The impact of electronic health record systems on clinical documentation times: A systematic review

BackgroundEffective management of hospital staff time is crucial to quality patient care. Recent years have seen widespread implementation of electronic health record (EHR) systems but the effect of this on documentation time is unknown. This review compares time spent on documentation tasks by hospital staff (physicians, nurses and interns) before and after EHR implementation.MethodsA systematic search identified 8153 potentially relevant citations. Studies examining proportion of total workload spent on documentation with ≥40 h of staff observation time were included. Meta-analysis was performed for physicians, nurses and interns comparing pre- and post-EHR results. Studies were weighted by person-hours observation time.ResultsTwenty-eight studies met selection criteria. Seventeen were pre-EHR, nine post-EHR and two examined both periods. With implementation of EHR, physicians’ documentation time increased from 16% (95% confidence interval (CI) 11–22%) to 28% (95% CI 19–37%), nurses from 9% (95% CI 6–12%) to 23% (95% CI 15–32%) and interns from 20% (95% CI 7–32%) to 26% (95% CI 10–42%).ConclusionsThere is a lack of long-term follow-up on the effects of EHR implementation. Initial adjustment to EHR appears to increase documentation time but there is some evidence that as staff become more familiar with the system, it may ultimately improve work flow.     

Research evidence on strategies enabling integration of electronic health records in the health care systems of low‐ and middle‐income countries: A literature review

Integration of electronic health records (EHRs) in the national health care systems of low‐ and middle‐income countries (LMICs) is vital for achieving the United Nations Sustainable Development Goal of ensuring healthy lives and promoting well‐being for all people of all ages. National EHR systems are increasing, but mostly in developed countries. Besides, there is limited research evidence on successful strategies for ensuring integration of national EHRs in the health care systems of LMICs. To fill this evidence gap, a comprehensive survey of literature was conducted using scientific electronic databases—PubMed, SCOPUS, Web of Science, and Global Health—and consultations with international experts. The review highlights the lack of evidence on strategies for integrating EHR systems, although there was ample evidence on implementation challenges and relevance of EHRs to vertical disease programs such as HIV. The findings describe the narrow focus of EHR implementation, the prominence of vertical disease programs in EHR adoption, testing of theoretical and conceptual models for EHR implementation and success, and strategies for EHR implementation. The review findings are further amplified through examples of EHR implementation in Sierra Leone, Malawi, and India. Unless evidence‐based strategies are identified and applied, integration of national EHRs in the health care systems of LMICs is difficult.     

Impact of electronic health record clinical decision support on diabetes care: a randomized trial

PURPOSE We wanted to assess the impact of an electronic health record–based diabetes clinical decision support system on control of hemoglobin A_1c (glycated hemoglobin), blood pressure, and low-density lipoprotein (LDL) cholesterol levels in adults with diabetes.METHODS We conducted a clinic-randomized trial conducted from October 2006 to May 2007 in Minnesota. Included were 11 clinics with 41 consenting primary care physicians and the physicians’ 2,556 patients with diabetes. Patients were randomized either to receive or not to receive an electronic health record (EHR)–based clinical decision support system designed to improve care for those patients whose hemoglobin A_1c, blood pressure, or LDL cholesterol levels were higher than goal at any office visit. Analysis used general and generalized linear mixed models with repeated time measurements to accommodate the nested data structure.RESULTS The intervention group physicians used the EHR-based decision support system at 62.6% of all office visits made by adults with diabetes. The intervention group diabetes patients had significantly better hemoglobin A_1c (intervention effect −0.26%; 95% confidence interval, −0.06% to −0.47%; P=.01), and better maintenance of systolic blood pressure control (80.2% vs 75.1%, P=.03) and borderline better maintenance of diastolic blood pressure control (85.6% vs 81.7%, P =.07), but not improved low-density lipoprotein cholesterol levels (P = .62) than patients of physicians randomized to the control arm of the study. Among intervention group physicians, 94% were satisfied or very satisfied with the intervention, and moderate use of the support system persisted for more than 1 year after feedback and incentives to encourage its use were discontinued.CONCLUSIONS EHR-based diabetes clinical decision support significantly improved glucose control and some aspects of blood pressure control in adults with type 2 diabetes.     

Quality and integration of public health information systems: A systematic review focused on immunization and vital records systems

Objectives:

Public health professionals rely on quantitative data for the daily practice of public health as well as organizational decision making and planning. However, several factors work against effective data sharing among public health agencies in the US. This review characterizes the reported barriers and enablers of effective use of public health IS from an informatics perspective.

Methods:

A systematic review of the English language literature for 2005 to 2011 followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format. The review focused on immunization information systems (IIS) and vital records information systems (VRIS). Systems were described according to the structural aspects of IS integration and data quality.

Results:

Articles describing IIS documented issues pertaining to the distribution of the system, the autonomy of the data providers, the heterogeneous nature of information sharing as well as the quality of the data. Articles describing VRIS were focused much more heavily on data quality, particularly whether or not the data were free from errors.

Conclusions:

For state and local practitioners to effectively utilize data, public health IS will have to overcome the challenges posed by a large number of autonomous data providers utilizing a variety of technologies.     

Migrating to electronic health record systems: A comparative study between the United States and the United Kingdom

The goal of this research is to compare the healthcare information technology (HIT)-related policies and infrastructures of two very differently-run countries: The United States (US) that owns the largest private healthcare system in the world, and the United Kingdom (UK) that has the largest public healthcare system worldwide. The paper specifically focuses on the differences between the two countries’ adoption of electronic healthcare record (EHR) systems, and their efforts toward interoperability, healthcare information security and privacy, and patient safety. Both authors on the paper are professionals in the HIT field and have firsthand experience designing and implementing electronic health record (EHR) systems. As a result, they both have a real-world grasp of HIT economics and the pressure of regulatory compliance. To complement their combined expertise and insight, the authors thoroughly reviewed the peer-reviewed and grey literature on healthcare policy. The paper’s findings suggest that although EHR implementation and adoption are on the rise in the US and the UK alike, both countries are facing considerable hurdles in executing their vision of establishing their respective nationwide EHR systems. To improve patient health and ensure patient safety, interoperability standards that enable seamless communication amongst differing healthcare systems and proper security and privacy regulations for data collection, data handling, and data sharing are paramount.     

Envisioning a learning health care system: the electronic primary care research network, a case study

PURPOSE

The learning health care system refers to the cycle of turning health care data into knowledge, translating that knowledge into practice, and creating new data by means of advanced information technology. The electronic Primary Care Research Network (ePCRN) was a project, funded by the US National Institutes of Health, with the aim to facilitate clinical research using primary care electronic health records (EHRs).

METHODS

We identified the requirements necessary to deliver clinical studies via a distributed electronic network linked to EHRs. After we explored a variety of informatics solutions, we constructed a functional prototype of the software. We then explored the barriers to adoption of the prototype software within US practice-based research networks.

RESULTS

We developed a system to assist in the identification of eligible cohorts from EHR data. To preserve privacy, counts and flagging were performed remotely, and no data were transferred out of the EHR. A lack of batch export facilities from EHR systems and ambiguities in the coding of clinical data, such as blood pressure, have so far prevented a full-scale deployment. We created an international consortium and a model for sharing further ePCRN development across a variety of ongoing projects in the United States and Europe.

CONCLUSIONS

A means of accessing health care data for research is not sufficient in itself to deliver a learning health care system. EHR systems need to use sophisticated tools to capture and preserve rich clinical context in coded data, and business models need to be developed that incentivize all stakeholders from clinicians to vendors to participate in the system.     

从循证公共卫生看流行病学研究证据生产现状

  目的  以Cochrane系统评价为例,分析公共卫生领域高级别证据的流行病学和描述性特征,为公共卫生循证决策提供参考依据。  方法  于2018年4月30日检索Cochrane library数据库收集公共卫生领域相关的Cochrane系统评价,应用EndNote X7、Excel 2013和Ucinet 6.0软件对纳入的文献进行筛选管理和数据分析。  结果  初检获得112篇文献,依据纳入排除标准筛选最终纳入69篇文献,其中高质量33篇、中等质量34篇;发表年份为2008 — 2018年,其中2010年发表文献最多（14篇,20.3 %）,2014年发表文献最少（2篇,2.9 %）;通讯作者主要来自英国（28篇,40.6 %）、澳大利亚（12篇,17.4 %）和美国（9篇,13.0 %）,仅5名中国学者以合作者身份参与研究;研究主题以“预防伤害”（22篇,31.9 %）和 “预防道路交通伤害”（18篇,26.1 %）为主;纳入研究设计主要包括随机对照试验（58篇,84.1 %）、临床对照试验/非随机和半随机对照试验（26篇,37.7 %）、前后对照试验（32篇,46.4 %）和间断地时间序列研究（19篇,27.5 %）;关键词社会网络图显示,“Intervention”、“Prevention”、“Program”、“Injury”、“Education”、“Children”、“Worker”、“Adults”均位于网络的核心位置,是公共卫生领域的研究热点。  结论  公共卫生研究领域中Cochrane系统评价以中国学者作为第一作者或通讯作者发表的研究甚少,纳入的研究主要关注伤害与道路交通伤害的预防。     

公共卫生舆情监测与风险研究综述

舆情监测是国家传染病和突发公共卫生事件监测系统的有力补充。在互联网时代,人们通过网络媒体、社交媒体等方式极其迅速的传播舆情信息,这些信息是非常重要的情报来源,成为预测疾病暴发、早期预警和防灾应急的重要手段。本文系统总结了国内外舆情监测在公共卫生事件监测预警中的研究进展及应用案例,归纳了三种舆情监测的方式,分析了舆情监测相对于传统监测系统的优势,能够有效地在事件发生前预警预测或事件发生后反馈应对。但是,目前舆情监测受到网络使用、媒体引导及搜索习惯的限制,建议未来将基于网络的舆情监测系统整合入已有的监测系统,探索适应我国的舆情监测平台和手段。     

Sense of place,place attachment,and belonging-in-place in empirical research: A scoping review for rural health workforce research

Rural communities around the world face chronic shortages of medical, nursing, and allied health professionals that contribute to serious inequalities between urban and rural residents. Three concepts have been identified as relevant for health workforce recruitment and retention: sense of place, place attachment, and belonging-in-place. However, there is limited information regarding operationalisation of these concepts within health workforce studies. This paper presents findings from a scoping review investigating empirical application of these concepts across a range of disciplines. Findings identify various strategies for empirical application of two of these three concepts to health workforce research and highlight the value of particular approaches for studies of rural health workforce retention. The paper concludes with several recommendations for future research.     

The Journey through Grief: Insights from a Qualitative Study of Electronic Health Record Implementation

ObjectiveTo improve understanding of facilitators of EHR system implementation, paying particular attention to opportunities to maximize physician adoption and effective deployment.ConclusionsLoss is one part of change often overlooked. Addressing it directly and compassionately can potentially facilitate the EHR implementation journey. We offer a summarized list of deployment strategies that are sensitive to these issues to support physician transition to new technologies that will bring value to clinical practice.     

The emerging landscape of health research based on biobanks linked to electronic health records: Existing resources,statistical challenges,and potential opportunities

Biobanks linked to electronic health records provide rich resources for health-related research. With improvements in administrative and informatics infrastructure, the availability and utility of data from biobanks have dramatically increased. In this paper, we first aim to characterize the current landscape of available biobanks and to describe specific biobanks, including their place of origin, size, and data types. The development and accessibility of large-scale biorepositories provide the opportunity to accelerate agnostic searches, expedite discoveries, and conduct hypothesis-generating studies of disease-treatment, disease-exposure, and disease-gene associations. Rather than designing and implementing a single study focused on a few targeted hypotheses, researchers can potentially use biobanks' existing resources to answer an expanded selection of exploratory questions as quickly as they can analyze them. However, there are many obvious and subtle challenges with the design and analysis of biobank-based studies. Our second aim is to discuss statistical issues related to biobank research such as study design, sampling strategy, phenotype identification, and missing data. We focus our discussion on biobanks that are linked to electronic health records. Some of the analytic issues are illustrated using data from the Michigan Genomics Initiative and UK Biobank, two biobanks with two different recruitment mechanisms. We summarize the current body of literature for addressing these challenges and discuss some standing open problems. This work complements and extends recent reviews about biobank-based research and serves as a resource catalog with analytical and practical guidance for statisticians, epidemiologists, and other medical researchers pursuing research using biobanks.     

Research gaps in routine health information system design barriers to data quality and use in low‐ and middle‐income countries: A literature review

Despite the potential impact of health information system (HIS) design barriers on health data quality and use and, ultimately, health outcomes in low‐ and middle‐income countries (LMICs), no comprehensive literature review has been conducted to study them in this context. We therefore conducted a formal literature review to understand system design barriers to data quality and use in LMICs and to identify any major research gaps related understanding how system design affects data use. We conducted an electronic search across 4 scientific databases—PubMed, Web of Science, Embase, and Global Health—and consulted a data use expert. Following a systematic inclusion and exclusion process, 316 publications (316 abstracts and 18 full papers) were included in the review. We found a paucity of scientific publications that explicitly describe system design factors that hamper data quality or data use for decision making. Although user involvement, work flow, human‐computer interactions, and user experience are critical aspects of system design, our findings suggest that these issues are not discussed or conceptualized in the literature. Findings also showed that individual training efforts focus primarily on imparting data analysis skills. The adverse impact of HIS design barriers on data integrity and health system performance may be even bigger in LMICs than elsewhere, leading to errors in population health management and clinical care. We argue for integrating systems thinking into HIS strengthening efforts to reduce the HIS design‐user reality gap.     

Patient perceptions of carrying their own health information: approaches towards responsibility and playing an active role in their own health – implications for a patient‐held health file

Objective To elicit patients’ views on whether they could contribute to improvements in their care by carrying their own health information to clinician encounters; and to consider the implications for the development of a patient‐held health file (PHF). Background Increasing rates of chronic disease lead to health care being delivered by multiple care providers often at distributed geographic locations. As a way of increasing the availability of patient information to care providers our project will trial a PHF. Patients carry these files to doctors’ appointments where clinicians record data for other doctors or the patient. Increasing the availability of patient information is anticipated to enhance the safety and quality of care delivery and improve health outcomes. Study design Qualitative semi‐structured interviews were conducted with 10 patients. Participants were evenly distributed in terms of gender, aged 60 years or greater and visited at least two specialists and one general practitioner. Findings In this exploratory study, patients who were currently active in decision making about their own health already recorded some health information. They were receptive to carrying their information and thought they should take some responsibility for their health. Patients who were more passive in making decisions about their health did not perceive a need to carry their own information and felt that their doctors communicated adequately. Conclusion Patient‐held health files provide an opportunity for patients to access their health information. Such files have the potential to improve health outcomes for patients who adopt both active and passive roles in relation to their own health and engaging with their health information.     

Parent participation in weight-related health interventions for children and adolescents: a systematic review and meta-analysis

Objective

To review child and adolescent weight-related health intervention characteristics, with a particular focus on levels of parental participation, and examine differences in intervention effectiveness.

Methods

Multiple social science, health, and medical databases were searched, and experimental randomized controlled studies of child and adolescent weight‐related health interventions, reported in January 2004 through December 2010, were collected. Intervention characteristics were reviewed, and pre- and post-measurement data, including body mass index, were extracted for analyses. Differences in effect sizes of experimental and control groups were used to evaluate effectiveness of interventions.

Results

Reports of 42 interventions were included. Intervention activities consisted of nutrition education, physical activity education, physical activity sessions, behavior education, behavior therapy, or a combination of these activities. Significant differences existed among levels of parent participation, p < 0.05. In addition, intervention duration positively predicted intervention effectiveness, p = 0.006, and the linear combination of parent participation and intervention duration significantly predicted intervention effectiveness, p = 0.001.

Conclusions

This study suggests that weight‐related health interventions that require parent participation more effectively reduce body mass indexes of child and adolescent participants. In addition, longer interventions that include parent participation appear to have greater success. Suggestions for future research and related interventions are provided.     

Formative research for the development of an Eye Health Strategic Planning and Evaluation Framework and a Checklist: A health systems approach

This formative research process aimed to develop an Eye Health Strategic Planning and Evaluation Framework and indicator Checklist. The research process utilized a multi‐phased multiple methods approach including literature review, initial expert review (n = 27), findings from a Cambodian Avoidable Blindness Initiative demonstration project (2009‐2012), observation and analysis of four rural sites of the Indian LV Prasad Eye Institute Pyramid Model (n = 21), and finally, a critique by Cambodian government eye health professionals/staff (n = 15), health center staff and community representatives (n = 77) and patients (n = 62). Results from three Cambodian population‐based surveys (KAP n = 599, patient follow‐up n = 354, and RAAB 4650) also informed the development of the Framework and the Checklist. The Framework domains include: situation analysis, determinants of accessibility, service delivery systems, operation systems, networks and linkages, outcomes, and impact. Domains were subdivided into 59 components. The Checklist consists of 253 indicator items. The Eye Health Strategic Planning and Evaluation Framework and the Checklist can assist policy makers, program planners, and evaluators to develop a comprehensive whole of systems approach to eye health care to improve coverage and utilization of services.     

Variability in date of prostate cancer diagnosis: a comparison of cancer registry,pathology report,and electronic health data sources

PurposeThe date of cancer diagnosis is a critical data element for clinical care and research. Because this date can be abstracted from various data sources, its comparability from source to source is unclear. This study compared the date of diagnosis from multiple sources within the same population of prostate cancer patients.MethodsWe linked cancer registry, pathology report, and electronic health data sources from the Kaiser Permanente Southern California health data systems for a cohort of 22,666 members diagnosed with prostate cancer between 2000 and 2010. The magnitude and direction of the differences in date of diagnosis were assessed for each date pairwise comparison. We reviewed 454 medical records to determine reasons for date discrepancies.ResultsAmong the date pairwise comparisons, differences in date of diagnosis spanned from 9.6 years earlier to 10 years later than each other. However, the overall median difference ranged from 1 to 16 days, thus suggesting that the vast majority of the date differences were small. Chart review results identified major categories of date discrepancies.ConclusionsThese data demonstrate variability in date of diagnosis across these data sources. This variability may have implications for epidemiologic estimates or patient identification in research studies using different data sources.     

Mapping the impact of patient and public involvement on health and social care research: a systematic review

Background

There is an increasing international interest in patient and public involvement (PPI) in research, yet relatively little robust evidence exists about its impact on health and social care research.

Objective

To identify the impact of patient and public involvement on health and social care research.

Design

A systematic search of electronic databases and health libraries was undertaken from 1995 to 2009. Data were extracted and quality assessed utilizing the guidelines of the NHS Centre for Reviews and Dissemination 2009 and the Critical Appraisal Skills Programme (CASP). Grey literature was assessed using the Dixon‐Woods et al. (2005) checklist.

Inclusion criteria

All study types that reported the impact PPI had on the health and/or social care research study.

Main results

A total of 66 studies reporting the impact of PPI on health and social care research were included. The positive impacts identified enhanced the quality and appropriateness of research. Impacts were reported for all stages of research, including the development of user‐focused research objectives, development of user‐relevant research questions, development of user‐friendly information, questionnaires and interview schedules, more appropriate recruitment strategies for studies, consumer‐focused interpretation of data and enhanced implementation and dissemination of study results. Some challenging impacts were also identified.

Conclusion

This study provides the first international evidence of PPI impact that has emerged at all key stages of the research process. However, much of the evidence base concerning impact remains weak and needs significant enhancement in the next decade.