Electronic Medical Record System Use and Determinants in Ethiopia: Systematic Review and Meta-Analysis

BACKGROUND

The strategic plan of the Ethiopian Ministry of Health recommends an electronic medical record (EMR) system to enhance health care delivery and streamline data systems. However, only a few exhaustive systematic reviews and meta-analyses have been conducted on the degree of EMR use in Ethiopia and the factors influencing success. This will emphasize the factors that make EMR effective and increase awareness of its widespread use among future implementers in Ethiopia.

OBJECTIVE

This study aims to determine the pooled estimate of EMR use and success determinants among health professionals in Ethiopia.

METHODS

We developed a protocol and searched PubMed, Web of Sciences, African Journals OnLine, Embase, MEDLINE, and Scopus to identify relevant studies. To assess the quality of each included study, we used the Joanna Briggs Institute quality assessment tool using 9 criteria. The applicable data were extracted using Microsoft Excel 2019, and the data were then analyzed using Stata software (version 11; StataCorp). The presence of total heterogeneity across included studies was calculated using the index of heterogeneity I² statistics. The pooled size of EMR use was estimated using a random effect model with a 95% CI.

RESULTS

After reviewing 11,026 research papers, 5 papers with a combined total of 2439 health workers were included in the evaluation and meta-analysis. The pooled estimate of EMR usage in Ethiopia was 51.85% (95% CI 37.14%-66.55%). The subgroup study found that the northern Ethiopian region had the greatest EMR utilization rate (58.75%) and that higher (54.99%) utilization was also seen in publications published after 2016. Age groups <30 years, access to an EMR manual, EMR-related training, and managerial support were identified factors associated with EMR use among health workers.

CONCLUSIONS

The use of EMR systems in Ethiopia is relatively low. Belonging to a young age group, accessing an EMR manual, receiving EMR-related training, and managerial support were identified as factors associated with EMR use among health workers. As a result, to increase the use of EMRs by health care providers, it is essential to provide management support and an EMR training program and make the EMR manual accessible to health professionals.

Electronic Medical Record System-Based Teleconsultations in Pediatric Surgery: An Initiative from a Tertiary Care Public-Funded Hospital in North India to Alleviate the COVID-19 Imposed Hospital Visit Restrictions

Background

There has been a dramatic effect of the coronavirus disease 2019 pandemic on the daily health-care services. The era of physical consultations is slowly being replaced with teleconsultation, and this current pandemic has tipped the scales further. This study highlights the preliminary experience in providing teleconsultation to pediatric surgical patients at a tertiary care hospital in north India.

Materials and Methods

A retrospective analysis of the electronic medical record system records of the patients undergoing teleconsultation at the authors' department between the June 26, 2020 and the September 26, 2020 was performed. The data were categorized on the basis of the type of consultation (urgent, semi-urgent, or routine) and the type of intervention. A comparison with the data from the corresponding months of 2019 was also performed.

Results

A total of 261 teleconsultations were conducted during the study period, with a success rate of 69% (181/261). Of these, 96% (171/178) were follow-up patients and 56% (99/178) presented with genitourinary complaints. After triaging, only 10% (18/178) of the patients required urgent medical/surgical attention.

Conclusion

In the current as well as postpandemic phase, teleconsultation can act as a potent triaging tool and can help in better utilization of resources alongside helping in the maintenance of social distancing by decreasing the number of physical visits to the hospital.

Evaluation of eye tracking for a decision support application

Eye tracking is used widely to investigate attention and cognitive processes while performing tasks in electronic medical record (EMR) systems. We explored a novel application of eye tracking to collect training data for a machine learning-based clinical decision support tool that predicts which patient data are likely to be relevant for a clinical task. Specifically, we investigated in a laboratory setting the accuracy of eye tracking compared to manual annotation for inferring which patient data in the EMR are judged to be relevant by physicians. We evaluated several methods for processing gaze points that were recorded using a low-cost eye-tracking device. Our results show that eye tracking achieves accuracy and precision of 69% and 53%, respectively compared to manual annotation and are promising for machine learning. The methods for processing gaze points and scripts that we developed offer a first step in developing novel uses for eye tracking for clinical decision support.

A system uptake analysis and GUIDES checklist evaluation of the Electronic Asthma Management System: A point-of-care computerized clinical decision support system

OBJECTIVE

Computerized clinical decision support systems (CCDSSs) promise improvements in care quality; however, uptake is often suboptimal. We sought to characterize system use, its predictors, and user feedback for the Electronic Asthma Management System (eAMS)-an electronic medical record system-integrated, point-of-care CCDSS for asthma-and applied the GUIDES checklist as a framework to identify areas for improvement.

MATERIALS AND METHODS

The eAMS was tested in a 1-year prospective cohort study across 3 Ontario primary care sites. We recorded system usage by clinicians and patient characteristics through system logs and chart reviews. We created multivariable models to identify predictors of (1) CCDSS opening and (2) creation of a self-management asthma action plan (AAP) (final CCDSS step). Electronic questionnaires captured user feedback.

RESULTS

Over 1 year, 490 asthma patients saw 121 clinicians. The CCDSS was opened in 205 of 1033 (19.8%) visits and an AAP created in 121 of 1033 (11.7%) visits. Multivariable predictors of opening the CCDSS and producing an AAP included clinic site, having physician-diagnosed asthma, and presenting with an asthma- or respiratory-related complaint. The system usability scale score was 66.3 ± 16.5 (maximum 100). Reported usage barriers included time and system accessibility.

DISCUSSION

The eAMS was used in a minority of asthma patient visits. Varying workflows and cultures across clinics, physician beliefs regarding asthma diagnosis, and relevance of the clinical complaint influenced uptake.

CONCLUSIONS

Considering our findings in the context of the GUIDES checklist helped to identify improvements to drive uptake and provides lessons relevant to CCDSS design across diseases.

Leveraging Eye Tracking to Prioritize Relevant Medical Record Data: Comparative Machine Learning Study

BACKGROUND

Electronic medical record (EMR) systems capture large amounts of data per patient and present that data to physicians with little prioritization. Without prioritization, physicians must mentally identify and collate relevant data, an activity that can lead to cognitive overload. To mitigate cognitive overload, a Learning EMR (LEMR) system prioritizes the display of relevant medical record data. Relevant data are those that are pertinent to a context-defined as the combination of the user, clinical task, and patient case. To determine which data are relevant in a specific context, a LEMR system uses supervised machine learning models of physician information-seeking behavior. Since obtaining information-seeking behavior data via manual annotation is slow and expensive, automatic methods for capturing such data are needed.

OBJECTIVE

The goal of the research was to propose and evaluate eye tracking as a high-throughput method to automatically acquire physician information-seeking behavior useful for training models for a LEMR system.

METHODS

Critical care medicine physicians reviewed intensive care unit patient cases in an EMR interface developed for the study. Participants manually identified patient data that were relevant in the context of a clinical task: preparing a patient summary to present at morning rounds. We used eye tracking to capture each physician's gaze dwell time on each data item (eg, blood glucose measurements). Manual annotations and gaze dwell times were used to define target variables for developing supervised machine learning models of physician information-seeking behavior. We compared the performance of manual selection and gaze-derived models on an independent set of patient cases.

RESULTS

A total of 68 pairs of manual selection and gaze-derived machine learning models were developed from training data and evaluated on an independent evaluation data set. A paired Wilcoxon signed-rank test showed similar performance of manual selection and gaze-derived models on area under the receiver operating characteristic curve (P=.40).

CONCLUSIONS

We used eye tracking to automatically capture physician information-seeking behavior and used it to train models for a LEMR system. The models that were trained using eye tracking performed like models that were trained using manual annotations. These results support further development of eye tracking as a high-throughput method for training clinical decision support systems that prioritize the display of relevant medical record data.

Health Professionals' Readiness and Its Associated Factors to Implement Electronic Medical Record System in Four Selected Primary Hospitals in Ethiopia

BACKGROUND

Incorporating electronic medical record systems (EMRs) into the healthcare system is not only about modernizing the health system, but is about saving lives by facilitating communication and practicing evidence-based decision. Globally, more than 50% of EMR projects fail before they reach their target. Even though EMRs are an essential tool for health care, their adoption and utilization remains low in developing countries including Ethiopia.

OBJECTIVE

The aim of this study was to determine health professionals' readiness and associated factors toward the implementation of EMRs in four selected primary hospitals in Ethiopia.

METHODS

An institutionbased cross-sectional study supplemented with a qualitative approach was conducted on 414 health professionals from March 2 to May 5, 2018 in four selected primary hospitals in Ethiopia. A self-administered questionnaire was used to collect the quantitative data and in-depth interviews were employed for the qualitative data. The data were analyzed using SPSS version 20 software. Descriptive statistics, bivariable, and multivariable logistic regression analyses were done. An adjusted odds ratio (AOR) with 95% CI was used to determine the association between the determinants and the outcome variable.

RESULTS

More than half (258; 62.3%) of health professionals were ready to use the electronic medical recording system. EMR knowledge (AOR = 2.64; 95% CI: [1.62, 4.29]), attitude (AOR = 1.63; 95% CI: [1.01, 2.63]), computer literacy (AOR = 3.30; 95% CI: [2.05, 5.31]), and EMR training (AOR = 3.63, ;5% CI: [1.69, 5.80]) were significantly associated with EMR readiness.

CONCLUSION AND RECOMMENDATION

In general, the overall readiness of health professionals for EMR implementation was found to be low. Comprehensive packages of capacity-building are crucial to raise the level of knowledge, attitude, and computer skill among health workers.

Cost of Diabetic Foot Ulcer Management in China: A 7-Year Single-Center Retrospective Review

BACKGROUND

The cost of care for diabetic foot ulcers has became a global economic burden. The study aimed to analyze diabetic foot ulcer cost changes over time and to identify factors associated with these variables, so as to strengthen and improve the management of diabetic foot ulcers.

METHODS

We retrospectively analyzed the data in the electronic medical record system of our wound treatment center. The homepage of the system was queried using the national clinical version 2.0 disease diagnosis code (ICD-10), the data of patient's basic information were exported. Through the statistics and analysis of these data, the socioeconomic changes and possible risk factors of diabetic foot ulcers management in recent years were obtained.

RESULTS

There were 3654 patients included in the study, an average of 522 per year. The total cost per patient increased from ¥15,535.58 in 2014 to ¥42,040.60 in 2020, with an average of ¥21,826.91. The average length of stay between 14.29 days and 31.4 days from 2014 to 2020, with an average of 18.10 days. Besides, the average incidence of peripheral arterial disease in diabetic foot ulcers patients admitted was as high as 81.9%, and the average amputation rate was 9.9%. The study reflected the total cost and length of stay of diabetic foot patients increased significantly from 2014 to 2020, which were related to age (>85 years), gender (male), peripheral arterial disease, amputation (P < 0.05).

CONCLUSION

A heavy cost from diabetic foot ulcers and its complications was significantly increased yearly, which was related to older age, co-morbidity, amputation and duration of hospitalization. The prevention and treatment of diabetic foot ulcers have a long way to go, early comprehensive prevention and multi-disciplinary cooperation may still be an effective way.

Integrating family planning services into HIV care: use of a point-of-care electronic medical record system in Lilongwe, Malawi

BACKGROUND

Integrating family planning (FP) services into human immunodeficiency virus (HIV) clinical care helps improve access to contraceptives for women living with HIV. However, high patient volumes may limit providers' ability to counsel women about pregnancy risks and contraceptive options.

OBJECTIVES

To assess trends in the use of contraceptive methods after implementing an  electronic medical record (EMR) system with FP questions and determine the reasons for non-use of contraceptives among women of reproductive age (15-49 years) receiving antiretroviral therapy (ART) at the Martin Preuss Center clinic in Malawi.

METHODS

In February 2012, two FP questions were incorporated into the ART EMR system (initial FP EMR module) to prompt providers to offer contraceptives to women. In July 2013, additional questions were added to the FP EMR module (enhanced FP EMR) to prompt providers to assess risks of unintended pregnancies, solicit reasons for non-use of contraceptives and offer contraceptives to non-pregnant women . We conducted a retrospective, longitudinal cohort study using the EMR routinely collected data. The primary outcome was the use of any modern contraceptive method. Descriptive statistics were used to describe the study population and report trends in contraceptive use during the initial and enhanced study periods.

RESULTS

Between February 2012 and December 2016, in HIV clinics, 20,253 women of reproductive age received ART, resulting in 163,325 clinic visits observations. The proportion of women using contraceptives increased significantly from 18% to 39% between February 2012 and June 2013, and from 39% to 67% between July 2013 and December 2016 (chi-square for trend p < 0.001). Common reasons reported for the non-use of contraceptives among those at risk of unintended pregnancy were: pregnancy ambivalence (n = 234, 51%) and never thought about it (n = 133, 29%).

CONCLUSION

Incorporating the FP EMR module into HIV clinical care prompted healthcare workers to encourage the use of contraceptives.

Managing and monitoring chronic non-communicable diseases in a primary health care clinic, Lilongwe, Malawi

SETTING

Patients with chronic non-communicable diseases attending a primary health care centre, Lilongwe, Malawi.

OBJECTIVE

Using an electronic medical record monitoring system, to describe the quarterly and cumulative disease burden, management and outcomes of patients registered between March 2014 and June 2015.

DESIGN

A cross-sectional study.

RESULTS

Of 1135 patients, with new registrations increasing each quarter, 66% were female, 21% were aged ⩾65 years, 20% were obese, 53% had hypertension alone, 18% had diabetes alone, 12% had asthma, 10% had epilepsy and 7% had both hypertension and diabetes. In every quarter, about 30% of patients did not attend the clinic and 19% were registered as lost to follow-up (not seen for ⩾1 year) in the last quarter. Of those attending, over 90% were prescribed medication, and 80-90% with hypertension and/or diabetes had blood pressure/blood glucose measured. Over 85% of those with epilepsy had no seizures and 60-75% with asthma had no severe attacks. Control of blood pressure (41-51%) and diabetes (15-38%) was poor.

CONCLUSION

It is feasible to manage patients with non-communicable diseases in a primary health care setting in Malawi, although more attention is needed to improve clinic attendance and the control of hypertension and diabetes.

Physicians' perception about electronic medical record system in Makkah Region, Saudi Arabia

Objectives:

The study was done to determine the physicians' perception about electronic medical record system (EMRS) in the context of its productivity in order to improve its functionality and advantages.

Materials and Methods:

This cross-sectional survey was performed from July to August 2009 with structured questionnaire of 15 closed-ended questions with five points Likert scaling starting from strongly disagree to strongly agree as 1–5, reflecting the perception of physicians about EMRS. The physicians of the Makkah region working in six different hospitals were selected. “Positive” response means if percent of responses were rated 4 or 5 (agree/strongly agree), “neutral” if rated 3, and negative if rated 1 or 2 (strongly disagree/disagree). Descriptive data analysis techniques were used.

Results:

We selected 317 completed questionnaires. Majority of subjects were from King Fahd Hospital, Jeddah (83, 26.3%), residents (147, 46.4%), male (200,63.1%), expatriates (207, 65%), and age group 36–45 years (133, 42%) were dominant. The stem regarding importance of computers for practicing medicine and EMRS to improve quality of practice was appreciated by majority, that is, 77.7 and 71.2%, respectively. However, “It does not disrupt the workflow” (35.1%) and “EMRS is comfortable while entering the data instead of writing” (34.8%) were appreciated negatively. Consultants (53.9%), male (53.4%), expatriates (56.7%), physicians of King Abdul Aziz Hospital, Ta'if (56.9%), and age group of 46–55 years (53.8%) appreciated EMRS positively. Overall perception of EMRS was found positive by 52.8%.

Conclusion:

Majority appreciated the EMRS, but specific concerns about its usage easiness and workflow disturbance were opposed by them also.

Validity of the Morse Fall Scale implemented in an electronic medical record system

AIMS AND OBJECTIVES

To examine the validity of the Morse Fall Scale by analysing the electronic medical records on fall risk during different phases of hospitalisation.

BACKGROUND

Regular monitoring on fall risk with a reliable and valid assessment tool is a key element in the fall prevention. In Korea, the Morse Fall Scale is currently being used in numerous medical institutions, yet it has not been comprehensively evaluated whether it is suitable and valid.

DESIGN

The study design was a retrospective case-control study.

METHODS

The participants included 151 fallers and 694 nonfallers. Data were extracted from a university hospital implementing Morse Fall Scale in the electronic medical records between October 2010 and June 2011. The nonfallers were selected by the stratified random sampling method among the patients who were in the hospital during the same period as the fallers. The Morse Fall Scale scores during three different time periods of hospital stay were used for analysis: the initial assessment score upon admission, the last and the maximum scores recorded from admission to the fall or discharge.

RESULTS

With the maximum Morse Fall Scale score and the best cut-off point of 51, validity indicators showed the highest performance: 0·72 for sensitivity, 0·91 for specificity, 0·63 for positive predictive value, 0·94 for negative predictive value, 0·63 for Youden Index and 0·77 for the area under the receiver operating characteristic curve.

CONCLUSION

The Morse Fall Scale showed relatively high predictive performance for the Korean population.

RELEVANCE TO CLINICAL PRACTICE

The study results recommend practice change in fall prevention. As the validity was highest when the patient was first classified into the high-risk group based on the Morse Fall Scale cut-off score 51, patients classified as high risk should be placed under special nursing interventions until the day of their discharge, regardless of change in the patient state.

Symptomatic severity of PRIME-MD diagnosed episodes of panic and generalized anxiety disorder in primary care

BACKGROUND

Panic disorder (PD) and generalized anxiety disorder (GAD) are often unrecognized by primary care physicians (PCPs). The Primary Care Evaluation of Mental Disorders (PRIME-MD) has been used as a case-finding instrument for depression. Yet, little is known on its usefulness as a case-finding tool for anxiety disorders within the context of a clinical trial.

OBJECTIVE

To examine the: (1) completion rate of the PRIME-MD by patients approached to enroll in a treatment study for PD and GAD; (2) distribution of anxiety diagnoses generated; (3) severity of PD and GAD episodes thus identified; and (4) level of PCPs' agreement with these diagnoses.

DESIGN

Cross-sectional interview.

PATIENTS

Individuals aged 18 to 64 who presented for care at 4 primary care practices.

MEASUREMENTS

The PRIME-MD, Structured Interview Guide for the Hamilton Anxiety Rating Scale (SIGH-A), and the Panic Disorder Severity Scale (PDSS).

RESULTS

Of the 6,700 patients who completed the PRIME-MD Patient Questionnaire (PQ), 2,926 (44%) screened positive for an anxiety disorder, and 1,216 (42%) met preliminary study eligibility and consented to the PRIME-MD Anxiety Module. Of these, 619 (51%) had either GAD (308), PD (94), or both (217) disorders. Later, 329 completed a telephone interview. Of these, 59% with GAD and 68% with PD reported moderate or greater levels of anxiety symptoms on the SIGH-A and PDSS, respectively, and PCPs agreed with the PRIME-MD diagnosis for 98% of these patients.

CONCLUSIONS

The PRIME-MD can efficiently screen patients for PD and GAD. Although patients thus identified endorse a wide range of anxiety symptoms, PCPs often agree with the diagnosis.