Clinically Excellent Use of the Electronic Health Record: Review

Implementation and use of electronic patient records in the Brazilian Air Force: a cross-sectional study1

OBJECTIVE

The objective was to analyze the implementation and use of the electronic patient record in the health services of the Brazilian Air Force.

METHODS

This is a cross-sectional study carried out with 234 physicians, between March and May 2021. The data collection instrument was sent by email. The electronic patient record was implemented in the Air Force approximately 3 years ago (64.5%), and about 81% of the physicians received training to operate it.

RESULTS

The most common records involve data related to consultations (90.1%) and interviews with physical examination (67.1%). Physicians cited that information storage (75.6%), agility, and feasibility of recording (55.1%) were the main advantages of the electronic patient record. As disadvantages, problems in electronic equipment (69.7%) and system errors (65%) were reported. Most participants considered that the implementation had a positive impact on work dynamics (75.6%) and productivity (66.7%), mainly regarding the components "Work processes" (57.3%) and "Amount of carried out activities" (21.4%). Keeping records was significantly associated with the job position (p<0.001), type of unit (p=0.008), time of implementation (p<0.001), and participation in training (p=0.028).

CONCLUSION

The implementation of the electronic patient record in the Air Force was recently done, and just over half of the physicians were trained prior to the implementation. The tool is considered compatible with work processes and has a positive effect on productivity.

Pathway From Type 2 Diabetes Diagnosis to Action: How to Move People Forward

Seven self-care behaviors-healthy coping, healthy eating, being active, taking medication, monitoring, reducing risk, and problem-solving-are recommended for individuals with diabetes to achieve optimal health and quality of life. People newly diagnosed with type 2 diabetes may find it challenging to learn and properly incorporate all of these self-care behaviors into their life. This qualitative study explored the experiences and perceived immediate self-management and psychosocial support needs in individuals newly diagnosed with type 2 diabetes. Data analysis revealed the significant challenges individuals encounter after a type 2 diabetes diagnosis. Five main themes were identified: 1) type 2 diabetes diagnosis competes with other complex life challenges, 2) difficulty in performing behavior modification actions, 3) lack of support, 4) emergence of emotional and psychological issues, and 5) need for planned individualized follow-up support after a type 2 diabetes diagnosis. This study revealed a gap in care after type 2 diabetes diagnosis. Individualized support is needed to assist people in moving successfully from diagnosis to being well equipped with the knowledge and skills necessary to properly manage the condition.

Which Electronic Health Record System Should We Use? A Systematic Review

The UK government had intended to introduce a comprehensive Electronic Health Record (EHR) system in England by 2020. These EHRs would run across primary, secondary, and social care, linking data in a single digital platform. The objectives of this systematic review were to identify studies that compare EHR in terms of direct comparison between systems and to evaluate them using System and Software Quality Requirements and Evaluation (SQuaRE) ISO/IEC 25010. A systematic review was performed by searching Embase and Ovid MEDLINE databases between 1974 and April 2021. All original studies that appraised EHR systems and their providers were included. The main outcome measures were EHR system comparison and the eight characteristics of SQuaRE: functional suitability, performance efficiency, compatibility, usability, reliability, security, maintainability, and portability. A total of 724 studies were identified using the search criteria. After a review of titles and abstracts, this was filtered down to 40 studies as per the exclusion and inclusion criteria set out in our study. Seven studies compared more than one EHR. The following number of studies looked at the various aspects of the SQuaRE, respectively - 19 studies: functional suitability, performance efficiency: 18 studies, compatibility: 12 studies, usability: 25 studies, reliability: 6 studies, security: 2 studies, maintainability: 16 studies, portability: 13 studies. Epic was the most studied EHR system and one of the most implemented systems in the US market and one of the top ten in the UK. It is difficult to assess which is the most advantageous EHR system when they are assessed by SQuaRE's 8 characteristics for software evaluation.

Impact of an Educational Comic to Enhance Patient-Physician-Electronic Health Record Engagement: Prospective Observational Study

Background

Electronic health record (EHR) use can impede or augment patient-physician communication. However, little research explores the use of an educational comic to improve patient-physician-EHR interactions.

Objective

To evaluate the impact of an educational comic on patient EHR self-advocacy behaviors to promote patient engagement with the EHR during clinic visits.

Methods

We conducted a prospective observational study with adult patients and parents of pediatric patients at the University of Chicago General Internal Medicine (GIM) and Pediatric Primary Care (PPC) clinics. We developed an educational comic highlighting EHR self-advocacy behaviors and distributed it to study participants during check-in for their primary care visits between May 2017 and May 2018. Participants completed a survey immediately after their visit, which included a question on whether they would be interested in a follow-up telephone interview. Of those who expressed interest, 50 participants each from the adult and pediatric parent cohorts were selected at random for follow-up telephone interviews 8 months (range 3-12 months) post visit.

Results

Overall, 71.0% (115/162) of adult patients and 71.6% (224/313) of pediatric parents agreed the comic encouraged EHR involvement. African American and Hispanic participants were more likely to ask to see the screen and become involved in EHR use due to the comic (adult P=.01, P=.01; parent P=.02, P=.006, respectively). Lower educational attainment was associated with an increase in parents asking to see the screen and to be involved (ρ=−0.18, P=.003; ρ=−0.19, P<.001, respectively) and in adults calling for physician attention (ρ=−0.17, P=.04), which was confirmed in multivariate analyses. Female GIM patients were more likely than males to ask to be involved (median 4 vs 3, P=.003). During follow-up phone interviews, 90% (45/50) of adult patients and all pediatric parents (50/50) remembered the comic. Almost half of all participants (GIM 23/50, 46%; PPC 21/50, 42%) recalled at least one best-practice behavior. At subsequent visits, adult patients reported increases in asking to see the screen (median 3 vs 4, P=.006), and pediatric parents reported increases in asking to see the screen and calling for physician attention (median 3 vs 4, Ps<.001 for both). Pediatric parents also felt that the comic had encouraged them to speak up and get more involved with physician computer use since the index visit (median 4 vs 4, P=.02) and that it made them feel more empowered to get involved with computer use at future visits (median 3 vs 4, P<.001).

Conclusions

Our study found that an educational comic may improve patient advocacy for enhanced patient-physician-EHR engagement, with higher impacts on African American and Hispanic patients and patients with low educational attainment.

Real-world implementation of precision psychiatry: Transdiagnostic risk calculator for the automatic detection of individuals at-risk of psychosis

BACKGROUND

Risk estimation models integrated into Electronic Health Records (EHRs) can deliver innovative approaches in psychiatry, but clinicians' endorsement and their real-world usability are unknown. This study aimed to investigate the real-world feasibility of implementing an individualised, transdiagnostic risk calculator to automatically screen EHRs and detect individuals at-risk for psychosis.

METHODS

Feasibility implementation study encompassing an in-vitro phase (March 2018 to May 2018) and in-vivo phase (May 2018 to April 2019). The in-vitro phase addressed implementation barriers and embedded the risk calculator (predictors: age, gender, ethnicity, index cluster diagnosis, age*gender) into the local EHR. The in-vivo phase investigated the real-world feasibility of screening individuals accessing secondary mental healthcare at the South London and Maudsley NHS Trust. The primary outcome was adherence of clinicians to automatic EHR screening, defined by the proportion of clinicians who responded to alerts from the risk calculator, over those contacted.

RESULTS

In-vitro phase: implementation barriers were identified/overcome with clinician and service user engagement, and the calculator was successfully integrated into the local EHR through the CogStack platform. In-vivo phase: 3722 individuals were automatically screened and 115 were detected. Clinician adherence was 74% without outreach and 85% with outreach. One-third of clinicians responded to the first email (37.1%) or phone calls (33.7%). Among those detected, cumulative risk of developing psychosis was 12% at six-month follow-up.

CONCLUSION

This is the first implementation study suggesting that combining precision psychiatry and EHR methods to improve detection of individuals with emerging psychosis is feasible. Future psychiatric implementation research is urgently needed.

Adoption and Performance of Complementary Clinical Information Technologies: Analysis of a Survey of General Practitioners

Background

The benefits from the combination of 4 clinical information systems (CISs)—electronic health records (EHRs), health information exchange (HIE), personal health records (PHRs), and telehealth—in primary care depend on the configuration of their functional capabilities available to clinicians. However, our empirical knowledge of these configurations and their associated performance implications is very limited because they have mostly been studied in isolation.

Objective

This study aims to pursue 3 objectives: (1) characterize general practitioners (GPs) by uncovering the typical profiles of combinations of 4 major CIS capabilities, (2) identify physician and practice characteristics that predict cluster membership, and (3) assess the variation in the levels of performance associated with each configuration.

Methods

We used data from a survey of GPs conducted throughout the European Union (N=5793). First, 4 factors, that is, EHRs, HIE, PHRs, and Telehealth, were created. Second, a cluster analysis helps uncover clusters of GPs based on the 4 factors. Third, we compared the clusters according to five performance outcomes using an analysis of variance (ANOVA) and a Tamhane T2 post hoc test. Fourth, univariate and multivariate multinomial logistic regressions were used to identify predictors of the clusters. Finally, with a multivariate multinomial logistic regression, among the clusters, we compared performance in terms of the number of patients treated (3 levels) over the last 2 years.

Results

We unveiled 3 clusters of GPs with different levels of CIS capability profiles: strong (1956/5793, 37.36%), medium (2764/5793, 47.71%), and weak (524/5793, 9.04%). The logistic regression analysis indicates that physicians (younger, female, and less experienced) and practice (solo) characteristics are significantly associated with a weak profile. The ANOVAs revealed a strong cluster associated with significantly high practice performance outcomes in terms of the quality of care, efficiency, productivity, and improvement of working processes, and two noncomprehensive medium and weak profiles associated with medium (equifinal) practice performance outcomes. The logistic regression analysis also revealed that physicians in the weak profile are associated with a decrease in the number of patients treated over the last 2 years.

Conclusions

Different CIS capability profiles may lead to similar equifinal performance outcomes. This underlines the importance of looking beyond the adoption of 1 CIS capability versus a cluster of capabilities when studying CISs. GPs in the strong cluster exhibit a comprehensive CIS capability profile and outperform the other two clusters with noncomprehensive profiles, leading to significantly high performance in terms of the quality of care provided to patients, efficiency of the practice, productivity of the practice, and improvement of working processes. Our findings indicate that medical practices should develop high capabilities in all 4 CISs if they have to maximize their performance outcomes because efforts to develop high capabilities selectively may only be in vain.

Perspectives of English, Chinese, and Spanish-Speaking Safety-Net Patients on Clinician Computer Use: Qualitative Analysis

Background

Safety-net systems serve patients with limited health literacy and limited English proficiency (LEP) who face communication barriers. However, little is known about how diverse safety-net patients feel about increasing clinician electronic health record (EHR) use.

Objective

The aim of this study was to better understand how safety-net patients, including those with LEP, view clinician EHR use.

Methods

We conducted focus groups in English, Spanish, and Cantonese (N=37) to elicit patient perspectives on how clinicians use EHRs during clinic visits. Using a grounded theory approach, we coded transcripts to identify key themes.

Results

Across multiple language groups, participants accepted multitasking and silent clinician EHR use if focused on their care. However, participants desired more screen share and eye contact, especially when demonstrating physical concerns. All participants, including LEP participants, wanted clinicians to include them in EHR use.

Conclusions

Linguistically diverse patients accept the value of EHR use during outpatient visits but desire more eye contact, verbal warnings before EHR use, and screen-sharing. Safety-net health systems should support clinicians in completing EHR-related tasks during the visit using patient-centered strategies for all patients.