Implementation of a Web-Based Communication System for Primary Care Providers and Cancer Specialists

Healthcare providers have reported challenges with coordinating care for patients with cancer. Digital technology tools have brought new possibilities for improving care coordination. A web- and text-based asynchronous system (eOncoNote) was implemented in Ottawa, Canada for cancer specialists and primary care providers (PCPs). This study aimed to examine PCPs' experiences of implementing eOncoNote and how access to the system influenced communication between PCPs and cancer specialists. As part of a larger study, we collected and analyzed system usage data and administered an end-of-discussion survey to understand the perceived value of using eOncoNote. eOncoNote data were analyzed for 76 shared patients (33 patients receiving treatment and 43 patients in the survivorship phase). Thirty-nine percent of the PCPs responded to the cancer specialist's initial eOncoNote message and nearly all of those sent only one message. Forty-five percent of the PCPs completed the survey. Most PCPs reported no additional benefits of using eOncoNote and emphasized the need for electronic medical record (EMR) integration. Over half of the PCPs indicated that eOncoNote could be a helpful service if they had questions about a patient. Future research should examine opportunities for EMR integration and whether additional interventions could support communication between PCPs and cancer specialists.

A Trend-Based Early Warning Score Can Be Implemented in a Hospital Electronic Medical Record to Effectively Predict Inpatient Deterioration

OBJECTIVES

To determine whether a statistically derived, trend-based, deterioration index is superior to other early warning scores at predicting adverse events and whether it can be integrated into an electronic medical record to enable real-time alerts.

DESIGN

Forty-three variables and their trends from cases and controls were used to develop a logistic model and deterioration index to predict patient deterioration greater than or equal to 1 hour prior to an adverse event.

SETTING

Two large Australian teaching hospitals.

PATIENTS

Cases were considered as patients who suffered adverse events (unexpected death, unplanned ICU transfer, urgent surgery, and rapid-response alert) between August 1, 2016, and April 1, 2019.

INTERVENTIONS

The logistic model and deterioration index were tested on historical data and then integrated into an electronic medical record for a 6-month prospective "silent" validation.

MEASUREMENTS AND MAIN RESULTS

Data were acquired from 258,732 admissions. There were 8,002 adverse events. The addition of vital sign and laboratory trend values to the logistic model increased the area under the curve from 0.84 to 0.89 and the sensitivity to predict an adverse event 1-48 hours prior from 0.35 to 0.41. A 48-hour simulation showed that the logistic model had a higher area under the curve than the Modified Early Warning Score and National Early Warning Score (0.87 vs 0.74 vs 0.71). During the silently run prospective trial, the sensitivity of the deterioration index to detect adverse event any time prior to the adverse event was 0.474, 0.369 1 hour prior, and 0.327 4 hours prior, with a specificity of 0.972.

CONCLUSIONS

A deterioration prediction model was developed using patient demographics, ward-based observations, laboratory values, and their trends. The model's outputs were converted to a deterioration index that was successfully integrated into a live hospital electronic medical record. The sensitivity and specificity of the tool to detect inpatient deterioration were superior to traditional early warning scores.

Differences in Clinician Electronic Health Record Use Across Adult and Pediatric Primary Care Specialties

This cross-sectional study examines differences in electronic health record use across adult and pediatric primary care specialties.

Length and Redundancy of Outpatient Progress Notes Across a Decade at an Academic Medical Center

IMPORTANCE

There is widespread concern that clinical notes have grown longer and less informative over the past decade. Addressing these concerns requires a better understanding of the magnitude, scope, and potential causes of increased note length and redundancy.

OBJECTIVE

To measure changes between 2009 and 2018 in the length and redundancy of outpatient progress notes across multiple medical specialties and investigate how these measures associate with author experience and method of note entry.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted at Oregon Health & Science University, a large academic medical center. Participants included clinicians and staff who wrote outpatient progress notes between 2009 and 2018 for a random sample of 200 000 patients. Statistical analysis was performed from March to August 2020.

EXPOSURES

Use of a comprehensive electronic health record to document patient care.

MAIN OUTCOMES AND MEASURES

Note length, note redundancy (ie, the proportion of text identical to the patient's last note), and percentage of templated, copied, or directly typed note text.

RESULTS

A total of 2 704 800 notes written by 6228 primary authors across 46 specialties were included in this study. Median note length increased 60.1% (99% CI, 46.7%-75.2%) from a median of 401 words (interquartile range [IQR], 225-660 words) in 2009 to 642 words (IQR, 399-1007 words) in 2018. Median note redundancy increased 10.9 percentage points (99% CI, 7.5-14.3 percentage points) from 47.9% in 2009 to 58.8% in 2018. Notes written in 2018 had a mean value of just 29.4% (99% CI, 28.2%-30.7%) directly typed text with the remaining 70.6% of text being templated or copied. Mixed-effect linear models found that notes with higher proportions of templated or copied text were significantly longer and more redundant (eg, in the 2-year model, each 1% increase in the proportion of copied or templated note text was associated with 1.5% [95% CI, 1.5%-1.5%] and 1.6% [95% CI, 1.6%-1.6%] increases in note length, respectively). Residents and fellows also wrote significantly (26.3% [95% CI, 25.8%-26.7%]) longer notes than more senior authors, as did more recent hires (1.8% for each year later [95% CI, 1.3%-2.4%]).

CONCLUSIONS AND RELEVANCE

In this study, outpatient progress notes grew longer and more redundant over time, potentially limiting their use in patient care. Interventions aimed at reducing outpatient progress note length and redundancy may need to simultaneously address multiple factors such as note template design and training for both new and established clinicians.

Harnessing the electronic health record to advance integrated care

INTRODUCTION

Integrated health care is utilized in primary care clinics to meet patients' physical, behavioral, and social needs. Current methods to collect and evaluate the effectiveness of integrated care require refinement. Using informatics and electronic health records (EHR) to distill large amounts of clinical data may help researchers measure the impact of integrated care more efficiently. This exploratory pilot study aimed to (a) determine the feasibility of using EHR documentation to identify behavioral health and social care components of integrated care, using social work as a use case, and (b) develop a lexicon to inform future research using natural language processing.

METHOD

Study steps included development of a preliminary lexicon of behavioral health and social care interventions to address basic needs, creation of an abstraction guide, identification of appropriate EHR notes, manual chart abstraction, revision of the lexicon, and synthesis of findings.

RESULTS

Notes (N = 647) were analyzed from a random sample of 60 patients. Notes documented behavioral health and social care components of care but were difficult to identify due to inconsistencies in note location and titling. Although the interventions were not described in detail, the outcomes of screening, referral, and brief treatment were included. The integrated care team frequently used EHR to share information and communicate.

DISCUSSION

Opportunities and challenges to using EHR data were identified and need to be addressed to better understand the behavioral health and social care interventions in integrated care. To best leverage EHR data, future research must determine how to document and extract pertinent information about integrated team-based interventions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Four Years Later: Examining Nurse Perceptions of Electronic Documentation Over Time

OBJECTIVE

To examine changes in registered nurse (RN) perceptions of electronic documentation over a 4-year period.

BACKGROUND

The investigators previously reported differences in RN perceptions prior to and 1 year after adoption of a comprehensive electronic health record (EHR).

METHODS

Investigators repeated the study 4 years after adoption, using the Nurses' Perceptions of Electronic Documentation tool and interviews with a subset of RNs.

RESULTS

Nurses scored higher on ease of use domain and lower on concern about the EHR domain and showed no difference on the impacts of the EHR domain. Interviews revealed that 4 years later, some aspects of documentation were easier; the tool was comprehensive, but not without risk, and nurses remained ambivalent about the EHR.

CONCLUSIONS

Use of EHR technology impacts nursing work. It is important to understand how nurses' perceptions change over time. This study gives nursing leaders insight into adoption and acceptance of an EHR.

Antimicrobial Stewardship by Leveraging Electronic Medical Records

This paper describes how an antimicrobial stewardship program was successfully developed and integrated into a university medical center's electronic healthcare records and improved antibiotic selection.

Early detection of pancreatic cancer

Pancreatic ductal adenocarcinoma is most frequently detected at an advanced stage. Such late detection restricts treatment options and contributes to a dismal 5-year survival rate of 3-15%. Pancreatic ductal adenocarcinoma is relatively uncommon and screening of the asymptomatic adult population is not feasible or recommended with current modalities. However, screening of individuals in high-risk groups is recommended. Here, we review groups at high risk for pancreatic ductal adenocarcinoma, including individuals with inherited predisposition and patients with pancreatic cystic lesions. We discuss studies aimed at finding ways of identifying pancreatic ductal adenocarcinoma in high-risk groups, such as among individuals with new-onset diabetes mellitus and people attending primary and secondary care practices with symptoms that suggest this cancer. We review early detection biomarkers, explore the potential of using social media for detection, appraise prediction models developed using electronic health records and research data, and examine the application of artificial intelligence to medical imaging for the purposes of early detection.

Toward the Design of an Engagement Tool for Effective Electronic Health Record Adoption

As healthcare systems continue to expand their use of electronic health records (EHRs), barriers to robust and successful engagement with such systems by stakeholders remain tenacious. To this effect, this research presents the results of a survey tool utilizing both original and modified constructs from the Consolidated Framework for Implementation Research to assess key points of engagement barriers and potential points of intervention for stakeholders of EHRs in a large-scale healthcare organization (500-bed level II regional trauma center). Based on the extensive assessment, the paper presents recommendations for the utility of engagement process modeling and discusses how intervention opportunities can be used to mitigate engagement barriers.

A Pilot Study of Use of a Software Platform for the Collection, Integration, and Visualization of Diabetes Device Data by Health Care Providers in a Multidisciplinary Pediatric Setting

BACKGROUND

Diabetes devices provide data for health care providers (HCPs) and people with type 1 diabetes to make management decisions. Extracting and viewing the data require separate, proprietary software applications for each device. In this pilot study, we examined the feasibility of using a single software platform (Tidepool) that integrates data from multiple devices.

MATERIALS AND METHODS

Participating HCPs (n = 15) used the software with compatible devices in all patient visits for 6 months. Samples of registration desk activity and office visits were observed before and after introducing the software, and HCPs provided feedback by survey and focus groups.

RESULTS

The time required to upload data and the length of the office visit did not change. However, the number of times the HCP referred to the device data with patients increased from a mean of 2.8 (±1.2) to 6.1 (±3.1) times per visit (P = 0.0002). A significantly larger proportion of children looked at the device data with the new application (baseline: 61% vs. study end: 94%, P = 0.015). HCPs liked the web-based user interface, integration of the data from multiple devices, the ability to remotely access data, and use of the application to initiate patient education. Challenges included the need for automated data upload and integration with electronic medical records.

CONCLUSIONS

The software did not add to the time needed to upload data or the length of clinic visits and promoted discussions with patients about data. Future studies of HCP use of the application will evaluate clinical outcomes and effects on patient engagement and self-management.

A pilot study: a teaching electronic medical record for educating and assessing residents in the care of patients

OBJECTIVE

We tested a novel, web-based teaching electronic medical record to teach and assess residents' ability to enter appropriate admission orders for patients admitted to the intensive care unit. The primary objective was to determine if this tool could improve the learners' ability to enter an evidence-based, comprehensive initial care plan for critically ill patients.

METHODS

The authors created three modules using de-identifed real patient data from selected patients that were admitted to the intensive care unit. All senior residents (113 total) were invited to participate in a dedicated two-hour educational session to complete the modules. Learner performance was graded against gold standard admission order sets created by study investigators based on the latest evidence-based medicine and guidelines.

RESULTS

The session was attended by 39 residents (34.5% of invitees). There was an average improvement of at least 20% in users' scores across the three modules (Module 3-Module 1 mean difference 22.5%; p = 0.001 and Module 3-Module 2 mean difference 20.3%; p = 0.001). Diagnostic acumen improved in successive modules. Almost 90% of the residents reported the technology was an effective form of teaching and would use it autonomously if more modules were provided.

CONCLUSIONS

In this pilot project, using a novel educational tool, users' patient care performance scores improved with a high level of user satisfaction. These results identify a realistic and well-received way to supplement residents' training and assessment on core clinical care and patient management in the face of duty hour restrictions.

Sometimes determination and compromise thwart success: lessons learned from an effort to study copying and pasting in the electronic medical record

None

An Overview of the Application of Wearable Technology to Nursing Practice

PROBLEM

Wearable technology is here and nurses are going to be increasingly responsible for patients who use it. Most research in this area has been done in other fields and now is the time for nurses to be more involved in this promising technology to improve patient lives.

METHODS

This paper synthesizes the current state of wearable technology, a brief history of nurse satisfaction with technology, current research about wearable technology, and implications for its future use in nursing.

FINDINGS

Other areas in health care are already employing wearable technology to improve gait in people with Parkinson's disease, provide automatic defibrillation in cardiac patients, and monitor poststroke rehabilitation. Nurses can be on the front lines of designing and patenting new ideas to improve the lives of their patients.

CONCLUSIONS

Nurses have always adopted the newest technologies such as electronic health records, electronic medication administration records, and simulation experiences in education. Wearable technology is the next step in this journey and the possible uses are endless. Involving patients in their own care is a major goal of nursing and more research is needed to connect patients and their caregivers to the benefits of wearable technology.

Identifying Barriers in the Use of Electronic Health Records in Hawai'i

Hawai'i faces unique challenges to Electronic Health Record (EHR) adoption due to physician shortages, a widespread distribution of Medically Underserved Areas and Populations (MUA/P), and a higher percentage of small independent practices. However, research on EHR adoption in Hawai'i is limited. To address this gap, this article examines the current state of EHR in Hawai'i, the barriers to adoption, and the future of Health Information Technology (HIT) initiatives to improve the health of Hawai'i's people. Eight focus groups were conducted on Lana'i, Maui, Hawai'i Island, Kaua'i, Moloka'i, and O'ahu. In these groups, a total of 51 diverse health professionals were asked about the functionality of EHR systems, barriers to use, facilitators of use, and what EHRs would look like in a perfect world. Responses were summarized and analyzed based on constant comparative analysis techniques. Responses were then clustered into thirteen themes: system compatibility, loss of productivity, poor interface, IT support, hardware/software, patient factors, education/training, noise in the system, safety, data quality concerns, quality metrics, workflow, and malpractice concerns. Results show that every group mentioned system compatibility. In response to these findings, the Health eNet Community Health Record initiative - which allows providers web-based access to patient health information from the patient's provider network- was developed as a step toward alleviating some of the barriers to sharing information between different EHRs. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation will introduce a new payment model in 2017 that is partially based on EHR utilization. Therefore, more research should be done to understand EHR adoption and how this ruling will affect providers in Hawai'i.

Exploring family and social context through the electronic health record: Physicians' experiences

INTRODUCTION

There is ample evidence that social and familial context significantly impacts health. However, family and social history templates typically used in clinical practice exclude prompts to explore important contextual information, such as family dynamics, health beliefs, housing, and neighborhood environment.

METHOD

At the Residency Program in Social Medicine at Montefiore Medical Center/Albert Einstein College of Medicine in Bronx, NY, we developed and piloted an expanded family and social information (FSI) template in our electronic health record (EHR) system. After 10 physicians used the FSI template during routine clinical practice, we conducted and qualitatively analyzed transcripts of semistructured interviews to assess their experiences.

RESULTS

The major themes of physician's experiences using the FSI template included: expanded thinking (promoted thinking and discussion about contextual information), relevancy to care (highlighted important life events, helpful resource for future care or for team-based care), fragmentation (patient narrative difficult to categorize into discrete sections), and abstract phrasing (prompts too abstract and/or too complex to explore well). Some minor themes (themes that were repeated often, but not consistent in all interviews) were also noted: practice demands, educational purpose, and wish list.

DISCUSSION

Within our small sample, we found that an expanded family and social information template broadened physicians' clinical thinking during routine visits. We also found that the structure of the EHR and practice demands create significant barriers to exploring a patient's narrative effectively. Themes identified in this research will inform national efforts to prioritize a contextual and biopsychosocial perspective in EHR systems. (PsycINFO Database Record

Bedside patient data viewer using RFID and e-Ink technology

In the daily routine of hospitals, which work with paper based medical records, the staff has to find the appropriate patient file if it needs information about the patient. With the introduction of ELGA the Austrian hospitals have to use specific standards for their clinical documentation. These structured documents can be used to feed an e-Ink reader with information about every patient in a hospital. Combined with RFID and security measures, the clinical staff is supported during the patient file searching process. The developed experimental setup of the Bedside Patient Data Viewer demonstrates a prototype of such a system. An Amazon Kindle Paperwhite is used to display processed data, supplied by a Raspberry Pi with an attached RFID module for identification purposes. Results show that such a system can be implemented, however a lot of organizational and technical issues remain to be solved.

A vital signs telemonitoring system - interoperability supported by a personal health record systema and a cloud service

This article presents the development process of an acquisition and data storage system managing clinical variables through a cloud storage service and a Personal Health Record (PHR) System. First, the paper explains how a Wireless Body Area Network (WBAN) that captures data from two sensors corresponding to arterial pressure and heart rate is designed. Second, this paper illustrates how data collected by the WBAN are transmitted to a cloud storage service. It is worth mentioning that this cloud service allows the data to be stored in a persistent way on an online database system. Finally, the paper describes, how the data stored in the cloud service are sent to the Indivo PHR System, where they are registered and charted for future revision by health professionals. The research demonstrated the feasibility of implementing WBAN networks for the acquisition of clinical data, and particularly for the use of Web technologies and standards to provide interoperability with PHR Systems at technical and syntactic levels.

Automatic prediction of rheumatoid arthritis disease activity from the electronic medical records

OBJECTIVE

We aimed to mine the data in the Electronic Medical Record to automatically discover patients' Rheumatoid Arthritis disease activity at discrete rheumatology clinic visits. We cast the problem as a document classification task where the feature space includes concepts from the clinical narrative and lab values as stored in the Electronic Medical Record.

MATERIALS AND METHODS

The Training Set consisted of 2792 clinical notes and associated lab values. Test Set 1 included 1749 clinical notes and associated lab values. Test Set 2 included 344 clinical notes for which there were no associated lab values. The Apache clinical Text Analysis and Knowledge Extraction System was used to analyze the text and transform it into informative features to be combined with relevant lab values.

RESULTS

Experiments over a range of machine learning algorithms and features were conducted. The best performing combination was linear kernel Support Vector Machines with Unified Medical Language System Concept Unique Identifier features with feature selection and lab values. The Area Under the Receiver Operating Characteristic Curve (AUC) is 0.831 (σ = 0.0317), statistically significant as compared to two baselines (AUC = 0.758, σ = 0.0291). Algorithms demonstrated superior performance on cases clinically defined as extreme categories of disease activity (Remission and High) compared to those defined as intermediate categories (Moderate and Low) and included laboratory data on inflammatory markers.

CONCLUSION

Automatic Rheumatoid Arthritis disease activity discovery from Electronic Medical Record data is a learnable task approximating human performance. As a result, this approach might have several research applications, such as the identification of patients for genome-wide pharmacogenetic studies that require large sample sizes with precise definitions of disease activity and response to therapies.

Harnessing clinical psychiatric data with an electronic assessment tool (OPCRIT+): the utility of symptom dimensions

Progress in personalised psychiatry is dependent on researchers having access to systematic and accurately acquired symptom data across clinical diagnoses. We have developed a structured psychiatric assessment tool, OPCRIT+, that is being introduced into the electronic medical records system of the South London and Maudsley NHS Foundation Trust which can help to achieve this. In this report we examine the utility of the symptom data being collected with the tool. Cross-sectional mental state data from a mixed-diagnostic cohort of 876 inpatients was subjected to a principal components analysis (PCA). Six components, explaining 46% of the variance in recorded symptoms, were extracted. The components represented dimensions of mania, depression, positive symptoms, anxiety, negative symptoms and disorganization. As indicated by component scores, different clinical diagnoses demonstrated distinct symptom profiles characterized by wide-ranging levels of severity. When comparing the predictive value of symptoms against diagnosis for a variety of clinical outcome measures (e.g. ‘Overactive, aggressive behaviour’), symptoms proved superior in five instances (R² range: 0.06–0.28) whereas diagnosis was best just once (R²∶0.25). This report demonstrates that symptom data being routinely gathered in an NHS trust, when documented on the appropriate tool, have considerable potential for onward use in a variety of clinical and research applications via representation as dimensions of psychopathology.

Investigating incidents of EHR failures in China: analysis of search engine reports

As the healthcare industry becomes increasingly dependent on information technology (IT), the failure of computerized systems could cause catastrophic effects on patient safety. We conducted an empirical study to analyze news articles available on the internet using Baidu and Google. 116 distinct EHR outage news reports were identified. We examined characteristics, potential causes, and possible preventive strategies. Risk management strategies based are discussed.

[Local communalization of clinical records between the municipal community hospital and local medical institutes by using information technology]

We introduced the electronic health record system in 2002. We produced a community medical network system to consolidate all medical treatment information from the local institute in 2010. Here, we report on the present status of this system that has been in use for the previous 2 years. We obtained a private server, set up a virtual private network(VPN)in our hospital, and installed dedicated terminals to issue an electronic certificate in 50 local institutions. The local institute applies for patient agreement in the community hospital(hospital designation style). They are then entitled to access the information of the designated patient via this local network server for one year. They can access each original medical record, sorted on the basis of the medical attendant and the chief physician; a summary of hospital stay; records of medication prescription; and the results of clinical examinations. Currently, there are approximately 80 new registrations and accesses per month. Information is provided in real time allowing up to date information, helping prescribe the medical treatment at the local institute. However, this information sharing system is read-only, and there is no cooperative clinical pass system. Therefore, this system has a limit to meet the demand for cooperation with the local clinics.

[The dilemma of data flood - reducing costs and increasing quality control]

Digitization is found everywhere in sonography. Printing of ultrasound images using the videoprinter with special paper will be done in single cases. The documentation of sonography procedures is more and more done by saving image sequences instead of still frames. Echocardiography is routinely recorded in between with so called R-R-loops. Doing contrast enhanced ultrasound recording of sequences is necessary to get a deep impression of the vascular structure of interest. Working with this data flood in daily practice a specialized software is required. Comparison in follow up of stored and recent images/sequences is very helpful. Nevertheless quality control of the ultrasound system and the transducers is simple and safe - using a phantom for detail resolution and general image quality the stored images/sequences are comparable over the life cycle of the system. The comparison in follow up is showing decreased image quality and transducer defects immediately.

Exemplars in the use of technology for management of depression in primary care

PURPOSE

Depression care management as part of larger efforts to integrate behavioral health care into primary care has been shown to be effective in helping patients and primary care clinicians achieve improved outcomes within the primary care environment. Central to care management systems is the use of registries which enable effective clinic population management. The aim of this article is to detail the methods and utility of technology in depression care management processes while also highlighting the real-world variations and barriers that exist in different clinical environments, namely a federally qualified health center and a Veterans Administration clinic.

METHODS

We analyzed descriptive data from the registries of Access Community Health Centers and the William S. Middleton Veterans Administration clinics along with historical reviews of their respective care management processes.

RESULTS

Both registry reviews showed trend data indicating improvement in scores of depression and provided baseline data on important system variables, such as the number of patients who are not making progress, the percentage of patients who are unreachable by phone, and the kind of actions needed to ensure evidence-based and efficient care. Both sites also highlighted systemic technical barriers to more complete implementation of care management processes.

CONCLUSIONS

Care management processes are an effective and efficient part of population-based care for depression in primary care. Implementation depends on available resources including hardware, software, and clinical personnel. Additionally, care management processes and technology have evolved over time based on local needs and are part of an integrated method to support the work of primary care clinicians in providing care for patients with depression.

CAH staff perceptions of a clinical information system implementation

OBJECTIVES

This study examines staff perceptions of patient care quality and the processes before and after implementation of a comprehensive clinical information system (CIS) in critical access hospitals (CAHs).

STUDY DESIGN

A prospective, nonexperimental design, evaluation study.

METHODS

A modified version of the Information Systems Expectations and Experiences (I-SEE) survey instrument was administered to staff in 7 CAHs annually over 3 years to capture baseline, readiness, and postimplementation perceptions.

RESULTS

Descriptive analyses examined 840 survey responses across 3 survey administrations and job categories (registered nurses [RNs], providers, and other clinical staff). Analysis of variance compared responses for main effects (ie, administration, staff position, hospital, and cohort) and interactions between groups over time. Correlations examined the relationships between variables. In general, the responses indicate a high level of positive perceptions regarding the processes and quality of care in these hospitals. For most of the items, responses were quite consistent across the 3 survey administrations. Significant changes occurred for 5 items; 4 reflecting information flow and increased communication, and 1 reflecting a decrease in improved patient care. Overall, providers had lower mean responses compared with nurses and other clinical staff. Significant interactions between administrations and job categories were found for 4 items.

CONCLUSIONS

Even though staff had overwhelmingly positive perceptions of patient care quality and processes, significant differences between providers, RNs, and other clinical staff were observed. Variability was also found across CAHs. Research on CIS implementation in small hospitals is rare and needed to guide the identification of factors and strategies related to success.

E-health in low- and middle-income countries: findings from the Center for Health Market Innovations

OBJECTIVE

To describe how information communication technology (ICT) is being used by programmes that seek to improve private sector health financing and delivery in low- and middle-income countries, including the main uses of the technology and the types of technologies being used.

METHODS

In-country partners in 16 countries directly searched systematically for innovative health programmes and compiled profiles in the Center for Health Market Innovations' database. These data were supplemented through literature reviews and with self-reported data supplied by the programmes themselves.

FINDINGS

In many low- and middle-income countries, ICT is being increasingly employed for different purposes in various health-related areas. Of ICT-enabled health programmes, 42% use it to extend geographic access to health care, 38% to improve data management and 31% to facilitate communication between patients and physicians outside the physician's office. Other purposes include improving diagnosis and treatment (17%), mitigating fraud and abuse (8%) and streamlining financial transactions (4%). The most common devices used in technology-enabled programmes are phones and computers; 71% and 39% of programmes use them, respectively, and the most common applications are voice (34%), software (32%) and text messages (31%). Donors are the primary funders of 47% of ICT-based health programmes.

CONCLUSION

Various types of ICT are being employed by private organizations to address key health system challenges. For successful implementation, however, more sustainable sources of funding, greater support for the adoption of new technologies and better ways of evaluating impact are required.

Personal health records: mobile biosensors and smartphones for developing countries

A target of telehealth is to maintain or improve the health of people outside the normal healthcare infrastructure. A modern paradigm in healthcare, and one which fits perfectly with telehealth, is "person self-monitoring", and this fits with the concept of "personal health record" (PHR). One factor in maintaining health is to monitor physiological parameters; this is of course especially important in people with chronic maladies such as diabetes or heart disease. Parameters to be monitored include blood pressure, pulse rate, temperature, weight, blood glucose, oxygen saturation, electrocardiogram (ECG), etc. So one task within telehealth would be to help monitor an individual's physiological parameters outside of healthcare institutions and store the results in a PHR in a way which is available, comprehensible and beneficial to the individual concerned and to healthcare providers. To date many approaches to this problem have been fragmented - emphasizing only part of the problem - or proprietary and not freely verifiable. We describe a framework to approach this task; it emphasizes the implementation of standards for data acquisition, storage and transmission in order to maximize the compatibility among disparate components, e.g. various PHR systems. Data from mobile biosensors is collected on a smartphone using the IEEE 11073 standard where possible; the data can be stored in a PHR on the phone (using standard formats) or can be converted in real-time into more useful information in the PHR, which is based on the International Classification for Primary Care (ICPC2e). The phone PHR data or information can be uploaded to a central online PHR using either the Wi-Fi or GSM transmission protocol together with the Continuity of Care Record message format (CCR, ASTM E2369).

Home care and technology: a case study

Health care aides (HCAs) are the backbone of the home care system and provide a range of services to people who, for various reasons related to chronic conditions and aging, are not able to take care of themselves independently. The demand for HCA services will increase and the current HCA supply will likely not keep up with this increasing demand without fundamental changes in the current environment. Information and communication technology (ICT) can address some of the workflow challenges HCAs face. In this project, we conducted an ethnographic study to document and analyse HCAs' workflows and team interactions. Based on our findings, we designed an ICT tool suite, integrating easily available existing and newly developed (by our team) technologies to address these issues. Finally, we simulated the deployment of our technologies, to assess the potential impact of these technological solutions on the workflow and productivity of HCAs, their healthcare teams and client care.

Automated NFC enabled rural healthcare for reliable patient record maintainance

Body sensor networks can be used for health monitoring of patients by expert medical doctors, in remote locations like rural areas in developing countries, and can also be used to provide medical aid to areas affected by natural disasters in any part of the world. An important issue to be addressed, when the number of patients is large, is to reliably maintain the patient records and have simple automated mobile applications for healthcare helpers to use. We propose an automated healthcare architecture using NFC-enabled mobile phones and patients having their patient ID on RFID tags. It utilizes NFC-enabled mobile phones to read the patient ID, followed by automated gathering of healthcare vital parameters from body sensors using Bluetooth, analyses the information and transmits it to a medical server for expert feedback. With limited hospital resources and less training requirement for healthcare helpers through simpler applications, this automation of healthcare processing can provide time effective and reliable mass health consultation from medical experts in remote locations.

Progress toward meaningful use: hospitals' adoption of electronic health records

OBJECTIVES

To update the status of electronic health record (EHR) adoption in US hospitals and assess their readiness for "Meaningful Use" (MU).

STUDY DESIGN

We used data from the 2010 American Hospital Association Annual Information Technology Survey. The survey was first conducted in 2007 and is made available both online and through the mail to all non-federal acute-care hospitals in the United States.

METHODS

We measure the percentages of applicable hospitals that have adopted "basic" and "comprehensive" EHRs as defined in previous literature. Additionally, we report the percentage of hospitals planning to apply for MU in the near term, and assess hospitals' readiness for the program and how readiness varies by key characteristics.

RESULTS

We received responses from 2902 hospitals (64% of all non-federal acute-care hospitals). More than 15% have adopted at least a "basic" EHR, representing nearly 75% growth since 2008. Approximately two-thirds plan to apply for MU before 2013; however, only 4.4% had implemented each of the "core" MU functionalities we measured. Hospitals closer to achieving MU are more likely to be larger non-profits (P <.001) and vary by other key characteristics. Certain functionalities included in MU, such as computerized provider order entry, electronic generation of quality measures, and electronic access to records for patients are proving more challenging to implement for all hospitals.

CONCLUSIONS

Broad enthusiasm exists among hospitals for participation in MU. However, adoption will have to accelerate above its current pace for readiness to match intention. Gaps in adoption show bringing all hospitals along is the key policy challenge.

Technology-driven intervention to improve hypertension outcomes in community health centers

OBJECTIVES

To assess the impact of an electronic medical record (EMR) with clinical decision support (CDS) and performance feedback on provider adherence to guideline-recommended care and blood pressure (BP) control compared with a standard EMR alone.

STUDY DESIGN

Quasi-experimental with repeated measures.

METHODS

The study was conducted in a 4-site, federally qualified health center, Open Door Family Medical Centers, located in New York. The research team, Open Door leadership, providers, and staff developed and implemented a tailored multicomponent CDS system, which included a BP alert, a hypertension (HTN) order set, an HTN template, and clinical reminders. We extracted patient-level data for each encounter 17 months prior to implementation of the intervention (June 2007-October 2008) and 15 months post-intervention (April 2009-June 2010), from the EMR's data tables for all adult nonobstetric patients with a diagnosis of HTN (N = 3636).

RESULTS

Rates of HTN control were significantly greater in the post-intervention period compared with the baseline period (50.9% vs 60.8%; P <.001). Process measures, derived from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Guidelines, also improved significantly. Logistic regression with generalized estimating equations showed that patients were 1.5 times more likely to have controlled BP post-intervention than pre-intervention. Correlates of poor BP control were black race, higher body mass index, diabetes, female gender, income, and a greater number of prescribed antihypertensive medications.

CONCLUSIONS

Our findings suggest that health information technology that is implemented as part of a multicomponent quality improvement initiative can lead to improvements in HTN care and outcomes.

The comparative effectiveness of 2 electronic prescribing systems

OBJECTIVES

The increasingly widespread adoption of electronic health records (EHRs) is substantially changing the American healthcare delivery system. Differences in the actual effectiveness of EHRs and their component applications, including electronic prescribing (e-prescribing), is not well understood. We compared the effects of 2 types of e-prescribing systems on medication safety as an example of how comparative effectiveness research (CER) can be applied to the study of healthcare delivery.

STUDY DESIGN AND METHODS

We previously conducted 2 non-randomized, prospective studies with pre-post controls comparing prescribing errors among: (1) providers who adopted a standalone e-prescribing system with robust technical and clinical decision support (CDS) and (2) providers who adopted an EHR with integrated e-prescribing with less robust available CDS and technical support. Both studies evaluated small groups of ambulatory care providers in the same New York community using identical methodology including prescription and chart reviews. We undertook this comparative effectiveness study to directly compare prescribing error rates among the 2 groups of e-prescribing adopters.

RESULTS

The stand-alone system reduced error rates from 42.5 to 6.6 errors per 100 prescriptions (P <.001). The integrated system reduced error rates from 26.0 to 16.0 per 100 prescriptions (P= .07). After adjusting for baseline differences, stand-alone users had a 4-fold lower rate of errors at 1 year (P <.001).

CONCLUSIONS

Despite improved work flow integration, the integrated e-prescribing application performed less well, likely due to differences in available CDS and technical resources. Results from this small study highlight the importance of CER that directly compares components of healthcare delivery.

Qualitative evaluation to explain success of multifaceted technology-driven hypertension intervention

OBJECTIVES

This study sought to examine the implementation of an electronic health record-based intervention to improve quality of hypertension care in community health centers. The primary goal was to use qualitative analysis to explain how different components of the intervention contributed to positive patient-level outcomes.

STUDY DESIGN

Qualitative process evaluation.

METHODS

The intervention included alerts, order sets, templates, clinical reminder algorithms, and provider performance feedback. Semi-structured interviews were conducted with primary care providers before (n = 16) and after (n = 16) intervention, and with key staff and leadership involved in the implementation (n = 6). The research team applied an iterative systematic qualitative coding process to identify salient themes. Several constructs from IT implementation theories guided the analysis.

RESULTS

The analysis focused on: (1) satisfaction and perceived usefulness of intervention components, (2) perceived proximal changes resulting from intervention, and (3) perceived facilitators of change. Different participants found different components useful. Proximal impact manifested in multiple ways (eg, more aggressive follow-up appointments and prescribing) and in increased overall attention to hypertension. Facilitators of success included leadership, organizational culture, provider engagement, rigorous implementation process, framing of intervention as quality improvement (QI), and health center capacity to process data.

CONCLUSIONS

We attribute the success of the intervention to a multifaceted approach where the combination of multiple intervention components resulted in across the-board change in hypertension care practices. In contrast with research that attempts to isolate the impact of circumscribed health information technology (HIT) tools, our experience suggests that HIT can achieve success in patient outcomes when rigorously implemented as a multifaceted intervention and framed as QI activity.

Impact and user satisfaction of a clinical information portal embedded in an electronic health record

In 2008, a clinical information tool was developed and embedded in the electronic health record system of an academic medical center. In 2009, the initial information tool, Clinical-e, was superseded by a portal called Clinical Focus, with a single search box enabling a federated search of selected online information resources. To measure the usefulness and impact of Clinical Focus, a survey was used to gather feedback about users' experience with this clinical resource. The survey determined what type of clinicians were using this tool and assessed user satisfaction and perceived impact on patient care decision making. Initial survey results suggest the majority of respondents found Clinical Focus easy to navigate, the content easy to read, and the retrieved information relevant and complete. The majority would recommend Clinical Focus to their colleagues. Results indicate that this tool is a promising area for future development.

Vital signs monitoring systems. A look at seven monitors and their connectivity solutions

Because they are capable of connecting with electronic medical records, today's vital signs monitoring systems can increase the accuracy and efficiency of getting vitals data into a patient's record. But this has also made the systems more complex--not only to install and use, but also to shop for. We've evaluated seven systems to make the choice easier.

Implementing change in a diverse and politicized landscape

Based on the experiences from an ongoing IT implementation project, this paper illustrates the complexity of large scale projects through the concept of diversity. The analysis shows how, no matter how mature the project becomes at coping with local diversity, it is still vulnerable to contextual diversity; especially when this is politicized. The paper concludes by pointing to the special responsibilities this puts on higher level decision makers.

[Research on information extraction of electronic medical records in Chinese]

This is a research to enhance the application of natural language understanding and ontology in the Chinese medical text semantic annotation and content analysis, and so to provide technology support for the computer-readable electronic medical records (EMR). The Chinese EMR information extraction and statistical analysis of related subjects in accordance to the user's demands were performed through building the named entity rules, the classified word list and field ontology by using GATE platform on the basis of EMR text set's construction and pre-processing. The automatic and artificial semantic annotation of EMR text set was implemented. The situation of drugs used in medicinal treatment and the distribution of patients' age and sex were obtained. The ontology-based semantic information extraction can improve the function of computer for text understanding, and the discovery of knowledge in EMR through field ontology is feasible.