Use of a Regional Health Information Exchange to Detect Crossover of Patients with MRSA between Urban Hospitals

Background

A significant portion of patients already known to be colonized or infected with Methicillin-Resistant Staphylococcus aureus (MRSA) may not be identified at admission by neighboring hospitals.

Methods

We utilized data from a Regional Health Information Exchange to assess the frequency that patients known to have MRSA at one healthcare system are admitted to a neighboring healthcare system unaware of their MRSA status. We conducted a retrospective, registry trial from January 1999 through January 2006 involving three healthcare systems in central Indianapolis, representing six hospitals.

Results

Over one year, 286 unique patients generated 587 admissions accounting for 4,335 inpatient days where the receiving hospital was not aware of the prior history of MRSA. The patients accounted for an additional 10% of MRSA admissions received by study hospitals over one year and over 3,600 inpatient days without contact isolation.

Conclusions

Information exchange could improve timely identification of known MRSA patients within an urban setting.     

The impact of the electronic medical record on structure,process, and outcomes within primary care: a systematic review of the evidence

Background

The electronic medical record (EMR)/electronic health record (EHR) is becoming an integral component of many primary-care outpatient practices. Before implementing an EMR/EHR system, primary-care practices should have an understanding of the potential benefits and limitations.

Objective

The objective of this study was to systematically review the recent literature around the impact of the EMR/EHR within primary-care outpatient practices.

Materials and methods

Searches of Medline, EMBASE, CINAHL, ABI Inform, and Cochrane Library were conducted to identify articles published between January 1998 and January 2010. The gray literature and reference lists of included articles were also searched. 30 studies met inclusion criteria.

Results and discussion

The EMR/EHR appears to have structural and process benefits, but the impact on clinical outcomes is less clear. Using Donabedian''s framework, five articles focused on the impact on healthcare structure, 21 explored healthcare process issues, and four focused on health-related outcomes.     

The impact of electronic medical records data sources on an adverse drug event quality measure

Objective

To examine the impact of billing and clinical data extracted from an electronic medical record system on the calculation of an adverse drug event (ADE) quality measure approved for use in The Joint Commission''s ORYX program, a mandatory national hospital quality reporting system.

Design

The Child Health Corporation of America''s “Use of Rescue Agents—ADE Trigger” quality measure uses medication billing data contained in the Pediatric Health Information Systems (PHIS) data warehouse to create The Joint Commission-approved quality measure. Using a similar query, we calculated the quality measure using PHIS plus four data sources extracted from our electronic medical record (EMR) system: medications charged, medication orders placed, medication orders with associated charges (orders charged), and medications administered.

Measurements

Inclusion and exclusion criteria were identical for all queries. Denominators and numerators were calculated using the five data sets. The reported quality measure is the ADE rate (numerator/denominator).

Results

Significant differences in denominators, numerators, and rates were calculated from different data sources within a single institution''s EMR. Differences were due to both common clinical practices that may be similar across institutions and unique workflow practices not likely to be present at any other institution. The magnitude of the differences would significantly alter the national comparative ranking of our institution compared to other PHIS institutions.

Conclusions

More detailed clinical information may result in quality measures that are not comparable across institutions due institution-specific workflow, differences that are exposed using EMR-derived data.     

A pilot study to evaluate the diagnostic accuracy of local terminology for malaria screening among children in rural Malawi

Background

Malaria is a serious health problem in Malawi. It is responsible for 43% of all out patient visits and 19% of all deaths occurring to children under five years of age. Rapid diagnosis and appropriate treatment can avert most malaria deaths. However this is not always possible in resource limited settings where functioning laboratories are almost nonexistent.

Methods

This paper assesses the accuracy of local terminology in detecting parasitemia in children using blood smears as the reference standard.

Results

The study observes that there are local terms that can be used as an inexpensive, readily available and easily implementable malaria screening test in Malawian children in rural areas. These terms include “malungo” (official name for malaria), “kutentha thupi” (hot body), “kutsegula m''mimba” (official term for diarrhoea) and “kukhosomola” (coughing). The local terms “malungo” and “kutentha thupi” yielded better results.

Conclusion

Although the local terminology produced results that are less than optimal, the study concludes that the knowledge of sensitivity and specificity of local terminology can be used by local healthcare practitioners to identify children who could benefit from malaria confirmation testing and presumptive treatment. The study, however, cautions that these terms should be used as an entry point to malaria case management as they do not distinguish the severity of the malaria infection and all of them produced a sensitivity of less than 50%.     

Evaluating re-identification risks with respect to the HIPAA privacy rule

Objective

Many healthcare organizations follow data protection policies that specify which patient identifiers must be suppressed to share “de-identified” records. Such policies, however, are often applied without knowledge of the risk of “re-identification”. The goals of this work are: (1) to estimate re-identification risk for data sharing policies of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule; and (2) to evaluate the risk of a specific re-identification attack using voter registration lists.

Measurements

We define several risk metrics: (1) expected number of re-identifications; (2) estimated proportion of a population in a group of size g or less, and (3) monetary cost per re-identification. For each US state, we estimate the risk posed to hypothetical datasets, protected by the HIPAA Safe Harbor and Limited Dataset policies by an attacker with full knowledge of patient identifiers and with limited knowledge in the form of voter registries.

Results

The percentage of a state''s population estimated to be vulnerable to unique re-identification (ie, g=1) when protected via Safe Harbor and Limited Datasets ranges from 0.01% to 0.25% and 10% to 60%, respectively. In the voter attack, this number drops for many states, and for some states is 0%, due to the variable availability of voter registries in the real world. We also find that re-identification cost ranges from $0 to $17 000, further confirming risk variability.

Conclusions

This work illustrates that blanket protection policies, such as Safe Harbor, leave different organizations vulnerable to re-identification at different rates. It provides justification for locally performed re-identification risk estimates prior to sharing data.     

Effects of librarian-provided services in healthcare settings: a systematic review

Objective

To assess the effects of librarian-provided services in healthcare settings on patient, healthcare provider, and researcher outcomes.

Materials and methods

Medline, CINAHL, ERIC, LISA (Library and Information Science Abstracts), and the Cochrane Central Register of Controlled Trials were searched from inception to June 2013. Studies involving librarian-provided services for patients encountering the healthcare system, healthcare providers, or researchers were eligible for inclusion. All librarian-provided services in healthcare settings were considered as an intervention, including hospitals, primary care settings, or public health clinics.

Results

Twenty-five articles fulfilled our eligibility criteria, including 22 primary publications and three companion reports. The majority of studies (15/22 primary publications) examined librarians providing instruction in literature searching to healthcare trainees, and measured literature searching proficiency. Other studies analyzed librarian-provided literature searching services and instruction in question formulation as well as the impact of librarian-provided services on patient length of stay in hospital. No studies were found that investigated librarians providing direct services to researchers or patients in healthcare settings.

Conclusions

Librarian-provided services directed to participants in training programs (eg, students, residents) improve skills in searching the literature to facilitate the integration of research evidence into clinical decision-making. Services provided to clinicians were shown to be effective in saving time for health professionals and providing relevant information for decision-making. Two studies indicated patient length of stay was reduced when clinicians requested literature searches related to a patient''s case.     

Women's groups' perceptions of neonatal and infant health problems in rural Malawi

Aims

To present the perceptions of women in rural Malawi regarding the health problems affecting neonates and infants and to explore the relevance of these perceptions for child health policy and strategy in Malawi.

Methods

Women''s groups in Mchinji district identified newborn and infant health problems (204 groups, 3484 women), prioritised problems they considered most important (204 groups, 3338 women) and recorded these problems on monitoring forms. Qualitative data was obtained through 6 focus-group discussions with the women''s groups and 22 interviews with individuals living in women''s group communities but not attending groups.

Results

Women in Malawi do not define the neonatal period according to any epidemiological definition. In order of importance they identified and prioritised the following problems for newborns and infants: diarrhoea, infection, preterm birth, tetanus, malaria, asphyxia, respiratory tract infection, hypothermia, jaundice, convulsions and malnutrition.

Conclusion

This study suggests that women in rural Malawi collectively have a developed understanding of neonatal and infant health problems. This makes a strong argument for the involvement of lay people in policy and strategy development and also suggests that this capacity, harnessed and strengthened through community mobilisation approaches, has the potential to improve neonatal and infant health and reduce mortality.     

Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings

Objective

To synthesize the literature on clinical decision-support systems'' (CDSS) impact on healthcare practitioner performance and patient outcomes.

Design

Literature search on Medline, Embase, Inspec, Cinahl, Cochrane/Dare and analysis of high-quality systematic reviews (SRs) on CDSS in hospital settings. Two-stage inclusion procedure: (1) selection of publications on predefined inclusion criteria; (2) independent methodological assessment of preincluded SRs by the 11-item measurement tool, AMSTAR. Inclusion of SRs with AMSTAR score 9 or above. SRs were thereafter rated on level of evidence. Each stage was performed by two independent reviewers.

Results

17 out of 35 preincluded SRs were of high methodological quality and further analyzed. Evidence that CDSS significantly impacted practitioner performance was found in 52 out of 91 unique studies of the 16 SRs examining this effect (57%). Only 25 out of 82 unique studies of the 16 SRs reported evidence that CDSS positively impacted patient outcomes (30%).

Conclusions

Few studies have found any benefits on patient outcomes, though many of these have been too small in sample size or too short in time to reveal clinically important effects. There is significant evidence that CDSS can positively impact healthcare providers'' performance with drug ordering and preventive care reminder systems as most clear examples. These outcomes may be explained by the fact that these types of CDSS require a minimum of patient data that are largely available before the advice is (to be) generated: at the time clinicians make the decisions.     

Patients with poorly controlled diabetes in primary care: healthcare clinicians' beliefs and attitudes

Objective

To determine doctors'' and nurses'' attitudes and beliefs about treating patients with type 2 diabetes with less than ideal glycaemic control while receiving maximal oral treatment in primary care.

Design

Focus groups.

Setting

Primary care.

Participants

Four focus groups of 23 GPs and practice nurses.

Results

General practice was thought to be the best setting for managing all patients with type 2 diabetes but there were concerns about a lack of resources and unfamiliarity with starting insulin. Issues around compliance were extensively discussed; the “failing diabetic” had dual meanings of failing glycaemic control and failing compliance and effort by both patient and doctor. Although views about insulin therapy differed, patients were understood to be resistant to starting insulin, representing for them a more serious stage of diabetes, with fears of needles and hypoglycaemia.

Conclusion

The role of diabetes specialist nurses working in primary care will be crucial in managing such patients to improve knowledge, for extra resources, for their experience of insulin use, and to change attitudes.     

“Not all my friends need to know”: a qualitative study of teenage patients,privacy, and social media

Background

The literature describes teenagers as active users of social media, who seem to care about privacy, but who also reveal a considerable amount of personal information. There have been no studies of how they manage personal health information on social media.

Objective

To understand how chronically ill teenage patients manage their privacy on social media sites.

Design

A qualitative study based on a content analysis of semistructured interviews with 20 hospital patients (12–18 years).

Results

Most teenage patients do not disclose their personal health information on social media, even though the study found a pervasive use of Facebook. Facebook is a place to be a “regular”, rather than a sick teenager. It is a place where teenage patients stay up-to-date about their social life—it is not seen as a place to discuss their diagnosis and treatment. The majority of teenage patients don''t use social media to come into contact with others with similar conditions and they don''t use the internet to find health information about their diagnosis.

Conclusions

Social media play an important role in the social life of teenage patients. They enable young patients to be “regular” teenagers. Teenage patients'' online privacy behavior is an expression of their need for self-definition and self-protection.     

Effectiveness of Topic-specific Infobuttons: A Randomized Controlled Trial

Objective

Infobuttons are decision support tools that provide links within electronic medical record systems to relevant content in online information resources. The aim of infobuttons is to help clinicians promptly meet their information needs. The objective of this study was to determine whether infobutton links that direct to specific content topics (“topic links”) are more effective than links that point to general overview content (“nonspecific links”).

Design

Randomized controlled trial with a control and an intervention group. Clinicians in the control group had access to nonspecific links, while those in the intervention group had access to topic links.

Measurements

Infobutton session duration, number of infobutton sessions, session success rate, and the self-reported impact that the infobutton session produced on decision making.

Results

The analysis was performed on 90 subjects and 3,729 infobutton sessions. Subjects in the intervention group spent 17.4% less time seeking for information (35.5 seconds vs. 43 seconds, p = 0.008) than those in the control group. Subjects in the intervention group used infobuttons 20.5% (22 sessions vs. 17.5 sessions, p = 0.21) more often than in the control group, but the difference was not significant. The information seeking success rate was equally high in both groups (89.4% control vs. 87.2% intervention, p = 0.99). Subjects reported a high positive clinical impact (i.e., decision enhancement or knowledge update) in 62% of the sessions.

Limitations

The exclusion of users with a low frequency of infobutton use and the focus on medication-related information needs may limit the generalization of the results. The session outcomes measurement was based on clinicians'' self-assessment and therefore prone to bias.

Conclusion

The results support the hypothesis that topic links are more efficient than nonspecific links regarding the time seeking for information. It is unclear whether the statistical difference demonstrated will result in a clinically significant impact. However, the overall results confirm previous evidence that infobuttons are effective at helping clinicians to answer questions at the point of care and demonstrate a modest incremental change in the efficiency of information delivery for routine users of this tool.     

Association of the dominant hand and needle stick injuries for Healthcare Workers in Taiwan

Background

Healthcare workers face the risk of acquiring blood-borne infections from patients through needle stick injuries. Understanding the factors that are associated with increased risk, for example, the role of the dominant hand, is important so that preventive measures can be focused.

Methods

The EPINet (Exposure Prevention, Information Network-a trade mark of Virginia University) questionnaire was used to collect the data. The EPInet system started 2003 in Taiwan under C-MESH. When healthcare workers sustain sharp injury, they complete the injury report form, and report to infection control personnel, who then transmitted the data to EPINet website monthly.

Results

93.5% of the healthcare workers reported being right handed and only 6.5% reported being left handed. About two-thirds (65%) of the reported injuries were by self, 30% injuries were by others and 5% were reported as injured by unknown.There was an association between the dominant hand injury and the needle stick original HCW user, p<0.0001. There is a significant difference between the dominant hand and the needlestick original HCW user.HCW whose dominant hand was the right hand were most likely at risk to be injured by “others” than “self” or “unknown HCW”; OR≤ 18.39; CI (0.42 ± 2.33).

Conclusion

Needlestick injuries among health care workers in Taiwan continue to pose a serious occupational problem. Historically, prevention has focused on the use of protective wear than assessment of which hand may be at greater risk than the other. There is a greater need to prevent hand injuries as the dominant hand remains the most used and injured in process of patient care.     

The feasibility of automating audit and feedback for ART guideline adherence in Malawi

Objective

To determine the feasibility of using electronic medical record (EMR) data to provide audit and feedback of antiretroviral therapy (ART) clinical guideline adherence to healthcare workers (HCWs) in Malawi.

Materials and methods

We evaluated recommendations from Malawi''s ART guidelines using GuideLine Implementability Appraisal criteria. Recommendations that passed selected criteria were converted into ratio-based performance measures. We queried representative EMR data to determine the feasibility of generating feedback for each performance measure, summed clinical encounters representing each performance measure''s denominator, and then measured the distribution of encounter frequency for individual HCWs across nurse and clinical officer groups.

Results

We analyzed 423 831 encounters in the EMR data and generated automated feedback for 21 recommendations (12%) from Malawi''s ART guidelines. We identified 11 nurse recommendations and eight clinical officer recommendations. Individual nurses and clinical officers had an average of 45 and 59 encounters per month, per recommendation, respectively. Another 37 recommendations (21%) would support audit and feedback if additional routine EMR data are captured and temporal constraints are modeled.

Discussion

It appears feasible to implement automated guideline adherence feedback that could potentially improve HCW performance and supervision. Feedback reports may support workplace learning by increasing HCWs'' opportunities to reflect on their performance.

Conclusion

A moderate number of recommendations from Malawi''s ART guidelines can be used to generate automated guideline adherence feedback using existing EMR data. Further study is needed to determine the receptivity of HCWs to peer comparison feedback and barriers to implementation of automated audit and feedback in low-resource settings.     

Information seeking and social support in online health communities: impact on patients' perceived empathy

Objective

Many healthcare organizations (HCOs) including Kaiser Permanente, Johns Hopkins, Cleveland Medical Center, and MD Anderson Cancer Center, provide access to online health communities as part of their overall patient support services. The key objective in establishing and running these online health communities is to offer empathic support to patients. Patients'' perceived empathy is considered to be critical in patient recovery, specifically, by enhancing patient''s compliance with treatment protocols and the pace of healing. Most online health communities are characterized by two main functions: informational support and social support. This study examines the relative impact of these two distinct functions—that is, as an information seeking forum and as a social support forum—on patients'' perceived empathy in online health communities.

Design

This study tests the impact of two variables that reflect the above functions of online health communities—information seeking effectiveness and perceived social support—on perceived empathy. The model also incorporates the potential moderating effect of homophily on these relationships.

Measurements

A web-based survey was used to collect data from members of the online health communities provided by three major healthcare centers. A regression technique was used to analyze the data to test the hypotheses.

Results

The study finds that it is the information seeking effectiveness rather than the social support which affects patient''s perceived empathy in online health communities run by HCOs. The results indicate that HCOs that provide online health communities for their patients need to focus more on developing tools that will make information seeking more effective and efficient.     

Effects of personal identifier resynthesis on clinical text de-identification

Objective

De-identified medical records are critical to biomedical research. Text de-identification software exists, including “resynthesis” components that replace real identifiers with synthetic identifiers. The goal of this research is to evaluate the effectiveness and examine possible bias introduced by resynthesis on de-identification software.

Design

We evaluated the open-source MITRE Identification Scrubber Toolkit, which includes a resynthesis capability, with clinical text from Vanderbilt University Medical Center patient records. We investigated four record classes from over 500 patients'' files, including laboratory reports, medication orders, discharge summaries and clinical notes. We trained and tested the de-identification tool on real and resynthesized records.

Measurements

We measured performance in terms of precision, recall, F-measure and accuracy for the detection of protected health identifiers as designated by the HIPAA Safe Harbor Rule.

Results

The de-identification tool was trained and tested on a collection of real and resynthesized Vanderbilt records. Results for training and testing on the real records were 0.990 accuracy and 0.960 F-measure. The results improved when trained and tested on resynthesized records with 0.998 accuracy and 0.980 F-measure but deteriorated moderately when trained on real records and tested on resynthesized records with 0.989 accuracy 0.862 F-measure. Moreover, the results declined significantly when trained on resynthesized records and tested on real records with 0.942 accuracy and 0.728 F-measure.

Conclusion

The de-identification tool achieves high accuracy when training and test sets are homogeneous (ie, both real or resynthesized records). The resynthesis component regularizes the data to make them less “realistic,” resulting in loss of performance particularly when training on resynthesized data and testing on real data.     

From web search to healthcare utilization: privacy-sensitive studies from mobile data

Objective

We explore relationships between health information seeking activities and engagement with healthcare professionals via a privacy-sensitive analysis of geo-tagged data from mobile devices.

Materials and methods

We analyze logs of mobile interaction data stripped of individually identifiable information and location data. The data analyzed consist of time-stamped search queries and distances to medical care centers. We examine search activity that precedes the observation of salient evidence of healthcare utilization (EHU) (ie, data suggesting that the searcher is using healthcare resources), in our case taken as queries occurring at or near medical facilities.

Results

We show that the time between symptom searches and observation of salient evidence of seeking healthcare utilization depends on the acuity of symptoms. We construct statistical models that make predictions of forthcoming EHU based on observations about the current search session, prior medical search activities, and prior EHU. The predictive accuracy of the models varies (65%–90%) depending on the features used and the timeframe of the analysis, which we explore via a sensitivity analysis.

Discussion

We provide a privacy-sensitive analysis that can be used to generate insights about the pursuit of health information and healthcare. The findings demonstrate how large-scale studies of mobile devices can provide insights on how concerns about symptomatology lead to the pursuit of professional care.

Conclusion

We present new methods for the analysis of mobile logs and describe a study that provides evidence about how people transition from mobile searches on symptoms and diseases to the pursuit of healthcare in the world.     

A Framework for evaluating the costs, effort, and value of nationwide health information exchange

Objective

The nationwide health information network (NHIN) has been proposed to securely link community and state health information exchange (HIE) entities to create a national, interoperable network for sharing healthcare data in the USA. This paper describes a framework for evaluating the costs, effort, and value of nationwide data exchange as the NHIN moves toward a production state. The paper further presents the results of an initial assessment of the framework by those engaged in HIE activities.

Design

Using a literature review and knowledge gained from active NHIN technology and policy development, the authors constructed a framework for evaluating the costs, effort, and value of data exchange between an HIE entity and the NHIN.

Measurement

An online survey was used to assess the perceived usefulness of the metrics in the framework among HIE professionals and researchers.

Results

The framework is organized into five broad categories: implementation; technology; policy; data; and value. Each category enumerates a variety of measures and measure types. Survey respondents generally indicated the framework contained useful measures for current and future use in HIE and NHIN evaluation. Answers varied slightly based on a respondent''s participation in active development of NHIN components.

Conclusion

The proposed framework supports efforts to measure the costs, effort, and value associated with nationwide data exchange. Collecting longitudinal data along the NHIN''s path to production should help with the development of an evidence base that will drive adoption, create value, and stimulate further investment in nationwide data exchange.     

The Omaha System: a systematic review of the recent literature

Background

The Omaha System (OS) is one of the oldest of the American Nurses Association recognized standardized terminologies describing and measuring the impact of healthcare services. This systematic review presents the state of science on the use of the OS in practice, research, and education.

Aims

(1) To identify, describe and evaluate the publications on the OS between 2004 and 2011, (2) to identify major trends in the use of the OS in research, practice, and education, and (3) to suggest areas for future research.

Methods

Systematic search in the largest online healthcare databases (PUBMED, CINAHL, Scopus, PsycINFO, Ovid) from 2004 to 2011. Methodological quality of the reviewed research studies was evaluated.

Results

56 publications on the OS were identified and analyzed. The methodological quality of the reviewed research studies was relatively high. Over time, publications’ focus shifted from describing clients’ problems toward outcomes research. There was an increasing application of advanced statistical methods and a significant portion of authors focused on classification and interoperability research. There was an increasing body of international literature on the OS. Little research focused on the theoretical aspects of the OS, the effective use of the OS in education, or cultural adaptations of the OS outside the USA.

Conclusions

The OS has a high potential to provide meaningful and high quality information about complex healthcare services. Further research on the OS should focus on its applicability in healthcare education, theoretical underpinnings and international validity. Researchers analyzing the OS data should address how they attempted to mitigate the effects of missing data in analyzing their results and clearly present the limitations of their studies.     

Impact of gastro-oesophageal reflux disease on work productivity despite therapy with proton pump inhibitors in Germany

Background

Gastro-oesophageal reflux disease (GERD) is a common disorder with consequences for the patient''s health-related quality of life (HRQoL). In Germany, few data are available on the impact of GERD on work-related productivity.

Aim

To study the impact of GERD on work productivity despite proton pump inhibitor (PPI) therapy and the association between productivity and symptom duration, severity, and HRQoL.

Methods

Retrospective data from randomly selected patients with chronic GERD symptoms, treated by office-based general practitioners or general internists with routine clinical care, were analyzed together with information from self-administered instruments assessing work productivity (WPAI-GERD), symptoms (RDQ), and HRQoL (QOLRAD).

Results

Reduced productivity was reported by 152 of 249 patients (61.0%), although 89.5% of them were treated with PPI. The reduction in work productivity was 18.5% in all patients and 30.3% in those with reduced productivity. Patients with impaired productivity showed a significantly lower HRQoL and more-severe symptoms of reflux disease. In all patients, the mean sick leave attributable to reflux symptoms was 0.6 hours in the previous seven days and 1.4 work days in the previous three months.

Conclusion

GERD has a substantial impact on work productivity in Germany, even in patients receiving routine clinical care and PPI therapy.