Using the electronic health record to build a culture of practice safety: evaluating the implementation of trigger tools in one general practice

Workload and workflow implications associated with the use of electronic clinical decision support tools used by health professionals in general practice: a scoping review

BACKGROUND

Electronic clinical decision support tools (eCDS) are increasingly available to assist General Practitioners (GP) with the diagnosis and management of a range of health conditions. It is unclear whether the use of eCDS tools has an impact on GP workload. This scoping review aimed to identify the available evidence on the use of eCDS tools by health professionals in general practice in relation to their impact on workload and workflow.

METHODS

A scoping review was carried out using the Arksey and O'Malley methodological framework. The search strategy was developed iteratively, with three main aspects: general practice/primary care contexts, risk assessment/decision support tools, and workload-related factors. Three databases were searched in 2019, and updated in 2021, covering articles published since 2009: Medline (Ovid), HMIC (Ovid) and Web of Science (TR). Double screening was completed by two reviewers, and data extracted from included articles were analysed.

RESULTS

The search resulted in 5,594 references, leading to 95 full articles, referring to 87 studies, after screening. Of these, 36 studies were based in the USA, 21 in the UK and 11 in Australia. A further 18 originated from Canada or Europe, with the remaining studies conducted in New Zealand, South Africa and Malaysia. Studies examined the use of eCDS tools and reported some findings related to their impact on workload, including on consultation duration. Most studies were qualitative and exploratory in nature, reporting health professionals' subjective perceptions of consultation duration as opposed to objectively-measured time spent using tools or consultation durations. Other workload-related findings included impacts on cognitive workload, "workflow" and dialogue with patients, and clinicians' experience of "alert fatigue".

CONCLUSIONS

The published literature on the impact of eCDS tools in general practice showed that limited efforts have focused on investigating the impact of such tools on workload and workflow. To gain an understanding of this area, further research, including quantitative measurement of consultation durations, would be useful to inform the future design and implementation of eCDS tools.

Continuous, risk-based, consultation peer review in out-of-hours general practice: a qualitative interview study of the benefits and limitations

Background

Systems to detect and minimise unwarranted variation in clinician practice are crucial to ensure increasingly multidisciplinary healthcare workforces are supported to practise to their full potential. Such systems are limited in English general practice settings, with implications for the efficiency and safety of care.

Aim

To evaluate the benefits and limitations of a continuous, risk-based, consultation peer-review system used for 10 years by an out-of-hours general practice service in Bristol, UK.

Design and setting

A qualitative study in South West England.

Method

Semi-structured interviews with intervention users (clinicians, peer reviewers, and clinical management), analysed by inductive thematic analysis and integrated into a programme theory.

Results

Twenty clinicians were interviewed between September 2018 and January 2019. Interviewees indicated that the intervention supported clinician learning through improved peer feedback, highlighting learning needs and validating practice. It was compared favourably with existing structures of ensuring clinician competence, supporting standardisation of supervision, clinical governance, and learning culture. These benefits were potentially limited by intervention factors such as differential feedback quality between clinician groups, the efficiency of methods to identify learning needs, and limitations of assessments based on written clinical notes. Contextual factors such as clinician experience, motivation, and organisational learning culture influenced the perception of the intervention as a support or a stressor.

Conclusion

The findings demonstrate the potential of continuous, risk-based, consultation peer review to support clinicians in an increasingly multidisciplinary general practice workforce to efficiently and safely practise to their full potential. The programme theory provides a theoretical basis to maximise the benefits and accommodate the potential limitations of this methodology

Using chronic kidney disease trigger tools for safety and learning: a qualitative evaluation in East London primary care

BACKGROUND

An innovative programme to improve identification and management of chronic kidney disease (CKD) in primary care was implemented across three clinical commissioning groups (CCGs) in 2016. This included a falling estimated glomerular filtration rate (eGFR) trigger tool built from data in the electronic health record (EHR). This tool notifies GP practices of falling eGFR values. By alerting clinicians to patients with possible CKD progression the tool invites clinical review, a referral option, and written reflection on management.

AIM

To identify practitioner perceptions of trigger tool use from interviews, and compare these with reflections on clinical management recorded within the tools.

DESIGN AND SETTING

A qualitative analysis set in 136 practices across East London during 2016-2018.

METHOD

Eight semi-structured interviews with GPs and practice staff were recorded, and thematic analysis was undertaken using framework analysis. The reflective comments recorded in the trigger tools of 1921 cases were categorised by age group, referral status, and by the drop in eGFR (>15 or >25 ml/min).

RESULTS

Three themes emerged from the interviews: getting started, patient safety, and trigger tools for learning. Well-organised practices found the tool was readily embedded into workflow and expressed greater motivation for using it. The tool was seen to support patient safety, and was used for learning about CKD management, both individually and as a practice. Reflective comments from 1921 trigger tools were reviewed. These supported the theme of patient safety. The free-text data, stratified by age, challenged the expectation that younger cases, at higher risk of progressive CKD, would have higher referral rates.

CONCLUSION

Building electronic trigger tools from the EHR can identify patients with a falling eGFR, prompting review of the eGFR trajectory and management plan. Interview and reflective data illustrated that practice use of the tool supports the patient safety agenda and encourages learning about CKD management.

Quality improvement of prescribing safety: a pilot study in primary care using UK electronic health records

Background

Quality improvement (QI) is a priority for general practice, and GPs are expected to participate in and provide evidence of QI activity. There is growing interest in harnessing the potential of electronic health records (EHR) to improve patient care by supporting practices to find cases that could benefit from a medicines review.

Aim

To develop scalable and reproducible prescribing safety reports using patient-level EHR data.

Design and setting

UK general practices that contribute de-identified patient data to the Clinical Practice Research Datalink (CPRD).

Method

A scoping phase used stakeholder consultations to identify primary care QI needs and potential indicators. QI reports containing real data were sent to 12 pilot practices that used Vision GP software and had expressed interest. The scale-up phase involved automating production and distribution of reports to all contributing practices that used both Vision and EMIS software systems. Benchmarking reports with patient-level case review lists for two prescribing safety indicators were sent to 457 practices in December 2017 following the initial scale-up (Figure 2).

Results

Two indicators were selected from the Royal College of General Practitioners Patient Safety Toolkit following stakeholder consultations for the pilot phase involving 12 GP practices. Pilot phase interviews showed that reports were used to review individual patient care, implement wider QI actions in the practice, and for appraisal and revalidation.

Conclusion

Electronic health record data can be used to provide standardised, reproducible reports that can be delivered at scale with minimal resource requirements. These can be used in a national QI initiative that impacts directly on patient care.

The role of medical data in efficient patient care delivery: a review

Background

Implementing accurate data management systems ensure safe and efficient transfer of confidential health care data. However, health care professionals overlooked their important tasks of medical data processing. Hence, using high-quality electronic health record (EHR) applications in health care is important to minimize medical errors. Therefore, this review tries to indicate the roles of EHR in advancing quality health care service provisions.

Methods

The keywords identified were EHR, EMR, medical data processing, medical data retention, medical data destruction, health care, and patient care, and a few related terms with different combinations. PubMed (National Library of Medicine), Google Scholar, and Google search engine were used to search for articles from those databases. Searching was done using boolean words “AND”, “OR”, and “NOT” using all [All fields] and [MeSH Terms] searching strategies.

Results

Articles were screened using the title, checked by their abstract, and the remaining related full-text materials were included or excluded by two individuals deciding its eligibility. Finally, 73 materials issued from 2013–2018 were used for qualitatively synthesizing and reconciling the idea to produce this review article.

Conclusion

Poor medical data processing systems are the key reasons for medical errors. Employing standardized data management systems reduce errors and associated sufferings. Therefore, using electronic tools in the health care institution ensures safe and efficient data management. Therefore, it is important to establish appropriate medical data management systems for efficient health care delivery.