Improving data sharing between acute hospitals in England: an overview of health record system distribution and retrospective observational analysis of inter-hospital transitions of care

OBJECTIVES

To determine the frequency of use and spatial distribution of health record systems in the English National Health Service (NHS). To quantify transitions of care between acute hospital trusts and health record systems to guide improvements to data sharing and interoperability.

DESIGN

Retrospective observational study using Hospital Episode Statistics.

SETTING

Acute hospital trusts in the NHS in England.

PARTICIPANTS

All adult patients resident in England that had one or more inpatient, outpatient or accident and emergency encounters at acute NHS hospital trusts between April 2017 and April 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

Frequency of use and spatial distribution of health record systems. Frequency and spatial distribution of transitions of care between hospital trusts and health record systems.

RESULTS

21 286 873 patients were involved in 121 351 837 encounters at 152 included trusts. 117 (77.0%) hospital trusts were using electronic health records (EHR). There was limited regional alignment of EHR systems. On 11 017 767 (9.1%) occasions, patients attended a hospital using a different health record system to their previous hospital attendance. 15 736 863 (73.9%) patients had two or more encounters with the included trusts and 3 931 255 (25.0%) of those attended two or more trusts. Over half (53.6%) of these patients had encounters shared between just 20 pairs of hospitals. Only two of these pairs of trusts used the same EHR system.

CONCLUSIONS

Each year, millions of patients in England attend two or more different hospital trusts. Most of the pairs of trusts that commonly share patients do not use the same record systems. This research highlights significant barriers to inter-hospital data sharing and interoperability. Findings from this study can be used to improve electronic health record system coordination and develop targeted approaches to improve interoperability. The methods used in this study could be used in other healthcare systems that face the same interoperability challenges.

Working with patients and the public to design an electronic health record interface: a qualitative mixed-methods study

BACKGROUND

Enabling patients to be active users of their own medical records may promote the delivery of safe, efficient care across settings. Patients are rarely involved in designing digital health record systems which may make them unsuitable for patient use. We aimed to develop an evidence-based electronic health record (EHR) interface and participatory design process by involving patients and the public.

METHODS

Participants were recruited to multi-step workshops involving individual and group design activities. A mixture of quantitative and qualitative questionnaires and observational methods were used to collect participant perspectives on interface design and feedback on the workshop design process.

RESULTS

48 recruited participants identified several design principles and components of a patient-centred electronic medical record interface. Most participants indicated that an interactive timeline would be an appropriate way to depict a medical history. Several key principles and design components, including the use of specific colours and shapes for clinical events, were identified. Participants found the workshop design process utilised to be useful, interesting, enjoyable and beneficial to their understanding of the challenges of information exchange in healthcare.

CONCLUSION

Patients and the public should be involved in EHR interface design if these systems are to be suitable for use by patient-users. Workshops, as used in this study, can provide an engaging format for patient design input. Design principles and components highlighted in this study should be considered when patient-facing EHR design interfaces are being developed.

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.

Guiding interoperable electronic health records through patient-sharing networks

Effective sharing of clinical information between care providers is a critical component of a safe, efficient health system. National data-sharing systems may be costly, politically contentious and do not reflect local patterns of care delivery. This study examines hospital attendances in England from 2013 to 2015 to identify instances of patient sharing between hospitals. Of 19.6 million patients receiving care from 155 hospital care providers, 130 million presentations were identified. On 14.7 million occasions (12%), patients attended a different hospital to the one they attended on their previous interaction. A network of hospitals was constructed based on the frequency of patient sharing between hospitals which was partitioned using the Louvain algorithm into ten distinct data-sharing communities, improving the continuity of data sharing in such instances from 0 to 65-95%. Locally implemented data-sharing communities of hospitals may achieve effective accessibility of clinical information without a large-scale national interoperable information system.

Tension haemothorax from a bleeding branch of the renal artery following isolated penetrating thoracic trauma: a rare presentation

A 27-year-old man presented to a major trauma centre with two posterolateral thoracic stab injuries over the right scapula and thoracoabdominal junction. He was tachycardic and hypotensive with a chest X-ray revealing a large right-sided tension haemothorax, requiring insertion of two intercostal chest drains. A subsequent CT scan demonstrated a grade 4 right kidney laceration with active back bleeding from a renal artery branch, through a right diaphragmatic defect, into the pleural cavity. Embolisation of the feeding renal vessel controlled the bleeding and avoided the need for a nephrectomy. The patient required subsequent video-assisted thoracoscopic evacuation of the haemothorax and diaphragmatic repair, confirming that there was no associated lung or major vessel injury. A ureteric stent was ultimately inserted to manage a persistent urinary leak. This case highlights a rare cause for a common traumatic presentation and the need for a multidisciplinary approach in effective management of complex, multiorgan trauma.

Bicycle helmet use to reduce the impact of head injuries in ladder users

BACKGROUND

The aim of this study was to determine if wearing a bicycle helmet during ladder use could reduce the incidence and severity of head injury in the event of a fall.

METHODS

A headform model with inbuilt accelerometers was used to determine the Head Injury Criterion (HIC) score of head impact by dropping 41 helmeted and unhelmeted headforms from eight heights. These results were compared.

RESULTS

There was a statistically significant difference between averaged HIC scores in helmeted and unhelmeted drops (P < 0.001). Unhelmeted HIC scores ranged from 387 at 0.25 m to 2121 at 0.6 m. Helmeted HIC scores ranged from 29 at 0.25 m to 1199 at 2.5 m. At a height of 0.5 m, the risk of severe brain injury (AIS ≥4) from direct frontal head impact is predicted to reduce from >50% to <5% with helmet use.

CONCLUSION

There was a significant decrease in the HIC scores when helmets are used and it is likely that the benefits would be seen in the clinical setting. These results provide an argument for the use of a bicycle helmets by all ladder users, in particular those over age 50 who are at increased risk of head injuries. We recommend that bicycle helmet use be incorporated into ladder injury prevention strategies.

Falciform ligament abscess from left sided portal pyaemia following malignant obstructive cholangitis

Abscess formation of the falciform ligament is incredibly rare and perplexing when encountered for the first time. It is reported to occur in the setting of cholecystitis and cholangitis, but the pathophysiology is poorly understood.

In this case report, we present a 73-year-old man with falciform ligament abscess following cholangitis from an obstructive ampullary carcinoma. The patient was referred to the Royal Adelaide Hospital from a country hospital, with progressive jaundice, anorexia and nausea. Prior to transfer, he deteriorated with cholangitis, dehydration and renal failure. On arrival, his abdomen was exquisitely tender along the course of the falciform ligament. His blood tests revealed an elevated white cell count of 14.9 x 10³/μl, bilirubin of 291μmol/l and creatinine of 347 μmol/l. His CA 19-9 was markedly elevated at 35,000 kU/l. A non-contrast computed tomography (CT) demonstrated gross biliary dilatation and a collection tracking along the path of the falciform ligament to the umbilicus.

The patient was commenced on intravenous antibiotics and underwent an urgent endoscopic retrograde cholangiopancreatogram (ERCP) with sphincterotomy and biliary stent drainage. Cholangiogram revealed a grossly dilated biliary tree, with abrupt transition at the ampulla, which on biopsy confirmed an obstructing ampullary carcinoma. Following ERCP, his jaundice and abdominal tenderness resolved. He was optimized over 4 weeks for an elective pancreaticoduodenectomy.

At operation, we found abscess transformation of the falciform ligament. Copious amounts of pus and necrotic material was drained. Part of the round ligament was resected along the undersurface of the liver. Histology showed that there was prominent histiocytic inflammation with granular acellular eosinophilic components. The patient recovered slowly but uneventfully.

A contrast CT scan undertaken 2 weeks post-operatively (approximately 7 weeks after the initial CT) revealed left portal venous thrombosis, which was likely to be a delayed discovery and was managed conservatively.

We present this patient’s operative images and radiographic findings, which may explain the pathophysiology behind this rare complication. We hypothesize that cholangitis, with secondary portal pyaemia and tracking via the paraumbilical veins, can cause infectious seeding of the falciform ligament, with consequent abscess formation.

Differing Serum Cea in Primary and Recurrent Rectal Cancer - A Reflection of Histology?

Background

Serum carcinoembryonic antigen (CEA) levels are not universally measured in colorectal cancers. CEA levels have been reported to be usually normal at time of primary rectal cancer diagnosis but elevated in recurrent disease. The aims of the study were to (1) compare serum CEA levels performed at time of primary and recurrent colorectal tumour diagnosis; and (2) to determine serum CEA levels in rectal cancers at primary diagnosis to analyse potential factors influencing differing CEA levels.

Methods

A retrospective analysis of patients treated for colorectal cancers at Modbury Hospital, South Australia was performed. Each admission was reviewed within the electronic database. Serum CEA levels and tumour-related factors were determined in patients who underwent curative surgery for their primary tumour and developed tumour recurrence/metastases within the study period.

Results

438 patients were treated for colorectal cancer in the study period. In patients who underwent curative surgery and developed a recurrence, serum CEA was elevated in 20% patients at primary diagnosis and in 46.6% patients at recurrence. Only 1 of 30 patients with rectal cancer had an elevated CEA at diagnosis of primary tumour. Tumour relationship to the peritoneal reflection did not appear to play a role.

Conclusions

In rectal cancers, serum CEA levels are often normal at the time of initial diagnosis. However, this should not preclude its use in post-operative surveillance. Serum CEA levels noted in primary rectal cancer appear unrelated to the relationship of the tumour to the peritoneal reflection. Stroma-related factors could possibly be involved and merit further investigation.

Memory for self-generated stimuli in young and old adults

Young and elderly adults were required to generate or study synonyms or rhymes of stimulus words. In one experiment, multiple-trial free recall was used to assess possible developmental differences in the generation effect, a 48-hr delayed recognition task was used in the second experiment. There was a significant generation effect for young and old adults on both retention tasks. The effect, however, did not emerge for the elderly participants in free recall until the second or third trial. The implications of utilizing internal stimulus generation as a potent mnemonic device were discussed.

Age differences in cerebral blood flow during rest and during mental activation measurements with and without monetary incentive

This experiment compared the diffuse and regional cerebral blood flow (CBF) during rest and during cognitive activation with and without incentive-induced arousal in young, middle-aged, and older adults. Two normal rest CBF measurements were followed by two mental mathematics activation CBF measurements. For the first activation measurement, half the participants in each age group were offered monetary incentive for correct performance and half the participants received no monetary incentive. All participants were offered monetary incentive on the final activation measurement. Older participants had lower resting blood flow at all detectors, but age-related reductions in blood flow were statistically significant only in anterior and inferior rolandic regions. The effect of monetary incentive was to increase blood flow at the inferior rolandic detector in both hemispheres. The CBF response to cognitive activation and monetary incentive did not differ in the three age groups.

Focal changes in cerebral blood flow produced by monetary incentive during a mental mathematics task in normal and depressed subjects

The purpose of this experiment was to determine the effect of incentive-induced arousal on the diffuse and regional cerebral blood flow (rCBF) response during cognitive activation for normal and depressed groups. Two normal rest CBF measurements were followed by two mental mathematics activation CBF measurements. For the first activation measurement, half the subjects in each group were offered monetary incentive for correct performance and half the subjects received no monetary incentive. All subjects were offered monetary incentive on the final activation run. The effect of monetary incentive on the first activation run was to increase CBF activation at four detectors in the left hemisphere. Incentive did not affect the CBF activation response when introduced following practice on the activation task (on the final run). Depressed groups had lower resting blood flow than normals, but the distribution of flow and the CBF response to incentive were almost identical in the two groups.

Event-related potentials to match and mismatch letters in an immediate item recognition task

During an immediate item recognition task, ERP differences to match and mismatch letters occurred in the N1 component, as well as the P3 component, of the stimulus related wave form. The pattern of ERP differences was similar to that reported previously for words in a delayed list recognition task, (Warren, 1980). The ERP differences to match and mismatch letters appeared unaffected by visual field of presentation (left, center, right) or hemisphere of recording site (P3, P4). It is suggested that the N1-P3 differences to match and mismatch stimuli may possibly reflect a pattern of neural activity associated with a two-stage recognition memory process.

Alpha asymmetry as a function of cognitive mode: the role of lateral eye movements

When monitored concurrently, the spontaneous lateral eye movements and alpha asymmetry associated with mental activity were themselves interrelated. Left eye movements were associated with a decrease in the ratio of right to left hemisphere alpha, while right eye movements resulted in an increase in this ratio, independent of cognitive task. The results were interpreted as evidence for a direct effect of oculomotor activity on alpha asymmetry.

Evoked potential correlates of recognition memory

During word recognition tasks, differences in the stimulus related potentials to 'old' (previously presented) and 'new' (not previously presented) words occurred as early as 160-190 ms after stimulus onset (N1) as well as in the late component of the wave forms (P3). The N1 differences may possibly reflect underlying neural activity directly related to the recognition memory process.

Changes in event related potentials during processing of Stroop stimuli

In a simplified Stroop test, subjects responded with a button press to either the color or word dimension of Stroop stimuli. Response times were analyzed as a function of condition (color or word), stimulus type (congruent or noncongruent color-word pairing) and visual field of presentation (left or right). Changes in the stimulus evoked potential (Experiment I) and the preresponse (premotor) potential (Experiment II) were measured as a function of the independent variables and hemisphere of recording site. Stimulus type had the expected Stroop effect on response time, with noncongruent stimuli associated with longer RTs. The pattern of changes in the event related potentials suggested that the typical Stroop interference effect (color condition) is localized in the response selection stage of processing. However, the less common reverse Stroop effect (word condition) probably results from more complex processing interactions during encoding of the color and word dimensions.

Binaural analysis in the aging auditory system

In a simulation of the "cocktail party" problem, subjects listened to recordings of a target voice, obscured by four background voices from adjacent locations in space. Listening conditions were either dichotic (with interaural directional cues preserved) or diotic (same input to both ears, directional cues removed). Elderly subjects were unable to use binaural directional cues as effectively as young subjects to improve intelligibility of the target voice. The results suggest that there is an age related deficit in the ability to perform the binaural signal analysis necessary to effectively separate speech signals from noise.