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Measuring data reliability for preventive services in electronic medical records

Background

Improvements in the quality of health care services are often measured using data present in medical records. Electronic Medical Records (EMRs) contain potentially valuable new sources of health data. However, data quality in EMRs may not be optimal and should be assessed. Data reliability (are the same data elements being measured over time?) is a prerequisite for data validity (are the data accurate?). Our objective was to measure the reliability of data for preventive services in primary care EMRs during the transition to EMR.

Methods

Our data sources were randomly selected eligible patients’ medical records and data obtained from provincial administrative datasets. Eighteen community-based family physicians in Toronto, Ontario that implemented EMRs starting in 2006 participated in this study. We measured the proportion of patients eligible for a service (Pap smear, screening mammogram or influenza vaccination) that received the service. We compared the change in rates of selected preventive services calculated from the medical record audits with the change in administrative datasets.

Results

In the first year of EMR use (2006) services decreased by 8.7% more (95% CI −11.0%– − 6.4%, p < 0.0001) when measured through medical record audits as compared with administrative datasets. Services increased by 2.4% more (95% CI 0%–4.9%, p = 0.05) in the medical record audits during the second year of EMR use (2007).

Conclusion

There were differences between the change measured through medical record audits and administrative datasets. Problems could include difficulties with organizing new data entry processes as well as continued use of both paper and EMRs. Data extracted from EMRs had limited reliability during the initial phase of EMR implementation. Unreliable data interferes with the ability to measure and improve health care quality

Perceptions of immunization information systems for collecting pandemic H1N1 immunization data within Canada's public health community: a qualitative study

BACKGROUND

Immunization information systems (IISs) are electronic registries used to monitor individual vaccination status and assess vaccine coverage. IISs are currently not widely used across Canada, where health jurisdictions employ a range of approaches to capture influenza immunization information. Conducted in advance of the 2009 H1N1 vaccination campaign, the objectives of this study were to understand the perceived value of individual-level data and IISs for influenza control, identify ideal system functions, and explore barriers to implementation.

METHODS

In July and August 2009, semi-structured interviews were conducted with key informants engaged in vaccine delivery and/or pandemic planning at regional, provincial/territorial and federal levels across Canada. Key informants were recruited using a combination of convenience and snowball sampling methodologies. Qualitative analysis was used to extract themes from interview content.

RESULTS

Patient management, assessment of vaccine coverage, and evaluation of safety and effectiveness were identified as public health priorities that would be achieved in a more timely manner, and with greater accuracy, through the use of an IIS. Features described as ideal included system flexibility, rapid data entry, and universality. Financial and human resource constraints as well as coordination between immunization providers were expressed as barriers to implementation.

CONCLUSIONS

IISs were perceived as valuable by key informants for strengthening management capacity and improving evaluation of both seasonal and pandemic influenza vaccination campaigns. However, certain implementation restrictions may need to be overcome for these benefits to be achieved.

Does computer use in patient-physician encounters influence patient satisfaction?

OBJECTIVE

To assess whether computer use by physicians during the patient-physician encounter influences patient satisfaction in a family medicine teaching centre.

DESIGN

Cross-sectional mailed survey.

SETTING

Queen's University Family Medicine Centre in Kingston, Ont.

PARTICIPANTS

A random sample of 300 patients from the family medicine centre, all of whom were older than 18 years of age and had visited their family physicians in the past year.

MAIN OUTCOME MEASURES

Patient preference for or against computer use by the physician and effect of computer use on various aspects of patient-physician interaction.

RESULTS

The response rate was 58.3%. Most respondents (51.4%) had no preference about computer use in the office, and most (88.0%) were either "very satisfied" or "satisfied" with their visits. When assessing the influence of patient and visit characteristics on computer preference, only the "doctor's attitude toward computer use" had a positive correlation with patient preference (P=.0012). Respondents were most likely to indicate "positive" or "very positive" effects of computer use on all aspects of the patient-physician interaction, except "level of distraction of the doctor" and "time spent chatting about nonmedical matters," which were most commonly reported as being unaffected by computer use. Specifically, 57.1% of respondents thought that computer use had either a "positive" or "very positive" effect on their overall satisfaction with their visits, with another 30.3% believing there was no effect.

CONCLUSION

Most patients expressed no preference for whether or not computers were used in their physicians' offices, although computers did seem to have a positive effect on overall satisfaction with visits. Doctors' attitudes toward computer use influenced their patients' preferences.

Primary care physicians' experiences with electronic medical records: implementation experience in community, urban, hospital, and academic family medicine

OBJECTIVE

To understand how remuneration and care setting affect the implementation of electronic medical records (EMRs).

DESIGN

Semistructured interviews were used to illicit descriptions from community-based family physicians (paid on a fee-for-service basis) and from urban, hospital, and academic family physicians (remunerated via alternative payment models or sessional pay for activities pertaining to EMR implementation).

SETTING

Small suburban community and large urban-, hospital-, and academic-based family medicine clinics in Alberta. All participants were supported by a jurisdictional EMR certification funding mechanism.

PARTICIPANTS

Physicians who practised in 1 or a combination of the above settings and had experience implementing and using EMRs.

METHODS

Purposive and maximum variation sampling was used to obtain descriptive data from key informants through individually conducted semistructured interviews. The interview guide, which was developed from key findings of our previous literature review, was used in a previous study of community-based family physicians on this same topic. Field notes were analyzed to generate themes through a comparative immersion approach.

MAIN FINDINGS

Physicians in urban, hospital, and academic settings leverage professional working relationships to investigate EMRs, a resource not available to community physicians. Physicians in urban, hospital, and academic settings work in larger interdisciplinary teams with a greater need for interdisciplinary care coordination, EMR training, and technical support. These practices were able to support the cost of project management or technical support resources. These physicians followed a planned system rollout approach compared with community physicians who installed their systems quickly and required users to transition to the new system immediately. Electronic medical records did not increase, or decrease, patient throughput. Physicians developed ways of including patients in the note-taking process.

CONCLUSION

We studied physicians' procurement approaches under various payment models. Our findings do not suggest that one remuneration approach supports EMR adoption any more than another. Rather, this study suggests that stronger physician professional networks used in information gathering, more complete training, and in-house technical support might be more influential than remuneration in facilitating the EMR adoption experience.

Primary Care Physicians' Experience with Electronic Medical Records: Barriers to Implementation in a Fee-for-Service Environment

Our aging population has exacerbated strong and divergent trends between health human resource supply and demand. One way to mitigate future inequities is through the adoption of health information technology (HIT). Our previous research showed a number of risks and mitigating factors which affected HIT implementation success. We confirmed these findings through semistructured interviews with nine Alberta clinics. Sociotechnical factors significantly affected physicians' implementation success. Physicians reported that the time constraints limited their willingness to investigate, procure, and implement an EMR. The combination of antiquated exam room design, complex HIT user interfaces, insufficient physician computer skills, and the urgency in patient encounters precipitated by a fee-for-service remuneration model and long waitlists compromised the quantity, if not the quality, of the information exchange. Alternative remuneration and access to services plans might be considered to drive prudent behavior during physician office system implementation.

Improving preventive service delivery at adult complete health check-ups: the Preventive health Evidence-based Recommendation Form (PERFORM) cluster randomized controlled trial

BACKGROUND

To determine the effectiveness of a single checklist reminder form to improve the delivery of preventive health services at adult health check-ups in a family practice setting.

METHODS

A prospective cluster randomized controlled trial was conducted at four urban family practice clinics among 38 primary care physicians affiliated with the University of Toronto. Preventive Care Checklist Forms were created to be used by family physicians at adult health check-ups over a five-month period. The sex-specific forms incorporate evidence-based recommendations on preventive health services and documentation space for routine procedures such as physical examination. The forms were used in two intervention clinics and two control clinics. Rates and relative risks (RR) of the performance of 13 preventive health maneuvers at baseline and post-intervention and the percentage of up-to-date preventive health services delivered per patient were compared between the two groups.

RESULTS

Randomly-selected charts were reviewed at baseline (n = 509) and post-intervention (n = 608). Baseline rates for provision of preventive health services ranged from 3% (fecal occult blood testing) to 93% (blood pressure measurement), similar to other settings. The percentage of up-to-date preventive health services delivered per patient at the end of the intervention was 48.9% in the control group and 71.7% in the intervention group. This is an overall 22.8% absolute increase (p = 0.0001), and 46.6% relative increase in the delivery of preventive health services per patient in the intervention group compared to controls. Eight of thirteen preventive health services showed a statistically significant change (p < 0.05) in favor of the intervention (adjusted RR (95% C.I.)): counseling on brushing/flossing teeth (9.2 (4.3-19.6)), folic acid counseling (7.5 (2.7-20.8)), fecal occult blood testing (6.7 (1.9-24.1)), smoking cessation counseling (3.9 (2.2-7.2)), tetanus immunization (3.0 (1.7-5.2)), history of alcohol intake (1.33 (1.2-1.5)), history of smoking habits (1.28 (1.2-1.4)) and blood pressure measurement (1.05 (1.00-1.10)).

CONCLUSION

This simple, low cost, clinically relevant intervention improves the delivery of preventive health services by prompting physicians of evidence-based recommendations in a checklist format that incorporates existing practice patterns. Periodic updates of the Preventive Care Checklist Forms will allow a feasible and easy-to-use tool for primary care physicians to provide evidence-based preventive health services to adults at routine health check-ups. The forms can also be incorporated into an electronic health record. The Preventive Care Checklist Forms are accessible in English and French at the College of Family Physicians of Canada web site.