based records) and social care (care-based records-e.g. child protection). (5) Achieving appropriate levels of information security, confidentiality, and privacy.

CONCLUSION

Routinely collected primary care computer data, aggregated into large databases, is used for audit, quality improvement, health service planning, epidemiological study and research. However, gaps exist in the literature about how to find relevant data, select appropriate research methods and ensure that the correct inferences are drawn.

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.

The use and interpretation of quasi-experimental studies in medical informatics

Quasi-experimental study designs, often described as nonrandomized, pre-post intervention studies, are common in the medical informatics literature. Yet little has been written about the benefits and limitations of the quasi-experimental approach as applied to informatics studies. This paper outlines a relative hierarchy and nomenclature of quasi-experimental study designs that is applicable to medical informatics intervention studies. In addition, the authors performed a systematic review of two medical informatics journals, the Journal of the American Medical Informatics Association (JAMIA) and the International Journal of Medical Informatics (IJMI), to determine the number of quasi-experimental studies published and how the studies are classified on the above-mentioned relative hierarchy. They hope that future medical informatics studies will implement higher level quasi-experimental study designs that yield more convincing evidence for causal links between medical informatics interventions and outcomes.

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.

Developing a large electronic primary care database (Doctors' Independent Network) for research

BACKGROUND AND OBJECTIVES

Primary care databases form a unique source of population-based clinical information on the prevalence and management of diagnosed disorders. Historically such databases have lacked individual level socio-economic markers. We describe the development of the Doctors' Independent Network (DIN) database for epidemiological and health services research. DIN includes a socio-economic marker (ACORN) based on postcode linkage at individual patient level. The validity of DIN is assessed against the General Practice Research Database (GPRD).

METHODS

External validity is assessed by comparing the demographic structure and prevalence rates for treated ischemic heart disease (IHD) and treated hay fever with those from the GPRD. We assess the utility of a socio-economic measure (ACORN) based on postcode-linkage at individual patient level by examining the trend in prevalence rates of IHD and hay fever by ACORN index.

RESULTS

142 practices providing high quality data were selected, with 1827361 fully registered patients contributing data between 1992 and 2001, representing an identical age-sex structure to that for England & Wales and GPRD. Regionally adjusted prevalence of treated IHD (7.29 and 5.37%, respectively for men and women aged 35+ in 1998) in DIN was highly comparable to GPRD (7.27 and 5.42%). In DIN, the odds ratio of IHD was 1.37 (95% CI 1.30-1.44) in subjects living in "striving" compared to "thriving" areas. The prevalence of treated hay fever prevalence was similar across databases, with inverse associations seen with ACORN in DIN (higher rates in "thriving" areas).

CONCLUSIONS

DIN provides comparable period prevalence rates to GPRD for two common conditions, with social trends as expected. Primary care databases such as these have the potential to replace the decennial national morbidity surveys carried out in UK general practices, with DIN having the important advantage of including a socio-economic index.

A comparison of multiple data sources to identify vaccinations for veterans with spinal cord injuries and disorders

Monitoring vaccination activity requires regular access to information about patient vaccination status. This report describes our experience using multiple Department of Veterans Affairs (VA) data sources to determine availability and completeness of vaccination information for veterans with spinal cord injuries and disorders (SCI&D). Administrative and clinical databases were limited to coding vaccine administration, undercounted vaccinations, and were unable to account for whether the vaccine was offered and the reasons for nonreceipt. Medical record review provided more detail but was labor intensive and costly. Patient surveys provided the richest information but were costly, time-consuming, and based on a sample of patients. Agreement was poor between data sources. This report suggests that while VA is well positioned to use national databases for clinical care decisions and to inform policy, vaccination data were incomplete. Electronic records must include data that are consistently entered and validated before they can be useful for care management and decision making.

The quality of record keeping in primary care: a comparison of computerised, paper and hybrid systems

BACKGROUND

Computerised record keeping in primary care is increasing. However, no study has systematically examined the completeness of computer records in practices using different forms of record keeping.

AIM

To compare computer-only record keeping to paper-only and hybrid systems, by measuring the number of consultations and symptoms recorded within individual consultations.

DESIGN OF STUDY

Retrospective cohort study.

SETTING

Eighteen general practices in the Exeter Primary Care Trust.

METHOD

This study was part of a retrospective case control study of cancer patients aged over 40 years. All recorded consultations for a 2-year period were identified and coded for 1396 patients. Records were classified as paper, computer, or hybrid, depending on which medium stored the clinical information from consultations.

RESULTS

More consultations were recorded in hybrid systems (median in 2 years = 11, interquartile range [IQR] = 6-18) than computer systems (median in 2 years = 9, IQR = 4-16.5) or paper systems (median in 2 years = 8, IQR = 5-14,): P <0.001. In a Poisson regression analysis, which included age, sex, and future cancer diagnosis, the rates of consultations recorded in paper and computer systems were 16% and 11% lower, respectively, than in hybrid systems. Fewer telephone consultations were recorded in paper systems, and fewer home visits in computer systems. Fewer symptoms were recorded in individual consultations on computer systems. Recording of absent symptoms and severity of symptoms was highest in paper systems.

CONCLUSION

Hybrid systems of primary care record keeping document higher numbers of consultations than computer-only or paper-only systems. The quality of individual consultation recording is highest in paper-only systems. This has medicolegal implications and may impact upon continuity of care.

Data quality of general practice electronic health records: the impact of a program of assessments, feedback, and training

OBJECTIVE

The aim of this study was to investigate the impact of a program of repeated assessments, feedback, and training on the quality of coded clinical data in general practice.

DESIGN

A prospective uncontrolled intervention study was conducted in a general practice research network.

MEASUREMENTS

Percentage of recorded consultations with a coded problem title and percentage of patients receiving a specific drug (e.g., tamoxifen) who had the relevant morbidity code (e.g., breast cancer) were calculated. Annual period prevalence of 12 selected morbidities was compared with parallel data derived from the fourth National Study of Morbidity Statistics from General Practice (MSGP4).

RESULTS

The first two measures showed variation between practices at baseline, but on repeat assessments all practices improved or maintained their levels of coding. The period prevalence figures also were variable, but over time rates increased to levels comparable with, or above, MSGP4 rates. Practices were able to provide time and resources for feedback and training sessions.

CONCLUSION

A program of repeated assessments, feedback, and training appears to improve data quality in a range of practices. The program is likely to be generalizable to other practices but needs a trained support team to implement it that has implications for cost and resources.