The challenges in making electronic health records accessible to patients

It is becoming increasingly apparent that there is a tension between growing consumer demands for access to information and a healthcare system that may not be prepared to meet these demands. Designing an effective solution for this problem will require a thorough understanding of the barriers that now stand in the way of giving patients electronic access to their health data. This paper reviews the following challenges related to the sharing of electronic health records: cost and security concerns, problems in assigning responsibilities and rights among the various players, liability issues and tensions between flexible access to data and flexible access to physicians.     

Applying requisite imagination to safeguard electronic health record transitions

Over the next decade, many health care organizations (HCOs) will transition from one electronic health record (EHR) to another; some forced by hospital acquisition and others by choice in search of better EHRs. Herein, we apply principles of Requisite Imagination, or the ability to imagine key aspects of the future one is planning, to offer 6 recommendations on how to proactively safeguard these transitions. First, HCOs should implement a proactive leadership structure that values communication. Second, HCOs should implement proactive risk assessment and testing processes. Third, HCOs should anticipate and reduce unwarranted variation in their EHR and clinical processes. Fourth, HCOs should establish a culture of conscious inquiry with routine system monitoring. Fifth, HCOs should foresee and reduce information access problems. Sixth, HCOs should support their workforce through difficult EHR transitions. Proactive approaches using Requisite Imagination principles outlined here can help ensure safe, effective, and economically sound EHR transitions.     

慢性肾脏病出院患者自测健康调查

目的 了解慢性肾脏病出院患者的健康状况。方法 采用自测健康评定量表（SRHMS V 1.0）对125例慢性肾小球肾炎、慢性肾功能衰竭、维持性透析、肾移植术后的出院患者进行现场问卷调查。结果 肾炎组的生理健康明显优于肾衰组、透析组、移植组（P＜0.01）,移植组的社会健康则差于肾炎组、肾衰组（P＜0.05）;而肾衰组、透析组和移植组的生理健康,四组的心理健康,肾炎组、肾衰组和透析组的社会健康则无明显差异;透析组和移植组的自测健康均明显差于肾炎组（P＜0.01）。结论 慢性肾脏病出院患者的自测健康与肾功能受损程度直接相关,慢性肾小球肾炎相对较好,维持性透析和肾移植术后较差。     

Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge

Serious medication errors occur commonly in the period after hospital discharge. Medication reconciliation in the postdischarge ambulatory setting may be one way to reduce the frequency of these errors. The authors describe the design and implementation of a novel tool built into an ambulatory electronic medical record (EMR) to facilitate postdischarge medication reconciliation. The tool compares the preadmission medication list within the ambulatory EMR to the hospital discharge medication list, highlights all changes, and allows the EMR medication list to be easily updated. As might be expected for a novel tool intended for use in a minority of visits, use of the tool was low at first: 20% of applicable patient visits within 30 days of discharge. Clinician outreach, education, and a pop-up reminder succeeded in increasing use to 41% of applicable visits. Review of feedback identified several usability issues that will inform subsequent versions of the tool and provide generalizable lessons for how best to design medication reconciliation tools for this setting.     

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.     

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.     

Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments

ObjectiveDiagnostic errors are major contributors to preventable patient harm. We validated the use of an electronic health record (EHR)-based trigger (e-trigger) to measure missed opportunities in stroke diagnosis in emergency departments (EDs).MethodsUsing two frameworks, the Safer Dx Trigger Tools Framework and the Symptom-disease Pair Analysis of Diagnostic Error Framework, we applied a symptom–disease pair-based e-trigger to identify patients hospitalized for stroke who, in the preceding 30 days, were discharged from the ED with benign headache or dizziness diagnoses. The algorithm was applied to Veteran Affairs National Corporate Data Warehouse on patients seen between 1/1/2016 and 12/31/2017. Trained reviewers evaluated medical records for presence/absence of missed opportunities in stroke diagnosis and stroke-related red-flags, risk factors, neurological examination, and clinical interventions. Reviewers also estimated quality of clinical documentation at the index ED visit.ResultsWe applied the e-trigger to 7,752,326 unique patients and identified 46,931 stroke-related admissions, of which 398 records were flagged as trigger-positive and reviewed. Of these, 124 had missed opportunities (positive predictive value for “missed” = 31.2%), 93 (23.4%) had no missed opportunity (non-missed), 162 (40.7%) were miscoded, and 19 (4.7%) were inconclusive. Reviewer agreement was high (87.3%, Cohen’s kappa = 0.81). Compared to the non-missed group, the missed group had more stroke risk factors (mean 3.2 vs 2.6), red flags (mean 0.5 vs 0.2), and a higher rate of inadequate documentation (66.9% vs 28.0%).ConclusionIn a large national EHR repository, a symptom–disease pair-based e-trigger identified missed diagnoses of stroke with a modest positive predictive value, underscoring the need for chart review validation procedures to identify diagnostic errors in large data sets.     

首次住院精神分裂症患者自动出院原因调查分析

目的了解我院首次住院精神分裂症患者自动出院的原因。方法根据文献资料设计相关因素的调查表,对首次住院精神分裂症患者自动出院原因进行调查,与非自动出院患者进行比较。结果与非自动出院患者相比,精神分裂症患者亚急性病程、患者及家属的文化程度偏低差异有统计学意义(P﹤0.01),而患者的性别、经济状况以及居住地方三个因素差异均无统计学意义(P均﹥0.05)。结论与亚急性病程入院的精神分裂症患者及家属建立良好的医患关系,加强精神卫生知识的沟通,是减少自动出院和提高治疗依从性的有效措施。     

92例住院患者健康素养情况调查

目的了解住院患者的健康素养现状及其在低健康素养情况下通常所做的弥补性行为,为实施适当的健康教育和健康促进策略提供依据。方法在患者住院评估表中增加可以用来识别住院患者是否处于低健康素养状态的三个问题:①"你经常需要别人帮你看医院的各种材料吗?";②"你自己在填写医疗表格时的信心如何?";③"你在学习有关自己疾病的相关知识时,是否经常会遇到理解不了的问题?";以及用来了解患者在低健康素养情况下,通常会做出哪些弥补性行为的问题"你在学习中遇到理解不了的问题时会怎么办?";对92例患者进行问卷调查。应用SPSS 17.0软件进行统计分析。结果①分别有39.1%、44.6%和38.0%的患者在看医学材料、填写医疗表格和学习疾病的相关知识时处于低健康素养状态。其中,老年患者的健康素养水平低于青壮年患者(P<0.01);文化程度越低的患者,健康素养水平越低(P<0.01);不同性别患者之间的健康素养水平差异无统计学意义(P>0.05)。②对"你在学习中遇到理解不了的问题时会怎么办?"问题,患者的回答依次为:问家里人(34.8%);问护士(20.7%);问大夫(14.1%);相信大夫,让签字就签字(9.8%);不懂就不懂,随它去(7.6%);试着自己把问题弄明白(6.5%);通常不会遇到理解不了的问题(5.4%)。结论相当数量的住院患者健康素养水平偏低,尤以老年人和文化程度低的患者为显著。而患者在低健康素养情况下的弥补性行为,可能并不利于患者正确理解和掌握健康信息,对疾病的预后产生积极影响,需引起注意。护士应根据具体情况,采取有效措施,提高患者的健康素养。     

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.     

改良导管切除术成功治疗乳头溢液37例

目的：探讨乳头溢液的手术治疗方法。使手术范围更局限准确,减少复发率。方法：回顾2000年1月至2003年1月37例乳头溢液病人的临床资料和随访结果。结果：37例乳头溢液患者中。除4例乳腺恶性肿瘤外,均接受乳腺病变导管切除及相应部分小叶切除,术中均找到病灶,术后无1例复发。结论：改良导管切除术在治疗乳头良性溢液疾病中是一种损伤小、定位准确、安全可靠的手术方式。     

系统理论在住院患者护理健康教育中的运用与效果

目的 改进住院患者护理健康教育效果.方法 通过系统理论的指导,成立护理健康教育专业委员会,了解教育对象的健康教育需求,提高护士的健康教育能力,规范健康教育的内容指引和流程,制作全方位的健康教育资料和工具,采用适宜的健康教育方法,通过表格式健康教育临床路径实施单落实健康教育,完善住院患者健康教育质量管理和效果评价标准,及时评价健康教育的效果.结果 出院前患者健康教育满意度相对较低,出院患者第三方健康教育满意度总体呈逐渐上升的趋势.结论 系统理论能有效指导住院患者护理健康教育效果的提升,需继续改进患者出院前的健康教育工作.     

授权理论健康教育对急性心肌梗死PCI术患者出院准备度的影响

目的 探讨授权理论健康教育对急性心肌梗死(AMI)患者行经皮冠状动脉介入治疗(PCI)术后出院准备度的影响。方法 根据纳入和排除标准,选取2018年1月至9月因AMI行PCI术的患者92例,随机分为对照组、干预组两组。对于对照组患者实施心内科AMI PCI术常规健康教育;对于干预组患者实施授权理论健康教育。评估两组患者出院准备度的差别。结果 干预组患者出院准备度总分值(93.55±4.21)与对照组患者总分值(89.20±2.44)相比,差异有统计学意义(P＜0.05)。结论 应用授权理论健康模式对AMI PCI术患者干预后,其出院准备度得分高于常规健康教育,值得在临床上推广使用。     

互动式健康教育对长期住院精神病患者康复的影响

目的探讨互动式健康教育模式对长期住院精神病患者康复的影响。方法将100例长期住院精神病患者随机分为观察组（50例）和对照组（50例）。观察组以互动式健康教育方法开展健康教育,对照组施行精神科标准健康教育模式,用自制问卷调查表和护士用住院患者观察量表（NOSIE）分别于教育前和教育8周后评定。结果观察组患者8周末对健康教育知识掌握情况、健康理念形成率高于对照组,NOSIE评分与对照组评分比较差异有统计学意义（P〈0.05）。结论互动式健康教育能促进患者对疾病防治知识的了解,有效改善精神病患者精神病性症状,提高生活质量,促进康复。     

基于J2EE技术的出院后健康管理服务体系的设计与实践

采用LINUX系统的运行环境和JAVA＋ORACLE＋STRUTS的开发框架,设计并开发了一个包括社区双向转诊、复查提醒、健康咨询、健康指导、个人健康档案、会员活动、健康刊物、短信平台、系统管理等功能模块的出院后健康管理服务平台,旨在建立规范有效的公众健康服务体系,提供健康咨询和健康指导等服务,解决患者诊疗前的知识普及、出院后的跟踪服务,力求充分利用有限的医疗资源来达到最大的健康管理效果。     

Evaluation of an electronic health record-supported obesity management protocol implemented in a community health center: a cautionary note

Objective Primary care clinicians are well-positioned to intervene in the obesity epidemic. We studied whether implementation of an obesity intake protocol and electronic health record (EHR) form to guide behavior modification would facilitate identification and management of adult obesity in a Federally Qualified Health Center serving low-income, Hispanic patients.Materials and Methods In three studies, we examined clinician and patient outcomes before and after the addition of the weight management protocol and form. In the Clinician Study, 12 clinicians self-reported obesity management practices. In the Population Study, BMI and order data from 5000 patients and all 40 clinicians in the practice were extracted from the EHR preintervention and postintervention. In the Exposure Study, EHR-documented outcomes for a sub-sample of 46 patients actually exposed to the obesity management form were compared to matched controls.Results Clinicians reported that the intake protocol and form increased their performance of obesity-related assessments and their confidence in managing obesity. However, no improvement in obesity management practices or patient weight-loss was evident in EHR records for the overall clinic population. Further analysis revealed that only 55 patients were exposed to the form. Exposed patients were twice as likely to receive weight-loss counseling following the intervention, as compared to before, and more likely than matched controls. However, their obesity outcomes did not differ.Conclusion Results suggest that an obesity intake protocol and EHR-based weight management form may facilitate clinician weight-loss counseling among those exposed to the form. Significant implementation barriers can limit exposure, however, and need to be addressed.