Perspectives on electronic medical records adoption: electronic medical records (EMR) in outcomes research

Hypertensive Hypoalgesia in a Complex Chronic Disease Population

Hypertension-related hypoalgesia, defined as lower pain sensitivity in individuals with high blood pressure, has yet to be examined in a large-scale study of complex care residents. Here, the Continuing Care Reporting System database, which contains health information on residents of Canadian complex chronic care facilities, was used for assessment. Hypertension was reported among 77,323 residents (55.5%, total N = 139,920). Propensity score matching, with a 1:1 ratio, was used to identify a control record without hypertension for each case. Multinomial logistic regression was used to quantify the effects of hypertension and sex on four-level ordinal pain variables, controlling for potential confounders. The matched dataset included n = 40,799 cases with hypertension and n = 40,799 without hypertension, with 57% female. Residents with hypertension had significantly lower odds of reporting pain (yes/no) (OR = 0.85, 95% CI 0.81–0.90, p < 0.001), including on measures of severe pain (OR = 0.69, 95% CI 0.63–0.76, p < 0.001). A significant interaction between hypertension and sex (OR = 1.17, 95% CI 1.03–1.32, p = 0.014) indicated that a significantly greater proportion of females without hypertension reported severe pain (8.71%). The results confirm the relationship between hypertension and reduced pain sensitivity on a population level.

What is Stopping Primary Health Centers to Go Digital? Findings of a Mixed-method Study at a District Level Health System in Southern India

Introduction

Electronic medical records (EMRs) are computerized medical information systems that collect, store, and display patient information and essential for the achievement of primary health-care goals. This study explores the availability and utilization of EMR and analyzed the barriers inhibiting their implementation at primary health centers (PHCs) in Nalgonda district of Telangana, India.

Methods

The research employed a sequential mixed-method design. Quantitative data were collected using a questionnaire by conducting facility surveys across 75 PHCs and in-depth interviews with district health authorities were conducted using a predesigned guide. Quantitative data were analyzed using descriptive statistics and thematic analysis of interviews resulted in four themes focusing on the factors inhibiting PHCs to use EMR.

Results

The availability of EMR facility was low (19.14%) and they are routinely used for maintaining immunization data in 83% of the PHCs. In contrast, none of the PHCs used EMR for prescribing medications to patients. Budgetary constraints, unavailability of dedicated information technology staff, gaps in technical knowledge, and perceptions about EMR as a time-consuming system were the commonly reported barriers inhibiting PHCs to go digital.

Conclusion

The availability and utilization of EMR keeping was low across PHCs of Nalgonda district. The study identified multiple barriers which hinder the implementation of EMR facilities at PHCs. Addressing these barriers is crucial for the successful implementation of EMR.

Association Between Multimorbid Disease Patterns and Pain Outcomes Among a Complex Chronic Care Population in Canada

PURPOSE

Disease multimorbidity and pain is a complex, yet common, problem for the aging population, and a significant burden on the health-care systems around the world. Despite this, disease comorbidity and the association with pain in a complex chronic care population is not well understood. This study examined the most prevalent disease combinations and their association with pain.

PATIENTS AND METHODS

The study initially included 139,920 residents, aged 18-101 years, admitted to publicly funded hospital facilities for complex chronic care in Canada between the years 2006 and 2016. Data were acquired through the Canadian Institute for Health Information (CIHI) Facility-Based Continuing Care Reporting System (CCRS). Descriptive and chi-square statistics were used to summarize and compare the sample characteristics. Binary logistic regression analyses were used to examine the association between multimorbid disease categories and pain outcomes.

RESULTS

The sample consisted of 139,573 residents (57% female), mostly older (mean age = 77.32 years), married (40%), or widowed (36%). Residents took an average of 11.9 medications and 77% were using analgesic medications. On average, residents had diagnoses from 3.06 disease categories (SD = 1.43). Heart/circulation diseases were the most prevalent among the sample (73%), with neurological second (46%) and musculoskeletal third (44%). Overall, 73% of residents reported pain, with 43% reporting moderate pain severity. Residents with multiple disease categories were more likely to report the presence of pain (OR = 1.08, 95% CI: 1.07-1.08, p < 0.001), with each additional disease category associated with an 8% increase in the odds of reporting pain.

CONCLUSION

The findings from this study help identify common comorbid disease patterns related to pain in an institutionalized, complex chronic care population. This information contributes to both the pain and multimorbidity literature, and is invaluable for creating care plans to meet the demands of a challenging population.

Tailored Helicobacter pylori eradication based on prior intake of macrolide antibiotics allows the use of triple therapy with optimal results in an area with high clarithromycin resistance

BACKGROUND

the previous intake of macrolide antibiotics is associated with a failure to eradicate Helicobacter pylori (H. pylori) with clarithromycin-containing regimens. However, the standard triple therapy achieves eradication rates of over 90% in patients without a previous use of macrolides in our health area. The aim of this study was to evaluate the efficacy of an H. pylori eradication strategy based on the intake of macrolides by the patient during the previous years.

METHODS

one hundred and sixty-nine patients with H. pylori infection were prospectively included in the study. The electronic medical record of each patient was reviewed at the time of inclusion. Depending on their previous intake of macrolides, patients were assigned to one of two eradication regimens: group A) patients without a previous intake of macrolides received an optimized triple therapy for 14 days; and group B) patients with a previous intake of macrolides received bismuth quadruple therapy for ten days.

RESULTS

ninety-one patients (53.84%) without a previous intake of macrolides received an optimized triple therapy (group A) and 78 patients (46.15%) with a previous intake of macrolides received bismuth quadruple therapy (group B). In group A, the H. pylori eradication rates were 90.11% in the intention-to-treat and 95.35% in the per-protocol analysis. In group B, the H. pylori eradication rates were 85.89% in the intention-to-treat and 98.5% in the per-protocol analysis. The overall eradication rates obtained using this strategy were 88.16% (95% CI: 82.32-92.02%) in the intention-to-treat and 96.75% (95% CI: 92.59-98.94%) in the per-protocol analysis.

CONCLUSIONS

an H. pylori eradication strategy based on the intake of macrolides during the previous years achieves overall eradication rates close to 90% and allows the use of standard triple therapy in more than half of the patients from a health area with a high level of clarithromycin resistance.

Current Status of the Adoption, Utilization and Helpfulness of Health Information Systems in Korea

As interest in medical informatization has been increasing steadily worldwide, the adoption of health information systems (HISs) in medical institutions is essential. In this study, we intended to identify users’ adoption, utilization and helpfulness derived from HISs to determine the status of medical informatization by using 2016 Korean Physician Survey data. A total of 8564 members responded to the 2016 survey, we extracted the data of 6949 HISs related part for this study. As a result, about 68% of the self-employed physicians adopted the Order Communication System and Electronic Medical Records, while only one-third adopted the Picture Archiving and Communication System. Overall, the proportions of utilization and helpfulness of HISs were higher for females; for employed physicians or professors; for physicians working in hospitals; and for those specializing in surgical medicine. As applying information technology to the medical environment becomes more important, HIS will become a necessary requirement and the demand for information systems considering user and patient oriented information environments will be increasing. Therefore, it is necessary to discuss the HISs use environment considering not only technical aspects but also users’ or patients’ viewpoints. In that respect, this study will give a meaningful evidence of HIS related policies.

The Role of the Pathologist in Population Health

CONTEXT.—

As part of its value-based care initiative, the College of American Pathologists has pursued research to better understand the role pathologists can have in population health.

OBJECTIVES.—

To answer the following questions: (1) what is the impact of population health and population health management on pathologists; (2) what roles are pathologists playing in population health management; (3) is population health something that pathologists in both larger and smaller settings can engage in; (4) are pathologists in a position to analyze laboratory data for population health, and, if so, what are the key information sources those pathologists must access; and (5) what steps can a pathologist take to become involved in population health?

DESIGN.—

We conducted 10 semistructured interviews with pathologists and other medical laboratory leaders who have been active in population health. These interviews were supplemented with a review of the medical literature.

RESULTS.—

Pathologists have demonstrated that laboratory data can provide unique value-added contributions to improving the health of populations. These contributions are not limited to pathologists in large, integrated settings. However, pathologists need to be proactive to contribute to health systems' population health efforts and may need to both enhance their own skills and the quality of their data to maximize the value of their contributions.

CONCLUSIONS.—

Although not necessarily a definitive summary of the roles that pathologists are playing in population health, this article identifies some of the promising and innovative activities occurring among pathologists and laboratorians.

A Literature Review of Electronic Health Records in Chiropractic Practice: Common Challenges and Solutions

OBJECTIVE

The purpose of this study was to review the literature on current challenges and propose solutions for the optimal utilization of the electronic health records (EHRs) in chiropractic practice.

METHODS

A search was performed in the PubMed, Index of Chiropractic Literature, and Current Index to Nursing and Allied Health Literature databases from November 2005 to February 2015. A combination of the following key words was used: electronic health records, electronic medical records, implementation, documentation, benefits, and challenges. Articles were categorized into common problems and solutions. These were filtered by application to chiropractic or educational institutions.

RESULTS

The search resulted in 45 papers, which included case reports of EHR implementation, governmental insurance reports, commentaries, controlled studies, narrative reviews of past experiences with conversion from paper systems, and the implementation of EHRs in small offices and chiropractic offices. Minimal literature was found that directly related to chiropractic EHRs. Improper utilization, incorrect use of the software, faulty implementation, workflow burdens, financial considerations, and insufficient training were found to negatively affect the quality of the record.

CONCLUSIONS

Documentation errors are often innate in the EHR software. Improper utilization, insufficient training, or difficulty in integration of the EHR into the clinical office setting results in poor implementation of the electronic version of the clinical record. Solutions that may decrease documentation errors include EHR training, continued financial incentives, and appropriate implementation process and utilization of available software features.

Data Mining Approach to Estimate the Duration of Drug Therapy from Longitudinal Electronic Medical Records

Background:

Electronic Medical Records (EMRs) from primary/ ambulatory care systems present a new and promising source of information for conducting clinical and translational research.

Objectives:

To address the methodological and computational challenges in order to extract reliable medication information from raw data which is often complex, incomplete and erroneous. To assess whether the use of specific chaining fields of medication information may additionally improve the data quality.

Methods:

Guided by a range of challenges associated with missing and internally inconsistent data, we introduce two methods for the robust extraction of patient-level medication data. First method relies on chaining fields to estimate duration of treatment (“chaining”), while second disregards chaining fields and relies on the chronology of records (“continuous”). Centricity EMR database was used to estimate treatment duration with both methods for two widely prescribed drugs among type 2 diabetes patients: insulin and glucagon-like peptide-1 receptor agonists.

Results:

At individual patient level the “chaining” approach could identify the treatment alterations longitudinally and produced more robust estimates of treatment duration for individual drugs, while the “continuous” method was unable to capture that dynamics. At population level, both methods produced similar estimates of average treatment duration, however, notable differences were observed at individual-patient level.

Conclusion:

The proposed algorithms explicitly identify and handle longitudinal erroneous or missing entries and estimate treatment duration with specific drug(s) of interest, which makes them a valuable tool for future EMR based clinical and pharmaco-epidemiological studies. To improve accuracy of real-world based studies, implementing chaining fields of medication information is recommended.

Comparative Effectiveness and Resource Usage in Patients Receiving First-line Taxane-based Chemotherapy for Stage IV Non-Small-cell Lung Cancer in a US Community Oncology Setting

BACKGROUND

Weekly (qw) nanoparticle albumin-bound (nab)-paclitaxel was approved for advanced non-small-cell lung cancer based on the results from a phase III trial in which nab-paclitaxel/carboplatin demonstrated a significantly greater response rate compared with paclitaxel/carboplatin every 3 weeks (q3w). Little information exists on relative real-world results.

MATERIALS AND METHODS

The present retrospective study used data from a national electronic medical record database. Patients receiving first-line nab-paclitaxel qw, paclitaxel qw, or paclitaxel q3w for stage IV non-small-cell lung cancer (NSCLC) were identified. The total cumulative dose, time to treatment discontinuation (TTD), and database persistence (a proxy measure for survival) were analyzed for all patients and for the squamous and elderly subgroups.

RESULTS

A total of 114, 208, and 153 patients received nab-paclitaxel qw, paclitaxel qw, and paclitaxel q3w, respectively. In the corresponding treatment arms, the median age was 72, 69, and 67 years; 56%, 48%, and 37% were aged ≥ 70 years; and 75%, 43%, and 23% had squamous cell NSCLC. The total cumulative dose was significantly greater with nab-paclitaxel qw. The TTD was longer with nab-paclitaxel qw than with paclitaxel qw (hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.40-0.72; P < .001) or with paclitaxel q3w (HR, 0.53; 95% CI, 0.38-0.73; P < .001). Database persistence was longer with nab-paclitaxel qw than with paclitaxel qw (HR, 0.56; 95% CI, 0.39-0.79; P = .001) or with paclitaxel q3w (HR, 0.52; 95% CI, 0.34-0.78; P = .002). The TTD after experiencing any hematologic adverse event was longer with nab-paclitaxel qw. The findings were consistent across the subgroup analyses.

CONCLUSION

In a real-world setting, nab-paclitaxel qw was associated with a significantly greater cumulative dose and significantly longer TTD and database persistence compared with paclitaxel qw and paclitaxel q3w.

Differences in the Prevalence of Obesity, Smoking and Alcohol in the United States Nationwide Inpatient Sample and the Behavioral Risk Factor Surveillance System

BACKGROUND

The lack of adequate and standardized recording of leading risk factors for morbidity and mortality in medical records have downstream effects on research based on administrative databases. The measurement of healthcare is increasingly based on risk-adjusted outcomes derived from coded comorbidities in these databases. However inaccurate or haphazard assessment of risk factors for morbidity and mortality in medical record codes can have tremendous implications for quality improvement and healthcare reform.

OBJECTIVE

We aimed to compare the prevalence of obesity, overweight, tobacco use and alcohol abuse of a large administrative database with a direct data collection survey.

MATERIALS AND METHODS

We used the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for four leading risk factors in the United States Nationwide Inpatient Sample (NIS) to compare them with a direct survey in the Behavioral Risk Factor Surveillance System (BRFSS) in 2011. After confirming normality of the risk factors, we calculated the national and state estimates and Pearson's correlation coefficient for obesity, overweight, tobacco use and alcohol abuse between NIS and BRFSS.

RESULTS

Compared with direct participant questioning in BRFSS, NIS reported substantially lower prevalence of obesity (p<0.01), overweight (p<0.01), and alcohol abuse (p<0.01), but not tobacco use (p = 0.18). The correlation between NIS and BRFSS was 0.27 for obesity (p = 0.06), 0.09 for overweight (p = 0.55), 0.62 for tobacco use (p<0.01) and 0.40 for alcohol abuse (p<0.01).

CONCLUSIONS

The prevalence of obesity, overweight, tobacco smoking and alcohol abuse based on codes is not consistent with prevalence based on direct questioning. The accuracy of these important measures of health and morbidity in databases is critical for healthcare reform policies.

Better big data

By 2018, Medicare payments will be tied to quality of care. The Centers for Medicare and Medicaid Services currently use quality-based metric for some reimbursements through their different programs. Existing and future quality metrics will rely on risk adjustment to avoid unfairly punishing those who see the sickest, highest-risk patients. Despite the limitations of the data used for risk adjustment, there are potential solutions to improve the accuracy of these codes by calibrating data by merging databases and compiling information collected for multiple reporting programs to improve accuracy. In addition, healthcare staff should be informed about the importance of risk adjustment for quality of care assessment and reimbursement. As the number of encounters tied to value-based reimbursements increases in inpatient and outpatient care, coupled with accurate data collection and utilization, the methods used for risk adjustment could be expanded to better account for differences in the care delivered in diverse settings.

Antibiotic stewardship in the intensive care unit

The rapid emergence and dissemination of antimicrobial-resistant microorganisms in ICUs worldwide constitute a problem of crisis dimensions. The root causes of this problem are multifactorial, but the core issues are clear. The emergence of antibiotic resistance is highly correlated with selective pressure resulting from inappropriate use of these drugs. Appropriate antibiotic stewardship in ICUs includes not only rapid identification and optimal treatment of bacterial infections in these critically ill patients, based on pharmacokinetic-pharmacodynamic characteristics, but also improving our ability to avoid administering unnecessary broad-spectrum antibiotics, shortening the duration of their administration, and reducing the numbers of patients receiving undue antibiotic therapy. Either we will be able to implement such a policy or we and our patients will face an uncontrollable surge of very difficult-to-treat pathogens.