De-identification of primary care electronic medical records free-text data in Ontario,Canada

Background  

Electronic medical records (EMRs) represent a potentially rich source of health information for research but the free-text in EMRs often contains identifying information. While de-identification tools have been developed for free-text, none have been developed or tested for the full range of primary care EMR data     

Observations on primary health care in Ontario, Canada.

The Canadian health care system has developed very differently from that of its neighbour, the United States of America. It has a publicly financed and administered universal insurance plan which provides good access to high quality medicine, free at the point of delivery. Increasing costs, however, mean that painful political decisions on health will have to be made. Experiments with alternative means of financing primary health care provision and the Canadian approach to postgraduate education may offer useful ideas for general practice in the United Kingdom.     

Alternative health care consultations in Ontario, Canada: A geographic and socio-demographic analysis

Background

Insulin deficiency is the prime basis of all diabetic manifestations and agents that can bring about insulin secretion would be of pivotal significance for cure of diabetes. To test this hypothesis, we carried out bioactivity guided fractionation of Oreocnide integrifolia (Urticaceae); a folklore plant consumed for ameliorating diabetic symptoms using experimental models.

Methods

We carried out bioassay guided fractionation using RINmF and C2C12 cell line for glucose stimulated insulin secretion (GSIS) and glucose uptake potential of fractions. Further, the bioactive fraction was challenged for its GSIS in cultured mouse islets with basal (4.5 mM) and stimulated (16.7 mM) levels of glucose concentrations. The Flavonoid rich fraction (FRF) was exposed to 2 mM streptozotocin stress and the anti-ROS/RNS potential was evaluated. Additionally, the bioactive fraction was assessed for its antidiabetic and anti-apoptotic property in-vivo using multidose streptozotocin induced diabetes in BALB/c mice.

Results

The results suggested FRF to be the most active fraction as assessed by GSIS in RINm5F cells and its ability for glucose uptake in C2C12 cells. FRF displayed significant potential in terms of increasing intracellular calcium and cAMP levels even in presence of a phosphodiesterase inhibitor, IBMX in cultured pancreatic islets. FRF depicted a dose-dependent reversal of all the cytotoxic manifestations except peroxynitrite and NO formation when subjected in-vitro along with STZ. Further scrutinization of FRF for its in-vivo antidiabetic property demonstrated improved glycemic indices and decreased pancreatic β-cell apoptosis.

Conclusions

Overall, the flavonoid mixture has shown to have significant insulin secretogogue, insulinomimetic and cytoprotective effects and can be evaluated for clinical trials as a therapeutant in the management of diabetic manifestations.     

Access to primary health care for Australian young people: service provider perspectives.

BACKGROUND: To adequately address the complex health needs of young people, their access to services, and the quality of services received, must be improved. AIMS: To explore the barriers to service provision for young people and to identify the training needs of primary healthcare service providers in New South Wales (NSW), Australia. DESIGN OF STUDY: A cross-sectional, qualitative study of the perspectives of a range of health service providers. SETTING: A range of primary healthcare organisations across NSW. METHODS: Samples of general practitioners (GPs), youth health workers, youth health coordinators, and community health centre staff were drawn from urban and rural clusters across NSW. Focus groups and interviews were used to identify barriers to service provision and the training needs of service providers. Data were tape recorded, transcribed, and analysed. RESULTS: Barriers to service provision among GPs and community health centre staff included inadequate time, flexibility, skills, and confidence in working with young people, and poor linkages with other relevant services. Training needs included better knowledge of and skills in adolescent health requirements, working with adolescents, and working with other services. Barriers to service provision for youth health workers and coordinators included lack of financial resources and infrastructure. There were few linkages between groups of service providers. CONCLUSION: Models of service provision that allow stronger linkages between service providers, sufficient time for consultation with young people, adequate training and support of health professionals, and flexibility of service provision, including outreach, should be explored and evaluated.     

Users' perspectives of key factors to implementing electronic health records in Canada: a Delphi study

ABSTRACT: BACKGROUND: Interoperable electronic health record (EHR) solutions are currently being implemented in Canada, as in many other countries. Understanding EHR users' perspectives is key to the success of EHR implementation projects. This Delphi study aimed to assess in the Canadian context the applicability, the importance, and the priority of pre-identified factors from a previous mixed-methods systematic review of international literature. METHODS: A three-round Delphi study was held with representatives of 4 Canadian EHR user groups defined as partners of the implementation process who use or are expected to use EHR in their everyday activity. These groups are: non-physician healthcare professionals, health information professionals, managers, and physicians. Four bilingual online questionnaire versions were developed from factors identified by the systematic review. Participants were asked to rate the applicability and the importance of each factor. The main outcome measures were consensus and priority. Consensus was defined a priori as strong (>= 75 %) or moderate (>= 60-74 %) according to user groups' level of agreement on applicability and importance, partial (>= 60 %) when participants agreed only on applicability or importance, or as no consensus (< 60 %). Priority for decision-making was defined as factors with strong consensus with scores of 4 or 5 on a five-point Likert scale for applicability and importance. RESULTS: Three Delphi rounds were completed by 64 participants. Levels of consensus of 100 %, 64 %, 64 %, and 44 % were attained on factors submitted to non-physician healthcare professionals, health information professionals, managers, and physicians, respectively. While agreement between and within user groups varied, key factors were prioritized if they were classified as strong (>= 75 % from questionnaire answers of user groups), for decision-making concerning EHR implementation. The10 factors that were prioritized are perceived usefulness, productivity, motivation, participation of end-users in the implementation strategy, patient and health professional interaction, lack of time and workload, resources availability, management, outcome expectancy, and interoperability. CONCLUSIONS: Amongst all factors influencing EHR implementation identified in a previous systematic review, ten were prioritized through this Delphi study. The varying levels of agreement between and within user groups could mean that users' perspectives of each factor are complex and that each user group has unique professional priorities and roles in the EHR implementation process. As more EHR implementations in Canada are completed it will be possible to corroborate this preliminary result with a larger population of EHR users.     

Unintended adverse consequences of introducing electronic health records in residential aged care homes

PurposeThe aim of this study was to investigate the unintended adverse consequences of introducing electronic health records (EHR) in residential aged care homes (RACHs) and to examine the causes of these unintended adverse consequences.MethodA qualitative interview study was conducted in nine RACHs belonging to three organisations in the Australian Capital Territory (ACT), New South Wales (NSW) and Queensland, Australia. A longitudinal investigation after the implementation of the aged care EHR systems was conducted at two data points: January 2009 to December 2009 and December 2010 to February 2011. Semi-structured interviews were conducted with 110 care staff members identified through convenience sampling, representing all levels of care staff who worked in these facilities. Data analysis was guided by DeLone and McLean Information Systems Success Model, in reference with the previous studies of unintended consequences for the introduction of computerised provider order entry systems in hospitals.ResultsEight categories of unintended adverse consequences emerged from 266 data items mentioned by the interviewees. In descending order of the number and percentage of staff mentioning them, they are: inability/difficulty in data entry and information retrieval, end user resistance to using the system, increased complexity of information management, end user concerns about access, increased documentation burden, the reduction of communication, lack of space to place enough computers in the work place and increasing difficulties in delivering care services. The unintended consequences were caused by the initial conditions, the nature of the EHR system and the way the system was implemented and used by nursing staff members.ConclusionsAlthough the benefits of the EHR systems were obvious, as found by our previous study, introducing EHR systems in RACH can also cause adverse consequences of EHR avoidance, difficulty in access, increased complexity in information management, increased documentation burden, reduction of communication and the risks of lacking care follow-up, which may cause negative effects on aged care services. Further research can focus on investigating how the unintended adverse consequences can be mitigated or eliminated by understanding more about nursing staff's work as well as the information flow in RACH. This will help to improve the design, introduction and management of EHR systems in this setting.     

Barriers and facilitators to HIV testing in primary care among health care providers

PurposeHuman immunodeficiency virus (HIV) is a preventable disease that can have improved outcomes with early diagnosis and treatment. The CDC recommends that HIV testing be incorporated into clinical settings as part of routine medical care.MethodsIndividual, open-ended interviews were conducted with primary care providers and administrators to obtain their views regarding the meaning of routine HIV testing and the barriers and facilitators to implementing routine HIV testing in their respective practices.ResultsMost respondents supported routine HIV testing, although their definitions of roufine varied. Barriers for providers included time and financial constraints to appropriately conduct HIV counseling and testing and inadequate HIV education and training. Facilitators for implementing routine HIV testing included patients' feelings of empowerment and reduced HIV stigma.ConclusionsThe implementation of routine HIV testing in primary care practices appears to be an acceptable public health intervention. Next steps should include efforts to standardize the definition of routine HIV testing and working with primary care settings to better understand and reduce barriers to routine testing.     

Priority setting, justice, and health care: conceptual analysis

In this paper, priority setting in health care is defined as distributional decisions at the individual level involving clear and direct limitation of access to beneficial health care according to some categorical criterion other than the market. The justification of a particular rule of priority setting depends on conceptual issues as well as on the choice of value premises. Especially important is the type of scarcity involved (whether the imbalance between supply and need can be overcome or not) and the concept of justice used or presupposed (for instance, whether the conception of justice emphasizes efficiency or fairness or both). The proposal put forward is that the task of medical ethics is to provide conceptual clarification and value premises relevant to justify rules of priority setting. The actual choice of such rules belongs primarily to the domain of politics.     

Non-visible versus visible haematuria and bladder cancer risk: a study of electronic records in primary care

Background

Diagnosis of bladder cancer relies on investigation of symptoms presented to primary care, notably visible haematuria. The importance of non-visible haematuria has never been estimated.

Aim

To estimate the risk of bladder cancer with non-visible haematuria.

Design and setting

A case–control study using UK electronic primary care medical records, including uncoded data to supplement coded records.

Method

A total of 4915 patients (aged ≥40 years) diagnosed with bladder cancer between January 2000 and December 2009 were selected from the Clinical Practice Research Datalink and matched to 21 718 controls for age, sex, and practice. Variables for visible and non-visible haematuria were derived from coded and uncoded data. Analyses used multivariable conditional logistic regression, followed by estimation of positive predictive values (PPVs) for bladder cancer using Bayes’ theorem.

Results

Non-visible haematuria (coded/uncoded data) was independently associated with bladder cancer: odds ratio (OR) 20 (95% confidence interval [CI] =12 to 33). The PPV of non-visible haematuria was 1.6% (95% CI = 1.2 to 2.1) in those aged ≥60 years and 0.8% (95% CI = 0.1 to 5.6) in 40–59-year-olds. The PPV of visible haematuria was 2.8% (95% CI = 2.5 to 3.1) and 1.2% (95% CI = 0.6 to 2.3) for the same age groups respectively, lower than those calculated using coded data alone. The proportion of records of visible haematuria in coded, rather than uncoded, format was higher in cases than in controls (P<0.002, χ² test). There was no evidence for such differential recording of non-visible haematuria by case/control status (P = 0.78), although, overall, the uncoded format was preferred (P<0.001).

Conclusion

Both non-visible and visible haematuria are associated with bladder cancer, although the visible form confers nearly twice the risk of cancer compared with the non-visible form. GPs’ style of record keeping varies by symptom and possible diagnosis.     

The benefits of introducing electronic health records in residential aged care facilities: A multiple case study

PurposeInformation and communications technology solutions have been introduced into the residential aged care system in order to improve the effectiveness and efficiency of aged care, however to date, the actual benefits have not been systematically analysed. The aim of this study was to identify the benefits of electronic health records (EHR) in residential aged care services and to examine how the benefits have been achieved.MethodA qualitative interview study was conducted in nine residential aged care facilities (RACFs) belonging to three organisations in the Australian Capital Territory (ACT), New South Wales (NSW) and Queensland, Australia. A longitudinal investigation after the implementation of the aged care EHR systems was conducted at two data points: January 2009 to December 2009 and December 2010 to February 2011. Semi-structured interviews were conducted with 110 care staff members selected through theoretical sampling, representing all levels of care staff who worked in those facilities.ResultsThree categories of benefits were perceived by the care staff members according to who gain the benefits: the benefits to individual care staff members, to residents and to the RACFs. The benefits to individual care staff members include an improvement of documentation efficiency, information and knowledge growth as well as empowering the staff; the benefits to residents are an improvement in the quality of individual residents’ health records, the higher quality of care and smoother communication between the residents and aged care staff; the RACFs gain an increased ability to manage information and acquire funding, an increase in their ability to control the care quality and improvements in the working environment and educational benefits. Three factors leading to these benefits were examined: the nature of the aged care EHR systems in comparison with paper-based records; the way the systems were used by the staff and one benefit that could lead to another.ConclusionsIn this study, EHR systems were perceived to have substantial benefits for care staff, residents and the aged care organisations introducing the systems. The benefits were derived from the nature of the aged care EHR systems, staff members’ continuous use of the systems, and one benefit led to the other.     

Confidentiality,privacy, and security of genetic and genomic test information in electronic health records: points to consider

As clinical genetics evolves, and we embark down the path toward more personalized and effective health care, the amount, detail, and complexity of genetic/genomic test information within the electronic health record will increase. This information should be appropriately protected to secure the trust of patients and to support interoperable electronic health information exchange. This article discusses characteristics of genetic/genomic test information, including predictive capability, immutability, and uniqueness, which should be considered when developing policies about information protection. Issues related to “genetic exceptionalism”; i.e., whether genetic/genomic test information should be treated differently from other medical information for purposes of data access and permissible use, are also considered. These discussions can help guide policy that will facilitate the biological and clinical resource development to support the introduction of this information into health care.     

Physician contributions to disparities in HIV/AIDS care: The role of provider perceptions regarding adherence

Racial/ethnic minorities in the United States are disproportionately affected by HIV/AIDS. In addition to having higher rates of HIV/AIDS, minorities with HIV/AIDS have higher mortality rates than others in the United States. Disparities in the care received by minorities living with HIV/AIDS contribute to these higher mortality rates. This article provides a review of HIV/AIDS health care disparities and explores providers’ contributions to these disparities. An important source of provider contribution to disparities appears to be differential prescribing based on perceptions and assumptions that minority patients may have lower adherence to highly active antiretroviral therapy. Literature regarding this topic is reviewed and strategies for reducing disparities are suggested.     

Access to health care for undocumented immigrants: rights and practice

The purpose of this article is to analyse undocumented immigrants' right to access to health care and their access in practice. Undocumented immigrants have a right to equal access to health care. Access to more than emergency health care in Denmark is dependent on immigration status. Medical doctors' duty to treat does not apply to non-emergency health needs, and the options existing in this situation remain ambiguous. However, in practice, undocumented immigrants in Denmark are able to receive more than emergency health care through unofficial networks of health care providers.     

Gynecologic cancer screening and communication with health care providers in women with Lynch syndrome

We evaluated knowledge of gynecologic cancer screening recommendations, screening behaviors, and communication with providers among women with Lynch syndrome (LS). Women aged ≥25 years who were at risk for LS‐associated cancers completed a semi‐structured interview and a questionnaire. Of 74 participants (mean age 40 years), 61% knew the appropriate age to begin screening, 75–80% correctly identified the recommended screening frequency, and 84% reported no previous screening endometrial biopsy. Women initiated discussions with their providers about their LS cancer risks, but many used nonspecific terms or relied on family history. Most were not offered high‐risk screening options. While many women were aware of risk‐appropriate LS screening guidelines, adherence was suboptimal. Improving communication between women and their providers regarding LS‐related gynecologic cancer risk and screening options may help improve adherence.     

Security and privacy in electronic health records: A systematic literature review

ObjectiveTo report the results of a systematic literature review concerning the security and privacy of electronic health record (EHR) systems.Data sourcesOriginal articles written in English found in MEDLINE, ACM Digital Library, Wiley InterScience, IEEE Digital Library, Science@Direct, MetaPress, ERIC, CINAHL and Trip Database.Study selectionOnly those articles dealing with the security and privacy of EHR systems.Data extractionThe extraction of 775 articles using a predefined search string, the outcome of which was reviewed by three authors and checked by a fourth.ResultsA total of 49 articles were selected, of which 26 used standards or regulations related to the privacy and security of EHR data. The most widely used regulations are the Health Insurance Portability and Accountability Act (HIPAA) and the European Data Protection Directive 95/46/EC. We found 23 articles that used symmetric key and/or asymmetric key schemes and 13 articles that employed the pseudo anonymity technique in EHR systems. A total of 11 articles propose the use of a digital signature scheme based on PKI (Public Key Infrastructure) and 13 articles propose a login/password (seven of them combined with a digital certificate or PIN) for authentication. The preferred access control model appears to be Role-Based Access Control (RBAC), since it is used in 27 studies. Ten of these studies discuss who should define the EHR systems’ roles. Eleven studies discuss who should provide access to EHR data: patients or health entities. Sixteen of the articles reviewed indicate that it is necessary to override defined access policies in the case of an emergency. In 25 articles an audit-log of the system is produced. Only four studies mention that system users and/or health staff should be trained in security and privacy.ConclusionsRecent years have witnessed the design of standards and the promulgation of directives concerning security and privacy in EHR systems. However, more work should be done to adopt these regulations and to deploy secure EHR systems.     

Adopting electronic medical records in primary care: lessons learned from health information systems implementation experience in seven countries

The adoption of health information systems is seen world wide as one method to mitigate the widening health care demand and supply gap. The purpose of this review was to identify the current state of knowledge about health information systems adoption in primary care. The goal was to understand factors and influencers affecting implementation outcomes from previous health information systems implementations experiences. A comprehensive systematic literature review of peer reviewed and grey literature was undertaken to identify the current state of knowledge regarding the implementation of health information systems. A total of 6 databases, 27 journal websites, 20 websites from grey sources, 9 websites from medical colleges and professional associations as well as 22 government/commission websites were searched. The searches returned almost 3700 article titles. Eighty-six articles met our inclusion and exclusion criteria.Articles show that systems’ graphical user interface design quality, feature functionality, project management, procurement and users’ previous experience affect implementation outcomes. Implementers had concerns about factors such as privacy, patient safety, provider/patient relations, staff anxiety, time factors, quality of care, finances, efficiency, and liability. The review showed that implementers can insulate the project from such concerns by establishing strong leadership, using project management techniques, establishing standards and training their staff to ensure such risks do not compromise implementation success. The review revealed the concept of socio-technical factors, or “fit” factors, that complicate health information systems deployment. The socio-technical perspective considers how the technical features of a health information system interact with the social features of a health care work environment.The review showed that quality of care, patient safety and provider/patient relations were not, positively or negatively, affected by systems implementation. The fact that no articles were found reviewing the benefits or drawbacks of health information systems accruing to patients should be concern to adopters, payers and jurisdictions. No studies were found that compared how provider-patient interactions in interviews are effected when providers used electronic health information systems as opposed to the paper equivalent. Very little information was available about privacy and liability.