A global travelers' electronic health record template standard for personal health records

Tourism as well as international business travel creates health risks for individuals and populations both in host societies and home countries. One strategy to reduce health-related risks to travelers is to provide travelers and relevant caregivers timely, ongoing access to their own health information. Many websites offer health advice for travelers. For example, the WHO and US Department of State offer up-to-date health information about countries relevant to travel. However, little has been done to assure travelers that their medical information is available at the right place and time when the need might arise. Applications of Information and Communication Technology (ICT) utilizing mobile phones for health management are promising tools both for the delivery of healthcare services and the promotion of personal health. This paper describes the project developed by international informaticians under the umbrella of the International Medical Informatics Association. A template capable of becoming an international standard is proposed. This application is available free to anyone who is interested. Furthermore, its source code is made open.     

Patient-initiated electronic health record amendment requests

Background and objective

Providing patients access to their medical records offers many potential benefits including identification and correction of errors. The process by which patients ask for changes to be made to their records is called an ‘amendment request’. Little is known about the nature of such amendment requests and whether they result in modifications to the chart.

Methods

We conducted a qualitative content analysis of all patient-initiated amendment requests that our institution received over a 7-year period. Recurring themes were identified along three analytic dimensions: (1) clinical/documentation area, (2) patient motivation for making the request, and (3) outcome of the request.

Results

The dataset consisted of 818 distinct requests submitted by 181 patients. The majority of these requests (n=636, 77.8%) were made to rectify incorrect information and 49.7% of all requests were ultimately approved. In 6.6% of the requests, patients wanted valid information removed from their record, 27.8% of which were approved. Among all of the patients requesting a copy of their chart, only a very small percentage (approximately 0.2%) submitted an amendment request.

Conclusions

The low number of amendment requests may be due to inadequate awareness by patients about how to make changes to their records. To make this approach effective, it will be important to inform patients of their right to view and amend records and about the process for doing so. Increasing patient access to medical records could encourage patient participation in improving the accuracy of medical records; however, caution should be used.     

Minimizing electronic health record patient-note mismatches

We measured the prevalence (or rate) of patient-note mismatches (clinical notes judged to pertain to another patient) in the electronic medical record. The rate ranged from 0.5% (95% CI 0.2% to 1.7%) before a pop-up window intervention to 0.3% (95% CI 0.1% to 1.1%) after the intervention. Clinicians discovered patient-note mismatches in 0.05–0.03% of notes, or about 10% of actual mismatches. The reduction in rates after the intervention was statistically significant. Therefore, while the patient-note mismatch rate is low compared to published rates of other documentation errors, it can be further reduced by the design of the user interface.     

Optimizing the electronic health record: An inpatient sprint addresses provider burnout and improves electronic health record satisfaction

ObjectiveWe sought reduce electronic health record (EHR) burden on inpatient clinicians with a 2-week EHR optimization sprint.Materials and MethodsA team led by physician informaticists worked with 19 advanced practice providers (APPs) in 1 specialty unit. Over 2 weeks, the team delivered 21 EHR changes, and provided 39 one-on-one training sessions to APPs, with an average of 2.8 hours per provider. We measured Net Promoter Score, thriving metrics, and time spent in the EHR based on user log data.ResultsOf the 19 APPs, 18 completed 2 or more sessions. The EHR Net Promoter Score increased from 6 to 60 postsprint (1.0; 95% confidence interval, 0.3-1.8; P = .01). The NPS for the Sprint itself was 93, a very high rating. The 3-axis emotional thriving, emotional recovery, and emotional exhaustion metrics did not show a significant change. By user log data, time spent in the EHR did not show a significant decrease; however, 40% of the APPs responded that they spent less time in the EHR.ConclusionsThis inpatient sprint improved satisfaction with the EHR.     

Quantifying clinical narrative redundancy in an electronic health record

Objective

Although electronic notes have advantages compared to handwritten notes, they take longer to write and promote information redundancy in electronic health records (EHRs). We sought to quantify redundancy in clinical documentation by studying collections of physician notes in an EHR.

Design and methods

We implemented a retrospective design to gather all electronic admission, progress, resident signout and discharge summary notes written during 100 randomly selected patient admissions within a 6 month period. We modified and applied a Levenshtein edit-distance algorithm to align and compare the documents written for each of the 100 admissions. We then identified and measured the amount of text duplicated from previous notes. Finally, we manually reviewed the content that was conserved between note types in a subsample of notes.

Measurements

We measured the amount of new information in a document, which was calculated as the number of words that did not match with previous documents divided by the length, in words, of the document. Results are reported as the percentage of information in a document that had been duplicated from previously written documents.

Results

Signout and progress notes proved to be particularly redundant, with an average of 78% and 54% information duplicated from previous documents respectively. There was also significant information duplication between document types (eg, from an admission note to a progress note).

Conclusion

The study established the feasibility of exploring redundancy in the narrative record with a known sequence alignment algorithm used frequently in the field of bioinformatics. The findings provide a foundation for studying the usefulness and risks of redundancy in the EHR.     

Impact of a web-based personally controlled health management system on influenza vaccination and health services utilization rates: a randomized controlled trial

Objective

To assess the impact of a web-based personally controlled health management system (PCHMS) on the uptake of seasonal influenza vaccine and primary care service utilization among university students and staff.

Materials and methods

A PCHMS called Healthy.me was developed and evaluated in a 2010 CONSORT-compliant two-group (6-month waitlist vs PCHMS) parallel randomized controlled trial (RCT) (allocation ratio 1:1). The PCHMS integrated an untethered personal health record with consumer care pathways, social forums, and messaging links with a health service provider.

Results

742 university students and staff met inclusion criteria and were randomized to a 6-month waitlist (n=372) or the PCHMS (n=370). Amongst the 470 participants eligible for primary analysis, PCHMS users were 6.7% (95% CI: 1.46 to 12.30) more likely than the waitlist to receive an influenza vaccine (waitlist: 4.9% (12/246, 95% CI 2.8 to 8.3) vs PCHMS: 11.6% (26/224, 95% CI 8.0 to 16.5); χ²=7.1, p=0.008). PCHMS participants were also 11.6% (95% CI 3.6 to 19.5) more likely to visit the health service provider (waitlist: 17.9% (44/246, 95% CI 13.6 to 23.2) vs PCHMS: 29.5% (66/224, 95% CI: 23.9 to 35.7); χ²=8.8, p=0.003). A dose–response effect was detected, where greater use of the PCHMS was associated with higher rates of vaccination (p=0.001) and health service provider visits (p=0.003).

Discussion

PCHMS can significantly increase consumer participation in preventive health activities, such as influenza vaccination.

Conclusions

Integrating a PCHMS into routine health service delivery systems appears to be an effective mechanism for enhancing consumer engagement in preventive health measures.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12610000386033. http://www.anzctr.org.au/trial_view.aspx?id=335463.     

Visualizing collaborative electronic health record usage for hospitalized patients with heart failure

Objective To visualize and describe collaborative electronic health record (EHR) usage for hospitalized patients with heart failure.Materials and methods We identified records of patients with heart failure and all associated healthcare provider record usage through queries of the Northwestern Medicine Enterprise Data Warehouse. We constructed a network by equating access and updates of a patient’s EHR to a provider-patient interaction. We then considered shared patient record access as the basis for a second network that we termed the provider collaboration network. We calculated network statistics, the modularity of provider interactions, and provider cliques.Results We identified 548 patient records accessed by 5113 healthcare providers in 2012. The provider collaboration network had 1504 nodes and 83 998 edges. We identified 7 major provider collaboration modules. Average clique size was 87.9 providers. We used a graph database to demonstrate an ad hoc query of our provider-patient network.Discussion Our analysis suggests a large number of healthcare providers across a wide variety of professions access records of patients with heart failure during their hospital stay. This shared record access tends to take place not only in a pairwise manner but also among large groups of providers.Conclusion EHRs encode valuable interactions, implicitly or explicitly, between patients and providers. Network analysis provided strong evidence of multidisciplinary record access of patients with heart failure across teams of 100+ providers. Further investigation may lead to clearer understanding of how record access information can be used to strategically guide care coordination for patients hospitalized for heart failure.     

电子病案的应用与管理初探

随着信息技术的发展,电子病案(Electronic medical record,EMR)施成为现实。本文探讨了电子病案的基本概念其应用 有利于病案资源共享,提高工作效率和保持病案完整对电子病案应用中存在的标准化和法律等问题进行了阐述。     

Using electronic health record alerts to provide public health situational awareness to clinicians

Alerting providers to public health situations requires timeliness and context-relevance, both lacking in current systems. Incorporating decision support tools into electronic health records may provide a way to deploy public health alerts to clinicians at the point of care. A timely process for responding to Health Alert Network messages sent by the New York City Department of Health and Mental Hygiene was developed by a network of community health centers. Alerts with order sets and recommended actions were created to notify primary care providers of local disease outbreaks. The process, effect, and lessons learned from alerts for Legionella, toxogenic E coli, and measles outbreaks are described. Electronic alerts have the potential to improve management of diseases during an outbreak, including appropriate laboratory testing, management guidance, and diagnostic assistance as well as to enhance bi-directional data exchange between clinical and public health organizations.     

A preliminary look at duplicate testing associated with lack of electronic health record interoperability for transferred patients

Duplication of medical testing results in a financial burden to the healthcare system. Authors undertook a retrospective review of duplicate testing on patients receiving coordinated care across two institutions, each with its own electronic medical record system. In order to determine whether duplicate testing occurred and if such testing was clinically indicated, authors analyzed records of 85 patients transferred from one site to the other between January 1, 2006 and December 31, 2007. Duplication of testing (repeat within 12 hours) was found in 32% of the cases examined; 20% of cases had at least one duplicate test not clinically indicated. While previous studies document that inaccessibility of paper records leads to duplicate testing when patients are transferred between care facilities, the current study suggests that incomplete electronic record transfer among incompatible electronic medical record systems can also lead to potentially costly duplicate testing behaviors. The authors believe that interoperable systems with integrated decision support could assist in minimizing duplication of testing at time of patient transfers.     

Measures of electronic health record use in outpatient settings across vendors

Electronic health record (EHR) log data capture clinical workflows and are a rich source of information to understand variation in practice patterns. Variation in how EHRs are used to document and support care delivery is associated with clinical and operational outcomes, including measures of provider well-being and burnout. Standardized measures that describe EHR use would facilitate generalizability and cross-institution, cross-vendor research. Here, we describe the current state of outpatient EHR use measures offered by various EHR vendors, guided by our prior conceptual work that proposed seven core measures to describe EHR use. We evaluate these measures and other reporting options provided by vendors for maturity and similarity to previously proposed standardized measures. Working toward improved standardization of EHR use measures can enable and accelerate high-impact research on physician burnout and job satisfaction as well as organizational efficiency and patient health.     

Factors associated with difficult electronic health record implementation in office practice

Little is known about physicians' perception of the ease or difficulty of implementing electronic health records (EHR). This study identified factors related to the perceived difficulty of implementing EHR. 163 physicians completed surveys before and after the implementation of EHR in an externally funded pilot program in three Massachusetts communities. Ordinal hierarchical logistic regression was used to identify baseline factors that correlated with physicians' report of difficulty with EHR implementation. Compared with physicians with ownership stake in their practices, physician employees were less likely to describe EHR implementation as difficult (adjusted OR 0.5, 95% CI 0.3 to 1.0). Physicians who perceived their staff to be innovative were also less likely to view EHR implementation as difficult (adjusted OR 0.4, 95% CI 0.2 to 0.8). Physicians who own their practice may need more external support for EHR implementation than those who do not. Innovative clinical support staff may ease the EHR implementation process and contribute to its success.     

Misdiagnosis: Burnout,moral injury,and implications for the electronic health record

Burnout is a long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment. Burnout in clinicians is receiving significant attention. Some have proposed that clinicians are experiencing symptoms of moral injury, defined as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Current efforts to improve the electronic health record (EHR) have focused on improving the user experience to reduce burden that has been identified as a contributing factor to provider burnout. However, if EHRs are contributing to moral injury, improvements to user experience will not eliminate the effects on providers. Current research has not evaluated the risk for moral injury resulting from the use of EHRs. This Perspective reviews the differences between burnout and moral injury, discusses the implications for clinicians using EHRs, and highlights the need for research to better define the problem.     

Assessing hospital electronic health record vendor performance across publicly reported quality measures

ObjectiveLittle is known regarding variation among electronic health record (EHR) vendors in quality performance. This issue is compounded by selection effects in which high-quality hospitals coalesce to a subset of market leading vendors. We measured hospital performance, stratified by EHR vendor, across 4 quality metrics.Materials and MethodsWe used data on 1272 hospitals in 2018 across 4 quality measures: Leapfrog Computerized Provider Order Entry/EHR Evaluation, Centers for Medicare and Medicaid Services Hospital Compare Star Ratings, Hospital-Acquired Condition (HAC) score, and Hospital Readmission Reduction Program (HRRP) ratio. We examined score distributions and used multivariable regression to evaluate the association between vendor and score, recovering partial R² to assess the proportion of quality variation explained by vendor.ResultsWe found significant variation across and within EHR vendors. The largest vendor, vendor A, had the highest mean score on the Leapfrog Computerized Provider Order Entry/EHR Evaluation and HRRP ratio, vendor G had the highest Hospital Compare score, and vendor F had the highest HAC score. In adjusted models, no vendor was significantly associated with higher performance on more than 2 measures. EHR vendor explained between 1.2% (HAC) and 7.6 (HRRP) of the variation in quality performance.DiscussionNo EHR vendor was associated with higher quality across all measures, and the 2 largest vendors were not associated with the highest scores. Only a small fraction of quality variation was explained by EHR vendor choice.ConclusionsTop performance on quality measures can be achieved with any EHR vendor; much of quality performance is driven by the hospital and how it uses the EHR.     

Factors associated with nurse well-being in relation to electronic health record use: A systematic review

ObjectiveAlthough nurses comprise the largest group of health professionals and electronic health record (EHR) user base, it is unclear how EHR use has affected nurse well-being. This systematic review assesses the multivariable (ie, organizational, nurse, and health information technology [IT]) factors associated with EHR-related nurse well-being and identifies potential improvements recommended by frontline nurses.Materials and MethodsWe searched MEDLINE, Embase, CINAHL, PsycINFO, ProQuest, and Web of Science for literature reporting on EHR use, nurses, and well-being. A quality appraisal was conducted using a previously developed tool.ResultsOf 4583 articles, 12 met inclusion criteria. Two-thirds of the studies were deemed to have a moderate or low risk of bias. Overall, the studies primarily focused on nurse- and IT-level factors, with 1 study examining organizational characteristics. That study found worse nurse well-being was associated with EHRs compared with paper charts. Studies on nurse-level factors suggest that personal digital literacy is one modifiable factor to improving well-being. Additionally, EHRs with integrated displays were associated with improved well-being. Recommendations for improving EHRs suggested IT-, organization-, and policy-level solutions to address the complex nature of EHR-related nurse well-being.ConclusionsThe overarching finding from this synthesis reveals a critical need for multifaceted interventions that better organize, manage, and display information for clinicians to facilitate decision making. Our study also suggests that nurses have valuable insight into ways to reduce EHR-related burden. Future research is needed to test multicomponent interventions that address these complex factors and use participatory approaches to engage nurses in intervention development.