Is There Evidence of Cost Benefits of Electronic Medical Records, Standards, or Interoperability in Hospital Information Systems? Overview of Systematic Reviews

Improving healthcare quality by unifying the American electronic medical report system: time for change

BACKGROUND

In recent years, innovation in healthcare technology has significantly improved the efficiency of the healthcare system. Advancements have led to better patient care and more cost-effective services. The electronic medical record (EMR) system, in particular, has enhanced interoperability and collaboration across healthcare departments by facilitating the exchange and utilization of patient data. The COVID-19 pandemic further accelerated this trend, leading to a surge in telemedicine services, which rely on electronic communication to deliver healthcare remotely.

MAIN BODY

Integrating artificial intelligence (AI) and machine learning (ML) in healthcare have been instrumental in analyzing vast data sets, allowing for identifying patterns and trends that can improve care delivery and pinpoint potential issues. The proposal of a unified EMR system in the USA aims to capitalize on these technological advancements. Such a system would streamline the sharing of patient information among healthcare providers, improve the quality and efficiency of care, and minimize the likelihood of errors in patient treatment.

CONCLUSION

A unified electronic medical record system represents a promising avenue for enhancing interoperability within the US healthcare sector. By creating a more connected and accessible network of patient information, it sets the stage for a transformation in healthcare delivery. This change is imperative for maintaining the momentum of progress in healthcare technology and realizing the full potential of recent advancements in patient care and system efficiency.

Identifying the Barriers to Acceptance of Blockchain-Based Patient-Centric Data Management Systems in Healthcare

A number of recent studies have shown that wastage and inefficiency are a significant problem in all global healthcare systems. One initiative that could radically improve the operational efficiency of health systems is to make a paradigm shift in data ownership-that is, to transition such systems to a patient-centric model of data management by deploying blockchain technology. Such a development would not only make an economic impact, by radically cutting wastage, but would deliver significant social benefits by improving patient outcomes and satisfaction. However, a blockchain-based solution presents considerable challenges. This research seeks to understand the principal factors, which act as barriers to the acceptance of a blockchain-based patient-centric data management infrastructure, in the healthcare systems of the GCC (Gulf Cooperation Council) countries. The study represents an addition to the current literature by examining the perspectives and views of healthcare professionals and users. This approach is rare within this subject area, and is identified in existing systematic reviews as a research gap: a qualitative investigation of motivations and attitudes among these groups is a critical need. The results of the study identified 12 key barriers to the acceptance of blockchain infrastructures, thereby adding to our understanding of the challenges that need to be overcome in order to benefit from this relatively recent technology. The research is expected to be of use to healthcare authorities in planning a way forward for system improvement, particularly in terms of successfully introducing patient-centric systems.

Impact of primary to secondary care data sharing on care quality in NHS England hospitals

Health information exchange (HIE) is seen as a key component of effective care but remains poorly evidenced at a health system level. In the UK National Health Service (NHS), the ability to share primary care data with secondary care clinicians is a focus of continued digital investment. In this study, we report the evolution of interoperable technology across a period of rapid digital transformation in NHS England from 2015 to 2019, and test association of primary to secondary care data-sharing capabilities with clinical care quality indicators across all acute secondary care providers (n = 135 NHS Trusts). In multivariable analyses, data-sharing capabilities are associated with reduction in patients breaching an Accident & Emergency (A&E) 4-h decision time threshold, and better patient-reported experience of acute hospital care quality. Using synthetic control analyses, we estimate mean 2.271% (STD+/-3.371) absolute reduction in A&E 4-h decision time breach, 12 months following introduction of data-sharing capabilities. Our findings support current digital transformation programmes for developing regional HIE networks but highlight the need to focus on implementation factors in addition to technological procurement.

Perceptions of chief clinical information officers on the state of electronic health records systems interoperability in NHS England: a qualitative interview study

BACKGROUND

In the era of electronic health records (EHR), the ability to share clinical data is a key facilitator of healthcare delivery. Since the introduction of EHRs, this aspect has been extensively studied from the perspective of healthcare providers. Less often explored are the day-to-day challenges surrounding the procurement, deployment, maintenance, and use of interoperable EHR systems, from the perspective of healthcare administrators, such as chief clinical information officers (CCIOs).

OBJECTIVE

Our study aims to capture the perceptions of CCIOs on the current state of EHR interoperability in the NHS, its impact on patient safety, the perceived facilitators and barriers to improving EHR interoperability, and what the future of EHR development in the NHS may entail.

METHODS

Semi-structured interviews were conducted between November 2020 - October 2021. Convenience sampling was employed to recruit NHS England CCIOs. Interviews were digitally recorded and transcribed verbatim. A thematic analysis was performed by two independent researchers to identify emerging themes.

RESULTS

Fifteen CCIOs participated in the study. Participants reported that limited EHR interoperability contributed to the inability to easily access and transfer data into a unified source, thus resulting in data fragmentation. The resulting lack of clarity on patients' health status negatively impacts patient safety through suboptimal care coordination, duplication of efforts, and more defensive practice. Facilitators to improving interoperability included the recognition of the need by clinicians, patient expectations, and the inherent centralised nature of the NHS. Barriers included systems usability difficulties, and institutional, data management, and financial-related challenges. Looking ahead, participants acknowledged that realising that vision across the NHS would require a renewed focus on mandating data standards, user-centred design, greater patient involvement, and encouraging inter-organisational collaboration.

CONCLUSION

Tackling poor interoperability will require solutions both at the technical level and in the wider policy context. This will involve demanding interoperability functionalities from the outset in procurement contracts, fostering greater inter-organisation cooperation on implementation strategies, and encouraging systems vendors to prioritise interoperability in their products. Only by comprehensively addressing these challenges would the full potential promised by the use of fully interoperable EHRs be realised.

Paper Charts: A Continued Barrier to Psychiatric Care in the Midst of a Broken and Fragmented Mental Health System

ABSTRACT

The use of electronic medical records (EMRs) has increased dramatically over the last 15 years. However, psychiatry has lagged. EMRs are not being used by many mental health professionals. There are many reasons, including financial burden, lack of technological support, stigma, disaggregation of upfront costs, indirect benefits, and concerns about privacy and Health Insurance Portability and Accountability Act compliance. Obtaining paper records is a lengthy process, making continuity of care and emergency care challenging. Even when records are made available, it is common for information to be incomplete. The objective of this article is to highlight how the continued use of paper charts may decrease the quality and timeliness of psychiatric care provided and to discuss the psychiatry-specific issues created by EMRs. A case illustrating the disruption of care by continued use of paper charts in psychiatric facilities is presented. The growing use of EMR creates new challenges that affect psychiatry in ways other fields are not affected. These challenges include confidentiality issues, the frequent change/spectrum of diagnoses, determining how much information should be recorded in a note, and what the implications are of the information recorded. This article will discuss the use of EMRs in psychiatry, as well as encourage medical students and residents to take a deeper dive into psychiatry-specific issues regarding the use of EMR. EMR use may have a profound impact on our patient outcomes, health care delivery system, shorter inpatient stay, as well as reduce health care costs.

Data needs and models for the opioid epidemic

The evolving nature of the opioid epidemic and continued increases in overdose deaths highlight a need for fundamental change in the collection and use of surveillance data to link them to implementation of effective service, treatment, and prevention approaches. Yet at present, the quality and timeliness of US surveillance data often limits data-driven approaches. We review current information needs, summarize limitations of existing data, propose complementary surveillance resources, and provide examples of promising approaches designed to meet the needs of data end-users. We conclude that there is a need for an approach that focuses on the needs of data end-users, such as public health systems leaders, policy makers, public, nonprofit and prepaid healthcare systems, and other systems, such as the justice system. Such an approach, which may require investments in new infrastructure, should prioritize improvements in data timeliness, sample representativeness, database linkage, and increased flexibility to adapt to shifts in the environment, while preserving the privacy of survey participants. Use of simulations, distributed research and data networks, alternative data sources, such as wastewater or digital data collection and use of blockchain technology, are some of promising avenues toward an improved and more user-centered surveillance system.

Primary care physicians' electronic health record proficiency and efficiency behaviors and time interacting with electronic health records: a quantile regression analysis

OBJECTIVE

This study aimed to understand the association between primary care physician (PCP) proficiency with the electronic health record (EHR) system and time spent interacting with the EHR.

MATERIALS AND METHODS

We examined the use of EHR proficiency tools among PCPs at one large academic health system using EHR-derived measures of clinician EHR proficiency and efficiency. Our main predictors were the use of EHR proficiency tools and our outcomes focused on 4 measures assessing time spent in the EHR: (1) total time spent interacting with the EHR, (2) time spent outside scheduled clinical hours, (3) time spent documenting, and (4) time spent on inbox management. We conducted multivariable quantile regression models with fixed effects for physician-level factors and time in order to identify factors that were independently associated with time spent in the EHR.

RESULTS

Across 441 primary care physicians, we found mixed associations between certain EHR proficiency behaviors and time spent in the EHR. Across EHR activities studied, QuickActions, SmartPhrases, and documentation length were positively associated with increased time spent in the EHR. Models also showed a greater amount of help from team members in note writing was associated with less time spent in the EHR and documenting.

DISCUSSION

Examining the prevalence of EHR proficiency behaviors may suggest targeted areas for initial and ongoing EHR training. Although documentation behaviors are key areas for training, team-based models for documentation and inbox management require further study.

CONCLUSIONS

A nuanced association exists between physician EHR proficiency and time spent in the EHR.

Optimising specialist geriatric medicine services by telehealth

Telehealth can effectively increase access to specialist care and reduce the need for travel. The Geri-Connect service was established in 2017 to support people living in residential aged care facilities in regional Victoria, Australia. Using the Model for the Assessment of Telemedicine, an evaluation of the Geri-Connect service identified service activity patterns and factors associated with uptake. Service activity from 2017 to 2020 and 10 semi-structured, key stakeholder interviews were captured and analysed. Between 2017 and 2020, video consultations were provided to 53 residential aged care facilities. Sustained growth (over 178%) and strong stakeholder acceptance highlight the effectiveness of this telegeriatric service. Four recommendations provide opportunities to further enhance service delivery including: implementation of an integrated health information system; systematic evaluation of service impact on stakeholders and residents, auditing and subsequent provision of targeted training; and regular auditing of software and hardware. Additionally, the need to augment fixed room hardware with mobile telehealth systems would increase access for residents with mobility problems. Dedicated personnel of the centralised team are best suited to implementing the recommendations. Whilst the provision of routine telehealth services into residential aged care facilities is challenging, the Geri-Connect service demonstrates that telehealth can be effectively provided to residential aged care facility residents needing specialist geriatric care.

Adoption of Innovation in Herpes Simplex Virus Keratitis

Herpes simplex keratitis, caused primarily by human herpes simplex virus type 1 (HSV-1), remains the most common infectious cause of unilateral blindness and vision impairment in the industrialized world. Major advances in the care of HSV keratitis have been driven in large part by the landmark Herpetic Eye Disease Study randomized clinical trials, which were among the first in ophthalmology to reflect emerging trial conventions, including multicenter subject enrollment, double-masking, placebo controls, and a priori sample size determinations. The results of these trials now form much of the evidence basis for the management of this disease. However, management patterns in clinical practice often deviate from evidence-based care. These perceived quality gaps have given rise to the evolving field of implementation science, which is concerned with the methods of promoting the application of evidence-based medicine within routine care. To overcome variations in the quality and consistency of care for HSV keratitis, a range of clinical- and technology-based innovations are proposed. The most pressing needs include the following: a rational and tractable disease classification scheme that provides an immediate link between the anatomical localization of disease (corneal epithelial, stromal, or endothelial) and the appropriate treatment, and the actualization of an electronic medical record system capable of providing evidence-based treatment algorithms at relevant points of care. The latter would also input data to population-wide disease registries to identify implementation-rich targets for quality improvement, education, and research. These innovations may allow us to reduce the human and economic burdens of this highly morbid, and often blinding, disease.

Implementing Electronic Health Records in Primary Care Using the Theory of Change: A Nigerian Case Study (Preprint)

Background

Objective

Methods

Results

Conclusions

The Impact of Guideline Integration into Electronic Medical Records on Outcomes for Patients with Diabetes: A Systematic Review

Optimal strategies for integration of clinical practice guidelines into electronic medical records and its impact on processes of care and clinical outcomes in diabetic patients are not well understood. A systematic review of CINAHL, MEDLINE, PubMed, and Cochrane Library databases in August 2016, November 2017, and June 2020 was conducted. Studies investigating integration of diabetes guidelines into ambulatory care electronic medical records reporting quantitative results were included. After screening 15,783 records, 21 articles were included. Lipid and blood pressure control consistently improved with guideline integration, but A1c control remained equivocal. Electronic guideline integration improved microvascular complication screening, vaccination, and documentation of cardiovascular risk factors, while medication prescription and blood pressure, lipid, and A1c documentation did not improve. Studies employing a combination of electronic record intervention strategies were associated with improvement in monitoring and attainment of guideline and screening targets. Thus, strategies employing combinations of interventions to incorporate guidelines into electronic records may improve processes of care and some clinical outcomes.

Electronic charting of radiation therapy planning and treatment: Report of Task Group 262

While most Radiation Oncology clinics have adopted electronic charting in one form or another, no consensus document exists that provides guidelines for safe and effective use of the Radiation Oncology electronic medical records (RO-EMR). Task Group 262 was formed to provide these guidelines as well as to provide recommendations to vendors for improving electronic charting functionality in future. Guidelines are provided in the following areas: Implementation and training for the RO-EMR, acceptance testing and quality assurance (QA) of the RO-EMR, use of the RO-EMR as an information repository, use of the RO-EMR as a workflow manager, electronic charting for brachytherapy and nonstandard treatments, and information technology (IT) considerations associated with the RO-EMR. The report was based on a literature search by the task group, an extensive survey of task group members on their respective RO-EMR practices, an AAPM membership survey on electronic charting, as well as group consensus.

Electronic Health Records, Interoperability and Patient Safety in Health Systems of High-income Countries: A Systematic Review Protocol

INTRODUCTION

The availability and routine use of electronic health records (EHRs) have become commonplace in healthcare systems of many high-income countries. While there is an ever-growing body of literature pertaining to their use, evidence surrounding the importance of EHR interoperability and its impact on patient safety remains less clear. There is, therefore, a need and opportunity to evaluate the evidence available regarding this relationship so as to better inform health informatics development and policies in the years to come. This systematic review aims to evaluate the impact of EHR interoperability on patient safety in health systems of high-income countries.

METHODS AND ANALYSIS

A systematic literature review will be conducted via a computerised search through four databases: PubMed, Embase, Health Management Information Consortium and PsycInfo for relevant articles published between 2010 and 2020. Outcomes of interest will include impact on patient safety and the broader effects on health systems. Quality of the randomised quantitative studies will be assessed using Cochrane Risk of Bias Tool. Non-randomised papers will be evaluated with the Risk of Bias In Non-Randomised Studies-of Interventions tool. Drummond's Checklist will be used for publications pertaining to economic evaluation. The National Institute for Health and Care Excellence quality appraisal checklist will be used to assess qualitative studies. A narrative synthesis will be conducted for included studies, and the body of evidence will be summarised in a summary of findings table.

ETHICS AND DISSEMINATION

This review will summarise published studies with non-identifiable data and, thus, does not require ethical approval. Findings will be disseminated through preprints, open access peer-reviewed publications, and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42020209285.

Improving prediction for medical institution with limited patient data: Leveraging hospital-specific data based on multicenter collaborative research network

BACKGROUND AND OBJECTIVE

Clinical decision support assisted by prediction models usually faces the challenges of limited clinical data and a lack of labels when the model is developed with data from a single medical institution. Accordingly, research on multicenter clinical collaborative networks, which can provide external medical data, has received increasing attention. With the increasing availability of machine learning techniques such as transfer learning, leveraging large-scale patient data from multiple hospitals to build data-driven predictive models with clinical application potential provides an alternative solution to address the problem of limited patient data.

METHODS

A multicenter hybrid semi-supervised transfer learning model (MHSTL) is proposed in this study on the basis of unified common data model to ensure multicenter data standardized representation. Then the hospital-specific features, along with the co-occurrence features across domains, are aligned through a representation learning architecture that is built based on deep neural networks and the newly proposed neural decision forest model. In this process, limited patient data from the target hospital, both labeled and unlabeled, are incorporated during the feature adaptation process, thereby contributing to better model performance. Without patient-level data sharing, the proposed model learning strategy which overcomes feature misalignment and distribution divergence, enables the multi-source transfer learning process in the case of insufficient and unlabeled patient data at target hospital.

RESULTS

The effectiveness of the proposed transfer learning model was evaluated on a collaborative research network of colorectal cancer patients in the US and China. The results demonstrate that the proposed model can achieve much better performance for predicting target risk with limited resources on patient data than baseline models      . Better discrimination and calibration ability are also observed when sufficient labeled data are not available in the target hospital for prognosis prediction tasks      . Further exploratory experiments show that the proposed approach exhibits good model generalizability regardless of the data heterogeneity. With the help of the SHapley Additive exPlanations for model interpretation, the effectiveness of incorporating hospital-specific features in the transfer learning model is shown.

CONCLUSIONS

In this study, the proposed method can develop prediction models from multiple source hospitals and exhibit good performance by leveraging cross-domain hospital-specific feature information, therefore enhancing the model prediction when applied to single medical institution with limited patient data.

Impact of electronic health records on predefined safety outcomes in patients admitted to hospital: a scoping review

OBJECTIVES

Review available evidence for impact of electronic health records (EHRs) on predefined patient safety outcomes in interventional studies to identify gaps in current knowledge and design interventions for future research.

DESIGN

Scoping review to map existing evidence and identify gaps for future research.

DATA SOURCES

PubMed, the Cochrane Library, EMBASE, Trial registers.

STUDY SELECTION

Eligibility criteria: We conducted a scoping review of bibliographic databases and the grey literature of randomised and non-randomised trials describing interventions targeting a list of fourteen predefined areas of safety. The search was limited to manuscripts published between January 2008 and December 2018 of studies in adult inpatient settings and complemented by a targeted search for studies using a sample of EHR vendors. Studies were categorised according to methodology, intervention characteristics and safety outcome.Results from identified studies were grouped around common themes of safety measures.

RESULTS

The search yielded 583 articles of which 24 articles were included. The identified studies were largely from US academic medical centres, heterogeneous in study conduct, definitions, treatment protocols and study outcome reporting. Of the 24 included studies effective safety themes included medication reconciliation, decision support for prescribing medications, communication between teams, infection prevention and measures of EHR-specific harm. Heterogeneity of the interventions and study characteristics precluded a systematic meta-analysis. Most studies reported process measures and not patient-level safety outcomes: We found no or limited evidence in 13 of 14 predefined safety areas, with good evidence limited to medication safety.

CONCLUSIONS

Published evidence for EHR impact on safety outcomes from interventional studies is limited and does not permit firm conclusions regarding the full safety impact of EHRs or support recommendations about ideal design features. The review highlights the need for greater transparency in quality assurance of existing EHRs and further research into suitable metrics and study designs.

Effectiveness of Digital Technologies to Support Nursing Care: Results of a Scoping Review

Background

The field of digital technologies being developed or applied to support nursing care is extensive. The aim of this scoping review is to provide an overview on technologies for which results on positive or negative effects on persons in need of care, caregivers or care institutions are available and to appraise the reliability of these results.

Methods

A scoping review design has been used to identify studies focussing on the effectiveness of digital technologies in nursing care for persons in need of care, caregivers or care institutions. The screening process included 19,510 scientific publications from 9 databases.

Results

A total of 123 single studies and 31 reviews were subjected to the analysis. The included technologies comprise nursing and health information technologies, such as assistive devices, information and communication technologies, sensors and robotics. The results show that there are many studies that demonstrate positive effects, but the level of evidence is mostly low and study sizes are often small. Hardly any technology has been researched intensively enough to produce conclusive results. Studies on a high level of evidence (RCTs) lack for most technological areas. Heterogeneous results in some areas indicate that effects may depend strongly on the mode and specific context into which the technologies are introduced.

Conclusion

Due to the limited evidence on effectiveness of digital technologies in nursing care, it is not surprising that care institutions are reluctant to put innovative technologies into practice. The scoping review indicates technology areas that should be subject to future research with higher quality studies. Research on outpatient, informal and cross-sectoral care should be intensified to further exploit the potential of digital technologies with a view to improving independence of care-recipients and unburdening formal and informal carers.

Does digital health technology improve physicians' job satisfaction and work-life balance? A cross-sectional national survey and regression analysis using an instrumental variable

OBJECTIVES

To examine the association between physicians' use of digital health technology and their job satisfaction and work-life balance.

DESIGN

A cross-sectional nationally representative survey of physicians and probit regression models were used to examine the association between using digital health technology and the probability of reporting high job satisfaction and a good work-life balance. Models included a rich set of covariates, including physicians' personality traits, and instrumental variable analysis was used to control for bias from unobservable confounders and reverse causality.

SETTING

Clinical practice settings in Australia, including physicians working in primary care, hospitals, outpatient settings, and physicians working in the public and private sectors.

PARTICIPANTS

Respondents to wave 11 (2018-2019) of the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey of doctors. The analysis sample included a broadly nationally representative sample of 7043 physicians, including general practitioners, specialists and physicians in training.

PRIMARY AND SECONDARY OUTCOME MEASURES

The proportion of respondents who used any digital health technology; proportion answered 'moderately satisfied' or 'very satisfied' to the statement on job satisfaction: 'Taking everything into account, how do you feel about your work'; proportion agreeing or strongly agreeing to the statement on work-life balance: 'The balance between my personal and professional commitments is about right.'

RESULTS

Physicians with positive beliefs about the effectiveness of using digital health technology were 3.8 percentage points (95% CI 2.7 to 5.0) more likely to use digital health technology compared with those who did not. Physicians with colleagues who already used digital health technology were also 4.1 percentage points (95% CI 2.6 to 5.6) more likely to use digital health technology. The availability of IT support and lack of privacy concerns increased the probability of using digital health technology by 1.6 percentage points (95% CI 1.0 to 2.3) and 0.5 percentage points (95% CI 0.1 to 1.0). Physicians who used digital health technology were 14.2 percentage points (95% CI -1.3 to 29.7) and 20.3 percentage points (95% CI 2.4 to 38.1) more likely to report respectively higher job satisfaction and good work-life balance, compared with the physicians who did not use it.

CONCLUSIONS

Findings suggested digital health technology served more as a work resource than work demand for physicians who used it.

Economic Value of Data and Analytics for Health Care Providers: Hermeneutic Systematic Literature Review

BACKGROUND

The benefits of data and analytics for health care systems and single providers is an increasingly investigated field in digital health literature. Electronic health records (EHR), for example, can improve quality of care. Emerging analytics tools based on artificial intelligence show the potential to assist physicians in day-to-day workflows. Yet, single health care providers also need information regarding the economic impact when deciding on potential adoption of these tools.

OBJECTIVE

This paper examines the question of whether data and analytics provide economic advantages or disadvantages for health care providers. The goal is to provide a comprehensive overview including a variety of technologies beyond computer-based patient records. Ultimately, findings are also intended to determine whether economic barriers for adoption by providers could exist.

METHODS

A systematic literature search of the PubMed and Google Scholar online databases was conducted, following the hermeneutic methodology that encourages iterative search and interpretation cycles. After applying inclusion and exclusion criteria to 165 initially identified studies, 50 were included for qualitative synthesis and topic-based clustering.

RESULTS

The review identified 5 major technology categories, namely EHRs (n=30), computerized clinical decision support (n=8), advanced analytics (n=5), business analytics (n=5), and telemedicine (n=2). Overall, 62% (31/50) of the reviewed studies indicated a positive economic impact for providers either via direct cost or revenue effects or via indirect efficiency or productivity improvements. When differentiating between categories, however, an ambiguous picture emerged for EHR, whereas analytics technologies like computerized clinical decision support and advanced analytics predominantly showed economic benefits.

CONCLUSIONS

The research question of whether data and analytics create economic benefits for health care providers cannot be answered uniformly. The results indicate ambiguous effects for EHRs, here representing data, and mainly positive effects for the significantly less studied analytics field. The mixed results regarding EHRs can create an economic barrier for adoption by providers. This barrier can translate into a bottleneck to positive economic effects of analytics technologies relying on EHR data. Ultimately, more research on economic effects of technologies other than EHRs is needed to generate a more reliable evidence base.

Effects of interorganisational information technology networks on patient safety: a realist synthesis

OBJECTIVE

Health services in many countries are investing in interorganisational networks, linking patients' records held in different organisations across a city or region. The aim of the systematic review was to establish how, why and in what circumstances these networks improve patient safety, fail to do so, or increase safety risks, for people living at home.

DESIGN

Realist synthesis, drawing on both quantitative and qualitative evidence, and including consultation with stakeholders in nominal groups and semistructured interviews.

ELIGIBILITY CRITERIA

The coordination of services for older people living at home, and medicine reconciliation for older patients returning home from hospital.

INFORMATION SOURCES

17 sources including Medline, Embase, CINAHL, Cochrane Library, Web of Science, ACM Digital Library, and Applied Social Sciences Index and Abstracts.

OUTCOMES

Changes in patients' clinical risks.

RESULTS

We did not find any detailed accounts of the sequences of events that policymakers and others believe will lead from the deployment of interoperable networks to improved patient safety. We were, though, able to identify a substantial number of theory fragments, and these were used to develop programme theories.There is good evidence that there are problems with the coordination of services in general, and the reconciliation of medication lists in particular, and it indicates that most problems are social and organisational in nature. There is also good evidence that doctors and other professionals find interoperable networks difficult to use. There was limited high-quality evidence about safety-related outcomes associated with the deployment of interoperable networks.

CONCLUSIONS

Empirical evidence does not currently justify claims about the beneficial effects of interoperable networks on patient safety. There appears to be a mismatch between technology-driven assumptions about the effects of networks and the sociotechnical nature of coordination problems.

PROSPERO REGISTRATION NUMBER

CRD42017073004.

The effects of interoperable information technology networks on patient safety: a realist synthesis

Background

Interoperable networks connect information technology systems of different organisations, allowing professionals in one organisation to access patient data held in another one. Health policy-makers in many countries believe that they will improve the co-ordination of services and, hence, the quality of services and patient safety. To the best of our knowledge, there have not been any previous systematic reviews of the effects of these networks on patient safety.

Objectives

The aim of the study was to establish how, why and in what circumstances interoperable information technology networks improved patient safety, failed to do so or increased safety risks. The objectives of the study were to (1) identify programme theories and prioritise theories to review; (2) search systematically for evidence to test the theories; (3) undertake quality appraisal, and use included texts to support, refine or reject programme theories; (4) synthesise the findings; and (5) disseminate the findings to a range of audiences.

Design

Realist synthesis, including consultation with stakeholders in nominal groups and semistructured interviews.

Settings and participants

Following a stakeholder prioritisation process, several domains were reviewed: older people living at home requiring co-ordinated care, at-risk children living at home and medicines reconciliation services for any patients living at home. The effects of networks on services in health economies were also investigated.

Intervention

An interoperable network that linked at least two organisations, including a maximum of one hospital, in a city or region.

Outcomes

Increase, reduction or no change in patients’ risks, such as a change in the risk of taking an inappropriate medication.

Results

We did not find any detailed accounts of the ways in which interoperable networks are intended to work and improve patient safety. Theory fragments were identified and used to develop programme and mid-range theories. There is good evidence that there are problems with the co-ordination of services in each of the domains studied. The implicit hypothesis about interoperable networks is that they help to solve co-ordination problems, but evidence across the domains showed that professionals found interoperable networks difficult to use. There is insufficient evidence about the effectiveness of interoperable networks to allow us to establish how and why they affect patient safety.

Limitations

The lack of evidence about patient-specific measures of effectiveness meant that we were not able to determine ‘what works’, nor any variations in what works, when interoperable networks are deployed and used by health and social care professionals.

Conclusions

There is a dearth of evidence about the effects of interoperable networks on patient safety. It is not clear if the networks are associated with safer treatment and care, have no effects or increase clinical risks.

Future work

Possible future research includes primary studies of the effectiveness of interoperable networks, of economies of scope and scale and, more generally, on the value of information infrastructures.

Study registration

This study is registered as PROSPERO CRD42017073004.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 40. See the NIHR Journals Library website for further project information.

Quality of Pregnancy Dating and Obstetric Interventions During Labor: Retrospective Database Analysis

BACKGROUND

The correct dating of pregnancy is critical to support timely decisions and provide obstetric care during birth. The early obstetric ultrasound assessment before 14 weeks is considered the best reference to assist in determining gestational age (GA), with an accuracy of ±5 to 7 days. However, this information is limited in many settings worldwide.

OBJECTIVE

The aim of this study is to analyze the association between the obstetric interventions during childbirth and the quality of GA determination, according to the first antenatal ultrasound assessment, which assisted the calculation.

METHODS

This is a hospital-based cohort study using medical record data of 2113 births at a perinatal referral center. The database was separated into groups and subgroups of analyses based on the reference used by obstetricians to obtain GA at birth. Maternal and neonatal characteristics, mode of delivery, oxytocin augmentation, and forceps delivery were compared between groups of pregnancies with GA determination at different reference points: obstetric ultrasound assessment 14 weeks, 20 weeks, and ≥20 weeks or without antenatal ultrasound (suboptimal dating). Ultrasound-based GA information was associated with outcomes between the interest groups using chi-square tests, odds ratios (OR) with 95% CI, or the Mann-Whitney statistical analysis.

RESULTS

The chance of nonspontaneous delivery was higher in pregnancies with 14 weeks ultrasound-based GA (OR 1.64, 95% CI 1.35-1.98) and 20 weeks ultrasound-based GA (OR 1.58, 95% CI 1.31-1.90) when compared to the pregnancies with ≥20 weeks ultrasound-based GA or without any antenatal ultrasound. The use of oxytocin for labor augmentation was higher for 14 weeks and 20 weeks ultrasound-based GA, OR 1.41 (95% CI 1.09-1.82) and OR 1.34 (95% CI 1.04-1.72), respectively, when compared to those suboptimally dated. Moreover, maternal blood transfusion after birth was more frequent in births with suboptimal ultrasound-based GA determination (20/657, 3.04%) than in the other groups (14 weeks ultrasound-based GA: 17/1163, 1.46%, P=.02; 20 weeks ultrasound-based GA: 25/1456, 1.71%, P=.048). Cesarean section rates between the suboptimal dating group (244/657, 37.13%) and the other groups (14 weeks: 475/1163, 40.84%, P=.12; 20 weeks: 584/1456, 40.10%, P=.20) were similar. In addition, forceps delivery rates between the suboptimal dating group (17/657, 2.6%) and the other groups (14 weeks: 42/1163, 3.61%, P=.24; 20 weeks: 46/1456, 3.16%, P=.47) were similar. Neonatal intensive care unit admission was more frequent in newborns with suboptimal dating (103/570, 18.07%) when compared with the other groups (14 weeks: 133/1004, 13.25%, P=.01; 20 weeks: 168/1263, 13.30%, P=.01), excluding stillbirths and major fetal malformations.

CONCLUSIONS

The present analysis highlighted relevant points of health care to improve obstetric assistance, confirming the importance of early access to technologies for pregnancy dating as an essential component of quality antenatal care.

Knowledge, attitude and behaviour of dental health care providers towards health electronic record systems in Saudi Arabia

OBJECTIVES

The present study aimed to discuss the knowledge, attitude and behaviour of dental health care providers towards electronic health record system in Saudi Arabia.

METHODS

The study adopted a questionnaire survey in which information regarding demographics, maintenance and effectiveness of electronic health record systems (EHRs) were mentioned. The data were collected from 270 participants from five regions in Saudi Arabia.

DISCUSSION

Electronic health record systems were found to be an important tool in collecting the information of patients without wasting time. An agreement between participants regarding the potentiality of EHRs to reduce medical errors was also detected.

CONCLUSIONS

Few factors such as privacy concerns, staff compliance and cost were found to be the factors influencing the attitudes of health care providers towards the adoption of EHRs. Thus, EHRs can be made efficient by addressing the problems to change the perceptions of health care providers.

Transitions of care across hospital settings in patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic, inflammatory disorder characterised by both intestinal and extra-intestinal pathology. Patients may receive both emergency and elective care from several providers, often in different hospital settings. Poorly managed transitions of care between providers can lead to inefficiencies in care and patient safety issues. To ensure that the sharing of patient information between providers is appropriate, timely, accurate and secure, effective data-sharing infrastructure needs to be developed. To optimise inter-hospital data-sharing for IBD patients, we need to better understand patterns of hospital encounters in this group.

AIM

To determine the type and location of hospital services accessed by IBD patients in England.

METHODS

This was a retrospective observational study using Hospital Episode Statistics, a large administrative patient data set from the National Health Service in England. Adult patients with a diagnosis of IBD following admission to hospital were followed over a 2-year period to determine the proportion of care accessed at the same hospital providing their outpatient IBD care, defined as their ‘home provider’. Secondary outcome measures included the geographic distribution of patient-sharing, regional and age-related differences in accessing services, and type and frequency of outpatient encounters.

RESULTS

95055 patients accessed hospital services on 1760156 occasions over a 2-year follow-up period. The proportion of these encounters with their identified IBD ‘home provider’ was 73.3%, 87.8% and 83.1% for accident and emergency, inpatient and outpatient encounters respectively. Patients living in metropolitan centres and younger patients were less likely to attend their ‘home provider’ for hospital services. The most commonly attended specialty services were gastroenterology, general surgery and ophthalmology.

CONCLUSION

Transitions of care between secondary care settings are common for patients with IBD. Effective systems of data-sharing and care integration are essential to providing safe and effective care for patients. Geographic and age-related patterns of care transitions identified in this study may be used to guide interventions aimed at improving continuity of care.

Patient-Sharing Relations in the Treatment of Diabetes and Their Implications for Health Information Exchange: Claims-Based Analysis

Background

Health information exchange (HIE) among care providers who cooperate in the treatment of patients with diabetes mellitus (DM) has been rated as an important aspect of successful care. Patient-sharing relations among care providers permit inferences about corresponding information-sharing relations.

Objectives

This study aimed to obtain information for an effective HIE platform design to be used in DM care by analyzing patient-sharing relations among various types of care providers (ToCPs), such as hospitals, pharmacies, and different outpatient specialists, within a nationwide claims dataset of Austrian DM patients. We focus on 2 parameters derived from patient-sharing networks: (1) the principal HIE partners of the different ToCPs involved in the treatment of DM and (2) the required participation rate of ToCPs in HIE platforms for the purpose of effective communication.

Methods

The claims data of 7.9 million Austrian patients from 2006 to 2007 served as our data source. DM patients were identified by their medication. We established metrics for the quantification of our 2 parameters of interest. The principal HIE partners were derived from the portions of a care provider’s patient-sharing relations with different ToCPs. For the required participation rate of ToCPs in an HIE platform, we determine the concentration of patient-sharing relations among ToCPs. Our corresponding metrics are derived in analogy from existing work for the quantification of the continuity of care.

Results

We identified 324,703 DM patients treated by 12,226 care providers; the latter were members of 16 ToCPs. On the basis of their score for 2 of our parameters, we categorized the ToCPs into low, medium, and high. For the most important HIE partner parameter, pharmacies, general practitioners (GPs), and laboratories were the representatives of the top group, that is, our care providers shared the highest numbers of DM patients with these ToCPs. For the required participation rate of type of care provide (ToCP) in HIE platform parameter, the concentration of DM patient-sharing relations with a ToCP tended to be inversely related to the ToCPs member count.

Conclusions

We conclude that GPs, pharmacies, and laboratories should be core members of any HIE platform that supports DM care, as they are the most important DM patient-sharing partners. We further conclude that, for implementing HIE with ToCPs who have many members (in Austria, particularly GPs and pharmacies), an HIE solution with high participation rates from these ToCPs (ideally a nationwide HIE platform with obligatory participation of the concerned ToCPs) seems essential. This will raise the probability of HIE being achieved with any care provider of these ToCPs. As chronic diseases are rising because of aging societies, we believe that our quantification of HIE requirements in the treatment of DM can provide valuable insights for many industrial countries.

OpenEHR and General Data Protection Regulation: Evaluation of Principles and Requirements

Background

Concerns about privacy and personal data protection resulted in reforms of the existing legislation in the European Union (EU). The General Data Protection Regulation (GDPR) aims to reform the existing directive on the topic of personal data protection of EU citizens with a strong emphasis on more control of the citizens over their data and in the establishment of rules for the processing of personal data. OpenEHR is a standard that embodies many principles of interoperable and secure software for electronic health records (EHRs) and has been advocated as the best approach for the development of hospital information systems.

Objective

This study aimed to understand to what extent the openEHR standard can help in the compliance of EHR systems to the GDPR requirements.

Methods

A list of requirements for an EHR to support GDPR compliance and also a list of the openEHR design principles were made. The requirements were categorized and compared with the principles by experts on openEHR and GDPR.

Results

A total of 50 GDPR requirements and 8 openEHR design principles were identified. The openEHR principles conformed to 30% (15/50) of GDPR requirements. All the openEHR principles were aligned with GDPR requirements.

Conclusions

This study showed that the openEHR principles conform well to GDPR, underlining the common wisdom that truly realizing security and privacy requires it to be built in from the start. By using an openEHR-based EHR, the institutions are closer to becoming compliant with GDPR while safeguarding the medical data.

An eHealth Platform for the Support of a Brazilian Regional Network of Mental Health Care (eHealth-Interop): Development of an Interoperability Platform for Mental Care Integration

BACKGROUND

The electronic exchange of health-related data can support different professionals and services to act in a more coordinated and transparent manner and make the management of health service networks more efficient. Although mental health care is one of the areas that can benefit from a secure health information exchange (HIE), as it usually involves long-term and multiprofessional care, there are few published studies on this topic, particularly in low- and middle-income countries.

OBJECTIVE

The aim of this study was to design, implement, and evaluate an electronic health (eHealth) platform that allows the technical and informational support of a Brazilian regional network of mental health care. This solution was to enable HIE, improve data quality, and identify and monitor patients over time and in different services.

METHODS

The proposed platform is based on client-server architecture to be deployed on the Web following a Web services communication model. The interoperability information model was based on international and Brazilian health standards. To test platform usage, we have utilized the case of the mental health care network of the XIII Regional Health Department of the São Paulo state, Brazil. Data were extracted from 5 different sources, involving 26 municipalities, and included national demographic data, data from primary health care, data from requests for psychiatric hospitalizations performed by community services, and data obtained from 2 psychiatric hospitals about hospitalizations. Data quality metrics such as accuracy and completeness were evaluated to test the proposed solution.

RESULTS

The eHealth-Interop integration platform was designed, developed, and tested. It contains a built-in terminology server and a record linkage module to support patients' identification and deduplication. The proposed interoperability environment was able to integrate information in the mental health care network case with the support of 5 international and national terminologies. In total, 27,353 records containing demographic and clinical data were integrated into eHealth-Interop. Of these records, 34.91% (9548/27,353) were identified as patients who were present in more than 1 data source with different levels of accuracy and completeness. The data quality analysis was performed on 26 demographic attributes for each integrable patient record, totaling 248,248 comparisons. In general, it was possible to achieve an improvement of 18.40% (45,678/248,248) in completeness and 1.10% (2731/248,248) in syntactic accuracy over the test dataset after integration and deduplication.

CONCLUSIONS

The proposed platform established an eHealth solution to fill the gap in the availability and quality of information within a network of health services to improve the continuity of care and the health services management. It has been successfully applied in the context of mental health care and is flexible to be tested in other areas of care.

Learning health systems need to bridge the ‘two cultures’ of clinical informatics and data science

Background

UK health research policy and plans for population health management are predicated upon transformative knowledge discovery from operational ‘Big Data’. Learning health systems require not only data, but feedback loops of knowledge into changed practice. This depends on knowledge management and application, which in turn depends upon effective system design and implementation. Biomedical informatics is the interdisciplinary field at the intersection of health science, social science and information science and technology that spans this entire scope.

Issues

In the UK, the separate worlds of health data science (bioinformatics, ‘Big Data’) and effective healthcare system design and implementation (clinical informatics, ‘Digital Health’) have operated as ‘two cultures’. Much National Health Service and social care data is of very poor quality. Substantial research funding is wasted on ‘data cleansing’ or by producing very weak evidence. There is not yet a sufficiently powerful professional community or evidence base of best practice to influence the practitioner community or the digital health industry.

Recommendation

The UK needs increased clinical informatics research and education capacity and capability at much greater scale and ambition to be able to meet policy expectations, address the fundamental gaps in the discipline’s evidence base and mitigate the absence of regulation. Independent evaluation of digital health interventions should be the norm, not the exception.

Conclusions

Policy makers and research funders need to acknowledge the existing gap between the ‘two cultures’ and recognise that the full social and economic benefits of digital health and data science can only be realised by accepting the interdisciplinary nature of biomedical informatics and supporting a significant expansion of clinical informatics capacity and capability.

Informatics for the Modern Intensive Care Unit

Advanced informatics systems can help improve health care delivery and the environment of care for critically ill patients. However, identifying, testing, and deploying advanced informatics systems can be quite challenging. These processes often require involvement from a collaborative group of health care professionals of varied disciplines with knowledge of the complexities related to designing the modern and "smart" intensive care unit (ICU). In this article, we explore the connectivity environment within the ICU, middleware technologies to address a host of patient care initiatives, and the core informatics concepts necessary for both the design and implementation of advanced informatics systems.