Paper versus computer: feasibility of an electronic medical record in general pediatrics

Digital Health Data Quality Issues: Systematic Review

BACKGROUND

The promise of digital health is principally dependent on the ability to electronically capture data that can be analyzed to improve decision-making. However, the ability to effectively harness data has proven elusive, largely because of the quality of the data captured. Despite the importance of data quality (DQ), an agreed-upon DQ taxonomy evades literature. When consolidated frameworks are developed, the dimensions are often fragmented, without consideration of the interrelationships among the dimensions or their resultant impact.

OBJECTIVE

The aim of this study was to develop a consolidated digital health DQ dimension and outcome (DQ-DO) framework to provide insights into 3 research questions: What are the dimensions of digital health DQ? How are the dimensions of digital health DQ related? and What are the impacts of digital health DQ?

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a developmental systematic literature review was conducted of peer-reviewed literature focusing on digital health DQ in predominately hospital settings. A total of 227 relevant articles were retrieved and inductively analyzed to identify digital health DQ dimensions and outcomes. The inductive analysis was performed through open coding, constant comparison, and card sorting with subject matter experts to identify digital health DQ dimensions and digital health DQ outcomes. Subsequently, a computer-assisted analysis was performed and verified by DQ experts to identify the interrelationships among the DQ dimensions and relationships between DQ dimensions and outcomes. The analysis resulted in the development of the DQ-DO framework.

RESULTS

The digital health DQ-DO framework consists of 6 dimensions of DQ, namely accessibility, accuracy, completeness, consistency, contextual validity, and currency; interrelationships among the dimensions of digital health DQ, with consistency being the most influential dimension impacting all other digital health DQ dimensions; 5 digital health DQ outcomes, namely clinical, clinician, research-related, business process, and organizational outcomes; and relationships between the digital health DQ dimensions and DQ outcomes, with the consistency and accessibility dimensions impacting all DQ outcomes.

CONCLUSIONS

The DQ-DO framework developed in this study demonstrates the complexity of digital health DQ and the necessity for reducing digital health DQ issues. The framework further provides health care executives with holistic insights into DQ issues and resultant outcomes, which can help them prioritize which DQ-related problems to tackle first.

Completeness of Medical Records of Trauma Patients Admitted to the Emergency Unit of a University Hospital, Upper Egypt

Trauma records in Egyptian hospitals are widely suspected to be inadequate for developing a practical and useful trauma registry, which is critical for informing both primary and secondary prevention. We reviewed archived paper records of trauma patients admitted to the Beni-Suef University Hospital in Upper Egypt for completeness in four domains: demographic data including contact information, administrative data tracking patients from admission to discharge, clinical data including vital signs and Glasgow Coma Scale scores, and data describing the causal traumatic event (mechanism of injury, activity at the time of injury, and location/setting). The majority of the 539 medical records included in the study had significant deficiencies in the four reviewed domains. Overall, 74.3% of demographic fields, 66.5% of administrative fields, 55.0% of clinical fields, and just 19.9% of fields detailing the causal event were found to be completed. Critically, oxygen saturation, arrival time, and contact information were reported in only 7.6%, 25.8%, and 43.6% of the records, respectively. Less than a fourth of the records provided any details about the cause of trauma. Accordingly, the current, paper-based medical record system at Beni-Suef University Hospital is insufficient for the development of a practical trauma registry. More efforts are needed to develop efficient and comprehensive documentation of trauma data in order to inform and improve patient care.

Ethical Issues and the Electronic Health Record

Ethical issues related to electronic health records (EHRs) confront health personnel. Electronic health records create conflict among several ethical principals. Electronic health records may represent beneficence because they are alleged to increase access to health care, improve the quality of care and health, and decrease costs. Research, however, has not consistently demonstrated access for disadvantaged persons, the accuracy of EHRs, their positive effects on productivity, nor decreased costs. Should beneficence be universally acknowledged, conflicts exist with other ethical principles. Autonomy is jeopardized when patients' health data are shared or linked without the patients' knowledge. Fidelity is breached by the exposure of thousands of patients' health data through mistakes or theft. Lack of confidence in the security of health data may induce patients to conceal sensitive information. As a consequence, their treatment may be compromised. Justice is breached when persons, because of their socioeconomic class or age, do not have equal access to health information resources and public health services. Health personnel, leaders, and policy makers should discuss the ethical implications of EHRs before the occurrence of conflicts among the ethical principles. Recommendations to guide health personnel, leaders, and policy makers are provided.

Health Economics ― Effect of Electronic Medical Record Systems on Cardiovascular Disease Outpatient Consultation Time ―

Because electronic medical record systems may affect productivity of clinical practice, we examined the effects of different types of medical record systems on consultation time and total fee claims for outpatient consultation for cardiovascular cases. We investigated consultation time (i.e., the sum of practice time and work-up time) and total fee claims by 13 cardiovascular physicians for 862 outpatients. The means of consultation time and total fee claims were calculated for 3 types of medical records: electronic, paper-based, and hybrid. No difference in mean consultation time was seen between the electronic and paper-based medical record groups (paper based, 11.4±0.3 min/case; electronic, 12.7±0.8 min/case; hybrid, 13.5±0.5 min/case). In contrast, the electronic group had the highest mean practice time (10.9±0.6 min/case) and the lowest mean work-up time (1.7±0.4 min/case). There was no difference in total fee claims between the 3 medical record groups. The total fee claims per practice time was lower for the electronic group than the paper-based (67.5±52.8 vs. 108.8±108.1 points/min, P<0.001). The findings suggest that physicians using the electronic medical record system can be more directly involved with patients due to higher productivity, as reflected in the lower work-up time.

Departmental collaborative approach for improving in-patient clinical documentation (five years experience)

Introduction

Health care institutes are cooperative areas where multiple health care services come together and work closely; physician, nurses and paramedics etc,. These multidisciplinary teams usually communicate with each other by documentation. Therefore, accurate documentation in health care organization is considered one of the vital processes. To make the documentation useful, it needs to be accurate, relevant, complete and confidential.

Objectives

The aim of this paper is to demonstrate the effect of the collaborative work in the Department of Pediatrics on improving the quality of inpatient clinical documentation over 5 years.

Methods

Improving clinical documentations went through several collaborative approaches, these include: Departmental Administration involvement, establishment of quality management team, regular departmental collaborative meeting as a monitoring and motivating tool, establishment of the residents quality team, Integration of quality projects into the new residents annual orientation, considering it as a part of the trainee personal evaluation, sending reminders to the consultants and residents on the adherence for admission note initiating and 24 h's verification, utilization of standardized template of admission note and progress note and emphasizing on the adherence to the approved medical abbreviation list only for any abbreviation to be used.

Results

During the period between the first quarter of 2012 to the fourth quarter of 2017; a significant improvement was noticed in the overall in-patient clinical documentation compliance rate, as it was ranging from lower 50% in 2012 and 2013, and increased gradually to reach upper 80% in the last quarters of 2016 and 2017. These figures are based on an independent audit that being done by the hospital quality management department and received by the department in a quarterly basis.

Conclusion

Despite multiple challenges for improving the compliance for clinical documentations, major improvement can be achieved when the collaboration and efforts among all stakeholders being shared and set as a common goal.

Impact of sharing electronic health records with patients on the quality and safety of care: a systematic review and narrative synthesis protocol

INTRODUCTION

Providing patients with access to electronic health records (EHRs) has emerged as a promising solution to improve quality of care and safety. As the efforts to develop and implement EHR-based data sharing platforms mature and scale up worldwide, there is a need to evaluate the impact of these interventions and to weigh their relative risks and benefits, in order to inform evidence-based health policies. The aim of this work is to systematically characterise and appraise the demonstrated benefits and risks of sharing EHR with patients, by mapping them across the six domains of quality of care of the Institute of Medicine (IOM) analytical framework (ie, patient-centredness, effectiveness, efficiency, timeliness, equity and safety).

METHODS AND ANALYSIS

CINAHL, Cochrane, Embase, HMIC, Medline/PubMed and PsycINFO databases will be searched from January 1997 to August 2017. Primary outcomes will include measures related with the six domains of quality of care of the IOM analytical framework. The quality of the studies will be assessed using the Cochrane Risk of Bias Tool, the ROBINS-I Tool and the Drummond's checklist. A narrative synthesis will be conducted for all included studies. Subgroup analysis will be performed by domain of quality of care domain and by time scale (ie, short-term, medium-term or long-term impact). The body of evidence will be summarised in a Summary of Findings table and its strength assessed according to the GRADE criteria.

ETHICS AND DISSEMINATION

This review does not require ethical approval as it will summarise published studies with non-identifiable data. This protocol complies with the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols guidelines. Findings will be disseminated widely through peer-reviewed publication and conference presentations, and patient partners will be included in summarising the research findings into lay summaries and reports.

PROSPERO REGISTRATION NUMBER

CRD42017070092.

Informatics and machine learning to define the phenotype

INTRODUCTION

For the past decade, the focus of complex disease research has been the genotype. From technological advancements to the development of analysis methods, great progress has been made. However, advances in our definition of the phenotype have remained stagnant. Phenotype characterization has recently emerged as an exciting area of informatics and machine learning. The copious amounts of diverse biomedical data that have been collected may be leveraged with data-driven approaches to elucidate trait-related features and patterns. Areas covered: In this review, the authors discuss the phenotype in traditional genetic associations and the challenges this has imposed.Approaches for phenotype refinement that can aid in more accurate characterization of traits are also discussed. Further, the authors highlight promising machine learning approaches for establishing a phenotype and the challenges of electronic health record (EHR)-derived data. Expert commentary: The authors hypothesize that through unsupervised machine learning, data-driven approaches can be used to define phenotypes rather than relying on expert clinician knowledge. Through the use of machine learning and an unbiased set of features extracted from clinical repositories, researchers will have the potential to further understand complex traits and identify patient subgroups. This knowledge may lead to more preventative and precise clinical care.

Transfers from intensive care unit to hospital ward: a multicentre textual analysis of physician progress notes

BACKGROUND

Little is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks.

METHODS

This was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients.

RESULTS

A total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9-2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p < 0.001). There was a discrepancy between documentation of patient issues in the last ICU and first ward notes; mean agreement of patient issues was 42% [95% CI 31-53%]. Qualitative analyses identified eight themes related to focus (central point - e.g., problem list), structure (organization, - e.g., note-taking style), and purpose (intention - e.g., documentation of patient course) of the notes that varied across clinical specialties and physician seniority.

CONCLUSIONS

Important gaps and variations in written documentation during transitions of patient care between ICU and hospital ward physicians are common, and include discrepancies in documentation of patient information.

[Effectiveness of an assessment of computerised medical records in a university hospital]

OBJECTIVE

The objective of this study was to evaluate a sample of electronic medical records (EMR) that was sufficiently representative of the different areas of care in a university hospital, as well as to verify the effectiveness of an initial intervention through a second evaluation.

METHODS

Medical records audits were performed in 2012 and 2013 by a blind peer review of random samples of care episodes, proportional to the activity of each clinical department, and with the same evaluation method being applied to all of them.

RESULTS

More than 1,000 episodes of care were reviewed in the 2audits. A significant improvement was found in hospital admissions (P=.000) in all the sections of the EMR analysed (P=.002), and was especially significant for the reason for consultation, for which its completion increased by 8.5% (p<.05), and also in the sections of the current process record (7.1%), physical examination (4.7%), allergies (3.9%), and clinical course (3.6%). The assessment of the discharge report, as a whole, showed an improvement (P=.001). In outpatient follow-up visits, a significant positive improvement was observed in the 4sections evaluated (P<.05), and also overall (P=.000).

CONCLUSIONS

According to study conditions, the dissemination of the results was effective in improving the quality of the EMR. The results have made it possible to implement actions to review the work processes in certain departments, and also the partial redesign of the interface on being a reproducible methodology accepted by the organisation.

E-health in Switzerland: The laborious adoption of the federal law on electronic health records (EHR) and health information exchange (HIE) networks

Within the framework of a broader e-health strategy launched a decade ago, in 2015 Switzerland passed a new federal law on patients' electronic health records (EHR). The reform requires hospitals to adopt interoperable EHRs to facilitate data sharing and cooperation among healthcare providers, ultimately contributing to improvements in quality of care and efficiency in the health system. Adoption is voluntary for ambulatories and private practices, that may however be pushed towards EHRs by patients. The latter have complete discretion in the choice of the health information to share. Moreover, careful attention is given to data security issues. Despite good intentions, the high institutional and organisational fragmentation of the Swiss healthcare system, as well as the lack of full agreement with stakeholders on some critical points of the reform, slowed the process of adoption of the law. In particular, pilot projects made clear that the participation of ambulatories is doomed to be low unless appropriate incentives are put in place. Moreover, most stakeholders point at the strategy proposed to finance technical implementation and management of EHRs as a major drawback. After two years of intense preparatory work, the law entered into force in April 2017.

How to Predict Oral Rehydration Failure in Children With Gastroenteritis

OBJECTIVES

Oral rehydration is the standard in most current guidelines for young children with acute gastroenteritis (AGE). Failure of oral rehydration can complicate the disease course, leading to morbidity due to severe dehydration. We aimed to identify prognostic factors of oral rehydration failure in children with AGE.

METHODS

A prospective, observational study was performed at the Emergency department, Erasmus Medical Centre, Rotterdam, The Netherlands, 2010-2012, including 802 previously healthy children, ages 1 month to 5 years with AGE. Failure of oral rehydration was defined by secondary rehydration by a nasogastric tube, or hospitalization or revisit for dehydration within 72 hours after initial emergency department visit.

RESULTS

We observed 167 (21%) failures of oral rehydration in a population of 802 children with AGE (median 1.03 years old, interquartile range 0.4-2.1; 60% boys). In multivariate logistic regression analysis, independent predictors for failure of oral rehydration were a higher Manchester Triage System urgency level, abnormal capillary refill time, and a higher clinical dehydration scale score.

CONCLUSIONS

Early recognition of young children with AGE at risk of failure of oral rehydration therapy is important, as emphasized by the 21% therapy failure in our population. Associated with oral rehydration failure are higher Manchester Triage System urgency level, abnormal capillary refill time, and a higher clinical dehydration scale score.

The effect of a test ordering software intervention on the prescription of unnecessary laboratory tests - a randomized controlled trial

Background

The way software for electronic health records and laboratory tests ordering systems are designed may influence physicians’ prescription. A randomised controlled trial was performed to measure the impact of a diagnostic and laboratory tests ordering system software modification.

Methods

Participants were family physicians working and prescribing diagnostic and laboratory tests.

The intervention group had a modified software with a basic shortcut menu changes, where some tests were withdrawn or added, and with the implementation of an evidence-based decision support based on United States Preventive Services Task Force (USPSTF) recommendations. This intervention group was compared with usual software (control group).

The outcomes were the number of tests prescribed from those: withdrawn from the basic menu; added to the basic menu; marked with green dots (USPSTF’s grade A and B); and marked with red dots (USPSTF’s grade D).

Results

Comparing the monthly average number of tests prescribed before and after the software modification, from those tests that were withdrawn from the basic menu, the control group prescribed 33.8 tests per 100 consultations before and 30.8 after (p = 0075); the intervention group prescribed 31.3 before and 13.9 after (p < 0001). Comparing the tests prescribed between both groups during the intervention, from those tests that were withdrawn from the basic menu, the intervention group prescribed a monthly average of 14.0 vs. 29.3 tests per 100 consultations in the control group (p < 0.001). From those tests that are USPSTF’s grade A and B, intervention group prescribed 66.8 vs. 74.1 tests per 100 consultations in the control group (p = 0.070). From those tests categorised as USPSTF grade D, the intervention group prescribed an average of 9.8 vs. 11.8 tests per 100 consultations in the control group (p = 0.003).

Conclusions

Removing unnecessary tests from a quick shortcut menu of the diagnosis and laboratory tests ordering system had a significant impact and reduced unnecessary prescription of tests.

The fact that it was not possible to perform the randomization at the family physicians’ level, but only of the computer servers is a limitation of our study. Future research should assess the impact of different tests ordering systems during longer periods.

Trial registration

ISRCTN45427977, May 1^st 2014 (retrospectively registered).

Implementation of clinical decision support in young children with acute gastroenteritis: a randomized controlled trial at the emergency department

Acute gastroenteritis (AGE) is one of the most frequent reasons for young children to visit emergency departments (EDs). We aimed to evaluate (1) feasibility of a nurse-guided clinical decision support system for rehydration treatment in children with AGE and (2) the impact on diagnostics, treatment, and costs compared with usual care by attending physician. A randomized controlled trial was performed in 222 children, aged 1 month to 5 years at the ED of the Erasmus MC-Sophia Children's hospital in The Netherlands ( 2010-2012). Outcome included (1) feasibility, measured by compliance of the nurses, and (2) length of stay (LOS) at the ED, the number of diagnostic tests, treatment, follow-up, and costs. Due to failure of post-ED weight measurement, we could not evaluate weight difference as measure for dehydration. Patient characteristics were comparable between the intervention (N = 113) and the usual care group (N = 109). Implementation of the clinical decision support system proved a high compliance rate. The standardized use of oral ORS (oral rehydration solution) significantly increased from 52 to 65%(RR2.2, 95%CI 1.09-4.31 p < 0.05). We observed no differences in other outcome measures.

CONCLUSION

Implementation of nurse-guided clinical decision support system on rehydration treatment in children with AGE showed high compliance and increase standardized use of ORS, without differences in other outcome measures. What is Known: • Acute gastroenteritis is one of the most frequently encountered problems in pediatric emergency departments. • Guidelines advocate standardized oral treatment in children with mild to moderate dehydration, but appear to be applied infrequently in clinical practice. What is New: • Implementation of a nurse-guided clinical decision support system on treatment of AGE in young children showed good feasibility, resulting in a more standardized ORS use in children with mild to moderate dehydration, compared to usual care. • Given the challenges to perform research in emergency care setting, the ED should be experienced and adequately equipped, especially during peak times.

An appraisal of published usability evaluations of electronic health records via systematic review

OBJECTIVE

In this systematic review, we aimed to evaluate methodological and reporting trends present in the current literature by investigating published usability studies of electronic health records (EHRs).

METHODS

A literature search was conducted for articles published through January 2015 using MEDLINE (Ovid), EMBASE, Scopus, and Web of Science, supplemented by citation and reference list reviews. Studies were included if they tested the usability of hospital and clinic EHR systems in the inpatient, outpatient, emergency department, or operating room setting.

RESULTS

A total of 4848 references were identified for title and abstract screening. Full text screening was performed for 197 articles, with 120 meeting the criteria for study inclusion.

CONCLUSION

A review of the literature demonstrates a paucity of quality published studies describing scientifically valid and reproducible usability evaluations at various stages of EHR system development. A lack of formal and standardized reporting of EHR usability evaluation results is a major contributor to this knowledge gap, and efforts to improve this deficiency will be one step of moving the field of usability engineering forward.

Does the Norwegian emergency medical dispatch classification as non-urgent predict no need for pre-hospital medical treatment? An observational study

Background

The number of ambulance call-outs in Norway is increasing owing to societal changes and increased demand from the public. Together with improved but more expensive education of ambulance staff, this leads to increased costs and staffing shortages. We wanted to study whether the current dispatch triage tools could reliably identify patients who only required transport, and not pre-hospital medical care. This could allow selection of such patients for designated transport units, freeing up highly trained ambulance staff to attend patients in greater need.

Methods

A cross-sectional observational study was used, drawing on all electronic and paper records in our ambulance service from four random days in 2012. The patients were classified into acuity groups, based on Emergency Medical Dispatch codes, and pre-hospital interventions were extracted from the Patient Report Forms.

Results

Of the 1489 ambulance call-outs included in this study, 82 PRFs (5 %) were missing. A highly significant association was found between acuity group and recorded pre-hospital intervention (p ≤ 0.001). We found no correlation between gender, distance to hospital, age and pre-hospital interventions. Ambulances staffed by paramedics performed more interventions (234/917, 26 %) than those with emergency medical technicians (42/282, 15 %). The strongest predictor for needing pre-hospital interventions was found to be the emergency medical dispatch acuity descriptor.

Discussion

This study has demonstrated that the Norwegian dispatch system is able to correctly identify patients who do not need pre-hospital interventions. Patients with a low acuity code had a very low level of pre-hospital interventions. Evaluation of adherence to protocol in the Emergency Medical Dispatch is not possible due to the inherent need for medical experience in the triage process.

Conclusions

This study validates the Norwegian dispatch tool (Norwegian index) as a predictor of patients who do not need pre-hospital interventions.

Electronic health records, adoption, quality of care, legal and privacy issues and their implementation in emergency departments

Recently, the healthcare sector has shown a growing interest in information technologies. Two popular health IT (HIT) products are the electronic health record (EHR) and health information exchange (HIE) networks. The introduction of these tools is believed to improve care, but has also raised some important questions and legal and privacy issues. The implementation of these systems has not gone smoothly, and still faces some considerable barriers. This article reviews EHR and HIE to address these obstacles, and analyzes the current state of development and adoption in various countries around the world. Moreover, legal and ethical concerns that may be encountered by EHR users and purchasers are reviewed. Finally, links and interrelations between EHR and HIE and several quality of care issues in today's healthcare domain are examined with a focus on EHR and HIE in the emergency department (ED), whose unique characteristics makes it an environment in which the implementation of such technology may be a major contributor to health, but also faces substantial challenges. The paper ends with a discussion of specific policy implications and recommendations based on an examination of the current limitations of these systems.

What do physicians read (and ignore) in electronic progress notes?

OBJECTIVE

Several studies have documented the preference for physicians to attend to the impression and plan section of a clinical document. However, it is not clear how much attention other sections of a document receive. The goal of this study was to identify how physicians distribute their visual attention while reading electronic notes.

METHODS

We used an eye-tracking device to assess the visual attention patterns of ten hospitalists as they read three electronic notes. The assessment included time spent reading specific sections of a note as well as rates of reading. This visual analysis was compared with the content of simulated verbal handoffs for each note and debriefing interviews.

RESULTS

Study participants spent the most time in the "Impression and Plan" section of electronic notes and read this section very slowly. Sections such as the "Medication Profile", "Vital Signs" and "Laboratory Results" received less attention and were read very quickly even if they contained more content than the impression and plan. Only 9% of the content of physicians' verbal handoff was found outside of the "Impression and Plan."

CONCLUSION

Physicians in this study directed very little attention to medication lists, vital signs or laboratory results compared with the impression and plan section of electronic notes. Optimizing the design of electronic notes may include rethinking the amount and format of imported patient data as this data appears to largely be ignored.

Impact analysis of an evidence-based guideline on diagnosis of urinary tract infection in infants and young children with unexplained fever

Several guidelines exist on urinary tract infection (UTI) in children. The objectives of this study were to (1) implement an evidence-based diagnostic guideline on UTI and evaluate determinants of successful implementation, and (2) determine compliance to and impact of the guideline in febrile, non-toilet trained children at the emergency department (ED). We performed a prospective cross-sectional observational study, with observations before and after implementation. Children aged 1 month to 2 years, presenting at the ED with unexplained fever (temperature above 38.5 °C), were included. We excluded children with a chronic underlying disease. Primary outcome measure was compliance to the standardized diagnostic strategy and determinants influencing compliance. Secondary outcome parameters included the following: number of used dipsticks, contaminated cultures, number of genuine UTI, frequency of prescribed antibiotic treatment, and hospitalization. The pre-intervention group {169 children (male 60.4 %, median age 1.0 [range 0.1-2.0])} was compared with the post-intervention group {150 children (male 54.7 %, median age 1.0 [range 0.1-1.9])}. In 42 patients (24.9 %), there was compliance to local guidelines before implementation, compared with 70 (46.7 %) after implementation (p-value < 0.001). Improvement in compliance after implementation was higher in patients 3-24 months and outside the office hours (p < 0.001).

CONCLUSION

Implementation of a guideline for diagnosing UTI in febrile children at the ED has led to a significantly better compliance, especially in children aged 3-24 months. However, this study also underlines the need for a well-defined implementation strategy after launching an (inter)national guideline, taking determinants influencing implementation into account.

Defining and measuring completeness of electronic health records for secondary use

We demonstrate the importance of explicit definitions of electronic health record (EHR) data completeness and how different conceptualizations of completeness may impact findings from EHR-derived datasets. This study has important repercussions for researchers and clinicians engaged in the secondary use of EHR data. We describe four prototypical definitions of EHR completeness: documentation, breadth, density, and predictive completeness. Each definition dictates a different approach to the measurement of completeness. These measures were applied to representative data from NewYork-Presbyterian Hospital's clinical data warehouse. We found that according to any definition, the number of complete records in our clinical database is far lower than the nominal total. The proportion that meets criteria for completeness is heavily dependent on the definition of completeness used, and the different definitions generate different subsets of records. We conclude that the concept of completeness in EHR is contextual. We urge data consumers to be explicit in how they define a complete record and transparent about the limitations of their data.

The effects of an electronic medical record on the completeness of documentation in the anesthesia record

OBJECTIVES

The purpose of this study is to evaluate the completeness of anesthesia recording before and after the introduction of an electronic anesthesia record.

METHODS

The study was conducted in a Korean teaching hospital where the EMR was implemented in October 2008. One hundred paper anesthesia records from July to September 2008 and 150 electronic anesthesia records during the same period in 2009 were randomly sampled. Thirty-four essential items were selected out of all the anesthesia items and grouped into automatically transferred items and manual entry items. 1, .5 and 0 points were given for each item of complete entry, incomplete entry and no entry respectively. The completeness of documentation was defined as the sum of the scores. The influencing factors on the completeness of documentation were evaluated in total and by the groups.

RESULTS

The average completeness score of the electronic anesthesia records was 3.15% higher than that of the paper records. A multiple regression model showed the type of the anesthesia record was a significant factor on the completeness of anesthesia records in all items (β=.98, p<.05) and automatically transferred items (β=.56, p<.01). The type of the anesthesia records had no influence on the completeness in manual entry items.

CONCLUSIONS

The completeness of an anesthesia record was improved after the implementation of the electronic anesthesia record. The reuse of the data from the EMR was the main contributor to the improved completeness.

Clinical prediction model to aid emergency doctors managing febrile children at risk of serious bacterial infections: diagnostic study

OBJECTIVE

To derive, cross validate, and externally validate a clinical prediction model that assesses the risks of different serious bacterial infections in children with fever at the emergency department.

DESIGN

Prospective observational diagnostic study.

SETTING

Three paediatric emergency care units: two in the Netherlands and one in the United Kingdom.

PARTICIPANTS

Children with fever, aged 1 month to 15 years, at three paediatric emergency care units: Rotterdam (n=1750) and the Hague (n=967), the Netherlands, and Coventry (n=487), United Kingdom. A prediction model was constructed using multivariable polytomous logistic regression analysis and included the predefined predictor variables age, duration of fever, tachycardia, temperature, tachypnoea, ill appearance, chest wall retractions, prolonged capillary refill time (>3 seconds), oxygen saturation <94%, and C reactive protein.

MAIN OUTCOME MEASURES

Pneumonia, other serious bacterial infections (SBIs, including septicaemia/meningitis, urinary tract infections, and others), and no SBIs.

RESULTS

Oxygen saturation <94% and presence of tachypnoea were important predictors of pneumonia. A raised C reactive protein level predicted the presence of both pneumonia and other SBIs, whereas chest wall retractions and oxygen saturation <94% were useful to rule out the presence of other SBIs. Discriminative ability (C statistic) to predict pneumonia was 0.81 (95% confidence interval 0.73 to 0.88); for other SBIs this was even better: 0.86 (0.79 to 0.92). Risk thresholds of 10% or more were useful to identify children with serious bacterial infections; risk thresholds less than 2.5% were useful to rule out the presence of serious bacterial infections. External validation showed good discrimination for the prediction of pneumonia (0.81, 0.69 to 0.93); discriminative ability for the prediction of other SBIs was lower (0.69, 0.53 to 0.86).

CONCLUSION

A validated prediction model, including clinical signs, symptoms, and C reactive protein level, was useful for estimating the likelihood of pneumonia and other SBIs in children with fever, such as septicaemia/meningitis and urinary tract infections.

An investigation of a healthcare management system with the use of multimodal interaction and 3D simulation

Purpose

Current healthcare applications produce a complex and inaccessible set of data that often needs to be investigated simultaneously. As such the conflicting software applications and mental effort being demanded from the user result in time‐consuming analysis and diagnosis. The purpose of this paper is to provide a prototype, interactive system for management of multiple data sets, currently used for gait analysis capturing, reconstruction and diagnosis. In summary, this work is concerned with the development of interactive information‐visualisation software that assists medical practitioners in simplifying and enhancing the retrieval, visualisation and analysis of medical data with the intention of improving the overall system leading to an improved service for the user and patient experience.

Design/methodology/approach

The design of the proposed system aims to combine all the related existing software currently used for gait analysis and diagnosis under one, user‐friendly package. The latter will have the capacity to offer also real‐time, three dimensional (3D) representations of all the derived data (CT, MRI, motion capture) in an interactive virtual reality (VR) environment.

Findings

It is intended that the proposed prototype solutions will enhance interactive systems for management of multiple data sets, currently used for gait analysis capturing, reconstruction and diagnosis. The derived data encapsulate a plethora of multimedia information aiming to enhance medical visualisation.

Originality/value

The proposed system offers simulation capacity and a VR visualisation experience, which enhances the gait analysis diagnostic process. The 3D data can be manipulated in real‐time through a novel human‐computer interface which uses multimodal interaction through the use of graphical user interfaces and gesture recognition. The system aims towards a cost‐effective, clearly presented and timely accessible system that follows a threefold approach; It entails managing the extensive amount of the daily produced medical data, combining the scattered information related to one patient in one interface with a filtering criteria to the required information, and visualising in 3D the data from different sources, in order to improve 3D mental mapping, increase productivity and consequently ameliorate quality of service and management.

NEOREG: design and implementation of an online Neonatal Registration System to access, follow and analyse the data of newborns with congenital cytomegalovirus infection

Today's registration of newborns with congenital cytomegalovirus (cCMV) infection is still performed on paper-based forms in Flanders, Belgium. This process has a large administrative impact. It is important that all screening tests are registered to have a complete idea of the impact of cCMV. Although these registrations are usable in computerised data analysis, these data are not available in a format to perform electronic processing. An online Neonatal Registry (NEOREG) System was designed and developed to access, follow and analyse the data of newborns remotely. It allows remote access and monitoring by the physician. The Java Enterprise layered application provides patients' diagnostic registration and treatment follow-up through a web interface and uses document forms in Portable Document Format (PDF), which incorporate all the elements from the existing forms. Forms are automatically processed to structured EHRs. Modules are included to perform statistical analysis. The design was driven by extendibility, security and usability requirements. The website load time, throughput and execution time of data analysis were evaluated in detail. The NEOREG system is able to replace the existing paper-based CMV records.

Electronic health record impact on work burden in small, unaffiliated, community-based primary care practices

BACKGROUND

The use of electronic health records (EHR) is widely recommended as a means to improve the quality, safety and efficiency of US healthcare. Relatively little is known, however, about how implementation and use of this technology affects the work of clinicians and support staff who provide primary health care in small, independent practices.

OBJECTIVE

To study the impact of EHR use on clinician and staff work burden in small, community-based primary care practices.

DESIGN

We conducted in-depth field research in seven community-based primary care practices. A team of field researchers spent 9-14 days over a 4-8 week period observing work in each practice, following patients through the practices, conducting interviews with key informants, and collecting documents and photographs. Field research data were coded and analyzed by a multidisciplinary research team, using a grounded theory approach.

PARTICIPANTS

All practice members and selected patients in seven community-based primary care practices in the Northeastern US.

KEY RESULTS

The impact of EHR use on work burden differed for clinicians compared to support staff. EHR use reduced both clerical and clinical staff work burden by improving how they check in and room patients, how they chart their work, and how they communicate with both patients and providers. In contrast, EHR use reduced some clinician work (i.e., prescribing, some lab-related tasks, and communication within the office), while increasing other work (i.e., charting, chronic disease and preventive care tasks, and some lab-related tasks). Thoughtful implementation and strategic workflow redesign can mitigate the disproportionate EHR-related work burden for clinicians, as well as facilitate population-based care.

CONCLUSIONS

The complex needs of the primary care clinician should be understood and considered as the next iteration of EHR systems are developed and implemented.

Methods and dimensions of electronic health record data quality assessment: enabling reuse for clinical research

OBJECTIVE

To review the methods and dimensions of data quality assessment in the context of electronic health record (EHR) data reuse for research.

MATERIALS AND METHODS

A review of the clinical research literature discussing data quality assessment methodology for EHR data was performed. Using an iterative process, the aspects of data quality being measured were abstracted and categorized, as well as the methods of assessment used.

RESULTS

Five dimensions of data quality were identified, which are completeness, correctness, concordance, plausibility, and currency, and seven broad categories of data quality assessment methods: comparison with gold standards, data element agreement, data source agreement, distribution comparison, validity checks, log review, and element presence.

DISCUSSION

Examination of the methods by which clinical researchers have investigated the quality and suitability of EHR data for research shows that there are fundamental features of data quality, which may be difficult to measure, as well as proxy dimensions. Researchers interested in the reuse of EHR data for clinical research are recommended to consider the adoption of a consistent taxonomy of EHR data quality, to remain aware of the task-dependence of data quality, to integrate work on data quality assessment from other fields, and to adopt systematic, empirically driven, statistically based methods of data quality assessment.

CONCLUSION

There is currently little consistency or potential generalizability in the methods used to assess EHR data quality. If the reuse of EHR data for clinical research is to become accepted, researchers should adopt validated, systematic methods of EHR data quality assessment.

A study of the difference in volume of information in chief complaint and present illness between electronic and paper medical records

The introduction of an electronic medical record (EMR) has been rapidly accelerating in South Korea. The EMR was expected to improve quality of care, readability, availability, and the quality of data. However, the reluctance of healthcare providers to use the EMR may have caused a reduction of information recorded in EMRs. The purpose of this study was to identify whether there was any loss of information following the introduction of a narrative text-based EMR in the recording of chief complaint and present illness in inpatient medical records. Inpatient medical records of a university hospital were retrospectively evaluated for one month before and one month after the introduction of the EMR in June 2006. The volume of information for chief complaint and present illness was measured by number of words in Korean and normalised bytes. Change in volume of information was measured by two-way ANOVA and multiple regression analyses, controlling for doctors' gender, age, and grade/year of residents, patients' readmission status, reasons for admission and service department to assess any effect of the introduction of an EMR. Total numbers of paper-based medical records (PMRs) and EMRs for analysis were 1,159 and 1,122, respectively. Forty-three doctors participated in the study. Thirty-one (72%) doctors were less than 30 years of age. Number of words proved a better outcome measure (R²=22 for CC, R²=36 for PI) than normalised bytes (R²=18 for CC, R²=35 for PI) for measuring volume of information. Results showed that the volume of information in the chief complaint and present illness was not decreased after the introduction of the EMR, except when the dependent variable was measured by number of words in the present illness. The study showed that the introduction of the EMR did not reduce the volume of information documented for chief complaint and present illness in inpatient medical records. However, further studies are needed to identify how to control the probable loss of information as showed in present illness measured by number of words.

Development of an electronic web-based software for the management of colorectal cancer target referral patients

In response to concern about lengthy waiting times for cancer treatment in the UK, the Department of Health introduced 'the colorectal cancer target referral scheme' to improve the referral process for suspected cancer. A user-centred web-based intranet software was developed reflecting the core work of the multi-disciplinary cancer team and the patient journey. The method used was primarily based on the concept of involving the end users (clinicians, nurses, administration staff) in the process of problem definition, software design, formative evaluation, development and implementation, from the very beginning, to ensure its relevance, functionality, and effectiveness. This software improved the interdisciplinary communication among doctors. All patients met the government waiting targets and proved to be a facilitative tool for audit, research and further prospective assessment of our service. Implementing a functional software design is mandatory for the management of target referral patients.

Toward an integrated knowledge environment to support modern oncology

Around the world, teams of researchers continue to develop a wide range of systems to capture, store, and analyze data including treatment, patient outcomes, tumor registries, next-generation sequencing, single-nucleotide polymorphism, copy number, gene expression, drug chemistry, drug safety, and toxicity. Scientists mine, curate, and manually annotate growing mountains of data to produce high-quality databases, while clinical information is aggregated in distant systems. Databases are currently scattered, and relationships between variables coded in disparate datasets are frequently invisible. The challenge is to evolve oncology informatics from a "systems" orientation of standalone platforms and silos into an "integrated knowledge environments" that will connect "knowable" research data with patient clinical information. The aim of this article is to review progress toward an integrated knowledge environment to support modern oncology with a focus on supporting scientific discovery and improving cancer care.

[Evaluation of a new computerized recording system for preoperative assessment data]

BACKGROUND AND OBJECTIVES

Little information is available on the use of computerized systems in preanesthetic assessment. Our aim was to evaluate staff acceptance of a computerized system for the structured recording of preoperative assessment data in our hospital. The time taken to complete the assessment was compared to the time usually taken to record the information on paper.

MATERIAL AND METHODS

Observational, descriptive cross-sectional survey of user satisfaction 3 months after the system had been launched. We later carried out a prospective observational study of 796 preanesthetic assessment visits, comparing the mean time the users took to record information on paper to the time required to enter the data into the computer, analyzing differences between anesthesiologists and according to American Society of Anesthesiologists (ASA) classification and patient age.

RESULTS

A total of 401 paper records and 395 electronic files were included. The users believed that the computerized system improved quality and accessibility of recorded data and clinical decision-making. The time required to enter data into the computer was believed to be the main drawback; the users took a mean (SD) 15.21 (5.41) minutes to enter the electronic data and 13.37 (5.08) minutes to record the information on paper (P < .001). There were also significant differences in the time taken to record data according to ASA classification and between anesthesiologists (P < .001).

CONCLUSIONS

In spite of drawbacks such as extra time taken to record electronic data, the users perceived benefits, such as improved quality and accessibility of records. For this reason, the computerized system was well accepted.

Paper-based versus computer-based records in the emergency department: staff preferences, expectations, and concerns

Although the potential benefits of computer-based records have been identified in different areas of the healthcare environment, in many settings paper-based records and computer-based records are still used in parallel. In this article, emergency department (ED) staff perspectives about the use of paper- or computer-based records are presented. This was a qualitative study in which data were collected using in-depth semi-structured interviews with the ED staff. The interviews were transcribed verbatim and data were analysed using framework analysis. In total, 34 interviews were undertaken. The study identified a number of factors which might encourage or discourage the use of paper-based and computer-based records in the ED. Users also expressed their concerns and expectations. Although there is a tendency towards computerizing healthcare settings, user acceptance of technology should not be underestimated. To improve user acceptance, users' concerns should be investigated and addressed appropriately.

Review: electronic health records and the reliability and validity of quality measures: a review of the literature

Previous reviews of research on electronic health record (EHR) data quality have not focused on the needs of quality measurement. The authors reviewed empirical studies of EHR data quality, published from January 2004, with an emphasis on data attributes relevant to quality measurement. Many of the 35 studies reviewed examined multiple aspects of data quality. Sixty-six percent evaluated data accuracy, 57% data completeness, and 23% data comparability. The diversity in data element, study setting, population, health condition, and EHR system studied within this body of literature made drawing specific conclusions regarding EHR data quality challenging. Future research should focus on the quality of data from specific EHR components and important data attributes for quality measurement such as granularity, timeliness, and comparability. Finally, factors associated with poor or variability in data quality need to be better understood and effective interventions developed.

A structured registration program can be validly used for quality assessment in general practice

BACKGROUND

Patient information, medical history, clinical outcomes and demographic information, can be registered in different ways in registration programs. For evaluation of diabetes care, data can easily be extracted from a structured registration program (SRP). The usability of data from this source depends on the agreement of this data with that of the usual data registration in the electronic medical record (EMR).Aim of the study was to determine the comparability of data from an EMR and from an SRP, to determine whether the use of SRP data for quality assessment is justified in general practice.

METHODS

We obtained 196 records of diabetes mellitus patients in a sample of general practices in the Netherlands. We compared the agreement between the two programs in terms of laboratory and non-laboratory parameters. Agreement was determined by defining accordance between the programs in absent and present registrations, accordance between values of registrations, and whether the differences found in values were also a clinically relevant difference.

RESULTS

No differences were found in the occurrence of registration (absent/present) in the SRP and EMR for all the laboratory parameters. Smoking behaviour, weight and eye examination were registered significantly more often in the SRP than in the EMR. In the EMR, blood pressure was registered significantly more often than in the SRP. Data registered in the EMR and in the SRP had a similar clinical meaning for all parameters (laboratory and non-laboratory).

CONCLUSIONS

Laboratory parameters showed good agreement and non-laboratory acceptable agreement of the SRP with the EMR. Data from a structured registration program can be used validly for research purposes and quality assessment in general practice.

The impact of the electronic health record on an academic pediatric primary care center

Many hospitals and practices are transitioning to electronic health records (EHR), but there is little information on the impact on patient care in a busy pediatric academic setting. The objective of this study was to determine the impacts of EHR on documentation, clinical processes, billing, ancillary staff responsibilities, scheduling, and cycle time. A descriptive study to assess the impact of EHR implementation and subsequent use on documentation, clinical processes, and patient access and flow was performed in a large urban academic pediatric primary care health center. Six months and 2 years after implementation, EHR impact on documentation was collected and compared with baseline value by measuring the percentage of charts with problem lists present. Several clinical improvement processes were collected at baseline and 6 months later including medication refill turnaround time, percentage of charts without attending signature at 3 days, and type of appointment billed on ill visits. The volume of appointments and cycle time were measured at regular intervals from baseline to 2 years after implementation. The percentage of paper charts attempted to be pulled for patient visits was obtained at baseline and 1 year later. Of the 500 charts audited before implementation, and 25 charts audited 6 months and 2 years after the implementation, the percentage of the presence of problem lists improved from 29% to 84%. Medication refill turnaround time improved from an average of 48 hours to 12 hours. Charts with incomplete documentation at 3 days postvisit decreased from 3% to 1.6%. Visit coding for detailed level visits (99214) increased by 13% and for problem-focused visits (99212) decreased by 7%, resulting in increased revenue collected. Medical records support staff needs decreased from 1 full-time equivalent to 0.5 full-time equivalent. One year after the EHR implementation, the medical records staff pulled and refiled 5.2% of paper charts compared with 100% at baseline. Despite plans to return to full volume of scheduling patients by 4 weeks postimplementation, volume continued to be reduced by 10% for 3 additional months because of user inefficiency and high number of new learners/users. Patient cycle time was increased from 76 minutes preimplementation to 119 minutes immediately postimplementation and decreased to 85 to 90 minutes 2 years later. EHR can be successfully implemented in a large urban academic pediatric healthcare center. EHR implementation improved documentation of patient care, improved clinical processes, and resulted in increased revenue. However, the implementation of the EHR also led to short-term decreased appointment availability and a persistent longer cycle time. Ongoing information system training support is a key for maintaining efficiency due to the large number of new learners.

Examining the value of electronic health records on labor and delivery

OBJECTIVE

The objective of the study was to evaluate the impact of an electronic health record (EHR) on documentation completeness and patient care in a labor and delivery unit.

STUDY DESIGN

We conducted a pre- and postintervention study to compare documentation quality and workflow before and after EHR implementation. Documentation was compared using chi(2) and Fisher's exact tests. Objective observers measured workflow activities across all shifts before and after EHR implementation and activities were compared using Kruskal-Wallis tests and analysis of covariance.

RESULTS

Paper admission records were significantly more likely to miss key clinical information such as chief complaints (contractions, membrane status, bleeding, fetal movement, 10-64% vs 2-5%; P < .0001) and prenatal laboratory results and history (Varicella, group B Streptococcus, human immunodeficiency virus, 26-66% vs 1-16%, P < .0001). Both direct patient care and computer activities increased after EHR implementation (2 vs 12 and 12 vs 17 activities/shift, respectively, P < .0001).

CONCLUSION

The introduction of an obstetric EHR improved documentation completeness without reducing direct patient care.

Development of a web-based register for the Dutch national study on biologicals in JIA: www.ABC-register.nl

OBJECTIVES

Most clinical studies use paper case record forms (CRFs) to collect data. In the Dutch multi-centre observational study on biologicals we encountered several disadvantages of using the paper CRFs. These are delay in data collection, lack of overview in collected data and difficulties in obtaining up-to-date interim reports. Therefore, we wanted to create a more effective method of data collection compared with CRFs on paper in a multi-centre study.

METHODS

We designed a web-based register with the intention to make it easy to use for participating physicians and at the same time accurate and up-to-date. Security demands were taken into account to secure the safety of the patient data.

RESULTS

The web-based register was tested with data from 161 juvenile idiopathic arthritis patients from nine different centres. Internal validity was obtained and user-friendliness guaranteed. To secure the completeness of the data automatically generated e-mail alerts were implemented into the web-based register. More transparency of data was achieved by including the option to automatically generate interim reports of data in the web-based register. The safety was tested and approved.

CONCLUSIONS

By digitalizing the CRF we achieved our aim to provide easy, rapid and safe access to the database and contributed to a new way of data collection. Although the web-based register was designed for the current multi-centre observational study, this type of instrument can also be applied to other types of studies. We expect that especially collaborative study groups will find it an efficient tool to collect data.

Ethical issues and the electronic health record

Ethical issues related to electronic health records (EHRs) confront health personnel. Electronic health records create conflict among several ethical principals. Electronic health records may represent beneficence because they are alleged to increase access to health care, improve the quality of care and health, and decrease costs. Research, however, has not consistently demonstrated access for disadvantaged persons, the accuracy of EHRs, their positive effects on productivity, nor decreased costs. Should beneficence be universally acknowledged, conflicts exist with other ethical principles. Autonomy is jeopardized when patients' health data are shared or linked without the patients' knowledge. Fidelity is breached by the exposure of thousands of patients' health data through mistakes or theft. Lack of confidence in the security of health data may induce patients to conceal sensitive information. As a consequence, their treatment may be compromised. Justice is breached when persons, because of their socioeconomic class or age, do not have equal access to health information resources and public health services. Health personnel, leaders, and policy makers should discuss the ethical implications of EHRs before the occurrence of conflicts among the ethical principles. Recommendations to guide health personnel, leaders, and policy makers are provided.

Cardiologists' charting varied by risk factor, and was often discordant with patient report

OBJECTIVE

To assess the completeness of cardiac risk factor documentation by cardiologists, and agreement with patient report.

STUDY DESIGN AND SETTING

A total of 68 Ontario cardiologists and 789 of their ambulatory cardiology patients were randomly selected. Cardiac risk factor data were systematically extracted from medical charts, and a survey was mailed to participants to assess risk factor concordance.

RESULTS

With regard to completeness of risk factor documentation, 90.4% of charts contained a report of hypertension, 87.2% of diabetes, 80.5% of dyslipidemia, 78.6% of smoking behavior, 73.0% of other comorbidities, 48.7% of family history of heart disease, and 45.9% of body mass index or obesity. Using Cohen's k, there was a concordance of 87.7% between physician charts and patient self-report of diabetes, 69.5% for obesity, 56.8% for smoking status, 49% for hypertension, and 48.4% for family history.

CONCLUSION

Two of four major cardiac risk factors (hypertension and diabetes) were recorded in 90% of patient records; however, arguably the most important reversible risk factors for cardiac disease (dyslipidemia and smoking) were only reported 80% of the time. The results suggest that physician chart report may not be the criterion standard for quality assessment in cardiac risk factor reporting.

Medication errors in neonates

Prevention of harm from medication errors has become a national priority. Medication errors in the neonatal intensive care unit are common, and most can be avoided. This article reviews the prevalence and types of medication errors affecting the care of the neonate and summarizes approaches that have been used to reduce these errors. Safety initiatives applicable to minimizing medication errors also are discussed.

Is OpenSDE an alternative for dedicated medical research databases? An example in coronary surgery

BACKGROUND

When using a conventional relational database approach to collect and query data in the context of specific clinical studies, a study with a new data set usually requires the design of a new database and entry forms. OpenSDE (SDE = Structured Data Entry) is intended to provide a flexible and intuitive way to create databases and entry forms for the collection of data in a structured format. This study illustrates the use of OpenSDE as a potential alternative to a conventional approach with respect to data modelling, database creation, data entry, and data extraction.

METHODS

A database and entry forms are created using OpenSDE and MSAccess to support collection of coronary surgery data, based on the Adult Cardiac Surgery Data Set of the Society of Thoracic Surgeons. Data of 52 cases are entered and nine different queries are designed, and executed on both databases.

RESULTS

Design of the data model and the creation of entry forms were experienced as more intuitive and less labor intensive with OpenSDE. Both resulting databases provided sufficient expressiveness to accommodate the data set. Data entry was more flexible with OpenSDE. Queries produced equal and correct results with comparable effort.

CONCLUSION

For prospective studies involving well-defined and straight forward data sets, OpenSDE deserves to be considered as an alternative to the conventional approach.

Randomized trial of a clinical decision support system: impact on the management of children with fever without apparent source

OBJECTIVE

To assess compliance with a clinical decision support system (CDSS) for diagnostic management of children with fever without apparent source and to study the effects of application of the CDSS on time spent in the emergency department (ED) and number of laboratory tests.

DESIGN

The CDSS was used by ED nursing staff to register children presenting with fever. The CDSS identified children that met inclusion criteria (1-36 months and fever without apparent source (FWS)) and provided patient-specific diagnostic management advice. Children at high risk for serious bacterial infection were randomized for the 'intervention' (n = 74) or the 'control' (n = 90) group. In the intervention group, the CDSS provided the advice to immediately order laboratory tests and in the control group the ED physician first assessed the children and then decided on ordering laboratory tests.

RESULTS

Compliance with registration of febrile children was 50% (683/1,399). Adherence to the advice to order laboratory tests was 82% (61/74). Children in the intervention group had a median (25(th)-75(th) percentile) length of stay at the ED of 138 (104-181) minutes. The median length of stay at the ED in the control group was 123 (83-179) minutes. Laboratory tests were significantly more frequently ordered in the intervention group (82%) than in the control group (44%, p < 0.001, chi(2) test).

CONCLUSION

Implementation of a CDSS for diagnostic management of young children with fever without apparent source was successful regarding compliance and adherence to CDSS recommendations, but had unexpected effects on patient outcome in terms of ED length of stay and number of laboratory tests. The use of the current CDSS was discontinued.

A qualitative investigation of the content of dental paper-based and computer-based patient record formats

OBJECTIVE

Approximately 25% of all general dentists practicing in the United States use a computer in the dental operatory. Only 1.8% maintain completely electronic records. Anecdotal evidence suggests that dental computer-based patient records (CPR) do not represent clinical information with the same degree of completeness and fidelity as paper records. The objective of this study was to develop a basic content model for clinical information in paper-based records and examine its degree of coverage by CPRs.

DESIGN

We compiled a baseline dental record (BDR) from a purposive sample of 10 paper record formats (two from dental schools and four each from dental practices and commercial sources). We extracted all clinical data fields, removed duplicates, and organized the resulting collection in categories/subcategories. We then mapped the fields in four market-leading dental CPRs to the BDR.

MEASUREMENTS

We calculated frequency counts of BDR categories and data fields for all paper-based and computer-based record formats, and cross-mapped information coverage at both the category and the data field level.

RESULTS

The BDR had 20 categories and 363 data fields. On average, paper records and CPRs contained 14 categories, and 210 and 174 fields, respectively. Only 72, or 20%, of the BDR fields occurred in five or more paper records. Categories related to diagnosis were missing from most paper-based and computer-based record formats. The CPRs rarely used the category names and groupings of data fields common in paper formats.

CONCLUSION

Existing paper records exhibit limited agreement on what information dental records should contain. The CPRs only cover this information partially, and may thus impede the adoption of electronic patient records.