Preparing the ground for the 'paperless hospital': a case study of medical records management in a UK outpatient services department

PurposeThe purpose of the study was to understand the preparations for the introduction of electronic patient record systems (EPRs) within the outpatient services department of a large acute hospital based in the UK. In particular, one of the main aims of the study was to examine in detail the likely impact of EPRs on the working practices of healthcare workers, their expectations regarding the impact of EPRs within the department and other sociotechnical aspects of the management of patient information.MethodsTwenty-seven semi-structured interviews were undertaken with staff in a variety of roles that deal with the management of medical records. The interviews focused on the organisation of the medical records department and current problems (e.g., missing records). In addition, the interviews contained questions about the specific role of medical records supervisors in the administration of records, as well as pathways and expectations about EPRs more generally. The data from the interviews was analysed using a mixture of thematic and template analysis and coded using constructs from a sociotechnical model of information system implementation and adoption.ResultsThe findings show that despite severe delays to the nationally led (NPfIT) roll-out of EPRs and associated IT infrastructure within the UK, staff attitudes within the department were broadly positive about the potential of future EPRs to deliver efficiencies (e.g., improved workflow within the department, reduced reliance on paper-based systems). One of the main influences on attitudes towards the type of EPRs that should exist within outpatients was prompted by negative reactions to the way in which NPfIT systems had been managed and attempted to be introduced in the past. A strong commitment to end-user involvement in EPRs design, together with a rejection of NPfIT, appears to have shaped attitudes towards future expectations of the adoption of new EPRs within the department. In addition, staff do not believe that a rapid change to ‘paperless’ working is likely to be possible.ConclusionsOur findings provide further evidence that there is a need to treat the implementation of EPRs not simply as an exercise in technical system delivery, but as a larger process of sociotechnical systems change. We conclude the paper with some guidelines, the aim of which is to provide guidance regarding EPRs implementation and adoption informed by sociotechnical principles and ideas.     

When obesity is desirable: a longitudinal study of the Miami HIV-1-infected drug abusers (MIDAS) cohort

Despite widespread nutrient deficiencies, a substantial proportion of the MIDAS cohort exhibits obesity, which has been linked to immune dysregulation in other clinical settings. Herein, the effects of obesity on immune function, disease progression, and mortality were evaluated longitudinally in 125 HIV-1-seropositive drug users, with comparison measures in 148 HIV-1-seronegative controls. Data were collected at a community clinic from 1992 to 1996, before administration of highly active antiretroviral therapy. Results indicated that overweight/obesity, defined as body mass index (BMI; kg/m2) > or =27, was evident in 18% of the HIV-1-seropositive patients and 29% of the seronegative patients. At baseline, no significant immunologic differences were observed among lean, nonobese, and obese groups. Over an 18-month period, 60.5% of the nonobese HIV-1-seropositive patients exhibited a 25% decline in CD4 cell count, compared with 18% of the obese patients (p<.004). During the follow-up period, 38% of the lean and 13% of the nonobese study subjects died of HIV-1-related causes. Measurements of BMI were inversely associated with progression to death, independent of CD4 count <200 cells/mm3 (p<.02). These data suggest that mild-to-moderate obesity in HIV-1-infected chronic drug users does not impair immune function and is associated with better HIV-1-related survival.     

Workforce trends in general practice in the UK: results from a longitudinal study of doctors' careers.

The career paths of 544 UK medical school graduates were followed for 10 years. Although general practice was not attractive to graduates initially, it became popular in subsequent years, mainly because it was seen as offering a superior quality of life. Once in general practice both men and women chose to work reduced hours and/or in non-principal posts. The findings suggest the need to look more closely at the nature of these trends and the implications for patient care and service provision.     

Haplotype analysis of the SDF-1 (CXCL12) gene in a longitudinal HIV-1/AIDS cohort study

The stromal-derived factor-1 (SDF-1) chemokine gene encodes the only natural ligand for CXCR4, the coreceptor for the pathogenic X4 HIV-1 strains. A single-nucleotide polymorphism (SNP) in the 3' untranslated region (SDF1-3'A=rs1801157) of SDF-1 was reported to be protective against infection and progression in some, but not other, epidemiological studies. To identify additional alleles that may influence HIV-1 infection and progression to AIDS, nine SNPs (including rs1801157) spanning 20.2 kb in and around the SDF-1 gene were genotyped in over 3000 African American (AA) and European American (EA) participants enrolled in five longitudinal HIV-1/AIDS natural cohort studies. Six or five haplotypes were present at frequencies greater than 5% in AA or EA, respectively. Six of the nine SNPs occur on only one common haplotype (>5%), while the remaining three SNPs were found on multiple haplotypes, suggesting a complex history of recombination. Among EA, rs754618 was associated with an increased risk of infection (OR=1.50, P=0.03), while rs1801157 (=SDF1-3'A) was associated with protection against infection (OR=0.63, P=0.01). In the MACS cohort, rs1801157 was associated with AIDS-87 (RH=0.31, P=0.02) and with death (RH=0.18, P=0.02). Significant associations to a single disease outcome were found for two SNPs and one haplotype in AA.     

Segmental morphometrics of the olive baboon (Papio anubis): a longitudinal study from birth to adulthood

The linear dimensions and inertial characteristics of the body are important in locomotion and they change considerably during the ontogeny of animals, including humans. This longitudinal and ontogenetic study has produced the largest dataset to date of segmental morphometrics in a Catarrhini species, the olive baboon. The objectives of the study were to quantify the changes in body linear and inertial dimensions and to explore their (theoretical) mechanical significance for locomotion. We took full‐body measurements of captive individuals at regular intervals. Altogether, 14 females and 16 males were followed over a 7‐year period, i.e. from infancy to adulthood. Our results show that individual patterns of growth are very consistent and follow the general growth pattern previously described in olive baboons. Furthermore, we obtained similar growth curve structures for segment lengths and masses, although the respective time scales were slightly different. The most significant changes in body morphometrics occurred during the first 2 years of life and concerned the distal parts of the body. Females and males were similar in size and shape at birth. The rate and duration of growth produced substantial size‐related differences throughout ontogeny, while body shapes remained very similar between the sexes. We also observed significant age‐related variations in limb composition, with a proximal shift of the centre of mass within the limbs, mainly due to changes in mass distribution and in the length of distal segments. Finally, we observed what we hypothesize to be ‘early biomechanical optimization’ of the limbs for quadrupedal walking. This is due to a high degree of convergence between the limbs’ natural pendular periods in infants, which may facilitate the onset of quadrupedal walking. Furthermore, the mechanical significance of the morphological changes observed in growing baboons may be related to changing functional demands with the onset of autonomous (quadrupedal) locomotion. From a wider perspective, these data provide unique insights into questions surrounding both the processes of locomotor development in primates and how these processes might evolve.     

The Copenhagen Prospective Study on Asthma in Childhood (COPSAC): design, rationale, and baseline data from a longitudinal birth cohort study.

BACKGROUND: The atopic diseases asthma, atopic dermatitis, and allergic rhinitis are the most common chronic diseases in children, and their prevalence has increased recently in industrialized nations. Little is known about the genetic-environmental interaction factors driving such proliferation. OBJECTIVE: To investigate the relationships among genetic, environmental, and lifestyle factors in the development of atopic diseases in high-risk children with the aim of developing evidence-based prevention strategies. METHODS: The Copenhagen Prospective Study on Asthma in Childhood is a single-center, birth cohort study of children of asthmatic mothers. Objective assessments begin at birth, with scheduled visits every 6 months and when acute symptoms manifest. Clinical outcomes comprise preasthma, asthma, atopic dermatitis, allergic rhinitis, allergy, lung function, and bronchial responsiveness. Exposure assessments comprise respiratory, intestinal, and skin microbiology; the child's diet; indoor and outdoor air quality; allergens; and indicators of lifestyle. Genetic characteristics of probands and parents are evaluated. Quality assurance follows Good Clinical Practice guidelines. RESULTS: Four hundred eleven infants of asthmatic mothers were enrolled at the age of 1 month. The children were born between August 2, 1998, and December 28, 2001. Compared with the Copenhagen population, mothers of the cohort population were less likely to have given natural childbirth. The households were slightly less affluent, with fewer children and fewer pets. Whites may be overrepresented. At age 2 years, 93% of the infants were still actively participating in the cohort. CONCLUSIONS: This longitudinal birth cohort study of high-risk Danish infants consists of objective phenotyping, detailed information on exposure, high data quality, and a high participant retention rate.     

Ischaemic preconditioning in the rat brain: a longitudinal magnetic resonance imaging (MRI) study

Ischaemic preconditioning in rats was studied using MRI. Ischaemic preconditioning was induced, using an intraluminal filament method, by 30 min middle cerebral artery occlusion (MCAO), and imaged 24 h later. The secondary insult of 100 min MCAO was induced 3 days following preconditioning and imaged 24 and 72 h later. Twenty-four hours following ischaemic preconditioning most rats showed small sub-cortical hyperintense regions not seen in sham-preconditioned rats. Twenty-four hours and 72 h following the secondary insult preconditioned animals showed significantly smaller lesions (24 h = 112 +/- 31 mm(3), mean +/- standard error; 72 h = 80 +/- 35 mm(3)), which were confined to the striatum, than controls (24 h = 234 +/- 32 mm(3), p = 0.026; 72 h = 275 +/- 37 mm(3), p = 0.003). In addition during lesion maturation from 24 to 72 h post-secondary MCAO, preconditioned rats displayed an average reduction in lesion size as measured by MRI whereas sham-preconditioned rats displayed increases in lesion size; this is the first report of such differential lesion volume evolution in cerebral ischaemic preconditioning. Copyright -Copyright 2001 John Wiley & Sons, Ltd.     

Adaptive behavior in the fra(X) syndrome: a longitudinal study in eight patients

In this study we investigated the development of adaptive behavior of 8 fragile X [fra(X)] males with special attention to social competence and compared the results with a control group of 8 fra(X) negative males matched for age, level of adaptive functioning, and period of institutionalization.     

Chronic fatigue syndrome and related disorders in UK veterans of the Gulf War 1990-1991: results from a two-phase cohort study

BACKGROUND: The aim was to determine the prevalence of chronic fatigue syndrome (CFS), chronic fatigue and fibromyalgia in UK military personnel after the Gulf War 1990-1991. METHOD: A two-phase cohort study was used. Three randomly selected subsamples identified from a population-based cross-sectional postal survey of over 10,000 current and ex-service UK military personnel (Gulf veterans were those deployed to the Gulf War 1990-1991; non-Gulf veterans were Bosnia peacekeepers 1992-1997 and those on active duty during the Gulf War 1990-1991 but not deployed) were recruited. Their disability status was assessed using the Short Form 36 physical functioning scale; Gulf veterans who reported physical disability (n=111) were compared with non-Gulf (n=133) veterans who reported similar levels of physical disability. Screening for known medical and psychiatric conditions was conducted to exclude medical explanations for disability and symptomatic distress. Standardised criteria for CFS, chronic fatigue and fibromyalgia were used. RESULTS: Disabled Gulf veterans were more likely to be overweight, have elevated gamma-glutamyl transferase levels and screen positive for hypertension. There were no other clinically significant differences in clinical markers for medically explainable conditions. Disabled Gulf veterans were more likely than similarly disabled Bosnia and Era veterans (adjusted odds ratio 7.8, 95% confidence interval 2.5-24.5) to meet the criteria for CFS. Rates for other medically unexplained conditions were not significantly increased. CONCLUSIONS: Symptoms in keeping with CFS account for a significant part of the symptomatic distress in Gulf veterans.     

The contribution of medical physics to the development of psoralen photochemotherapy (PUVA) in the UK: a personal reminiscence

Psoralen photochemotherapy (PUVA) is the combined treatment of skin disorders with a photosensitizing drug (Psoralen) and UltraViolet A radiation. The introduction of PUVA therapy has arguably been the most important development in dermatology over the past 30 years and from the first days of the treatment being introduced in the UK, British medical physicists were an integral part of the effort to establish it. Medical physicists have contributed to this development in a number of ways, from designing irradiation units in the early days of the technique, through to collaborating with dermatologists in prosecuting clinical and experimental studies aimed at improving patient outcomes. That the dose of UVA radiation is administered quantitatively, and not qualitatively, has probably been the single most important contribution made by several medical physicists over this period. However, despite concerns that were expressed almost 30 years ago about the accuracy with which UVA doses are administered to patients, the medical physics community still has some way to go before we can be satisfied that statements about UVA irradiance and dose can be made with confidence.     

Outcome measures of extracorporeal life support (ECLS) in trauma patients versus patients without trauma: a 7-year single-center retrospective cohort study

This single-center retrospective study included a total of 99 extracorporeal life support (ECLS) cannulated patients assigned to a traumatic extracorporeal life-support cohort (TECLS) or a non-traumatic extracorporeal life-support cohort (NTECLS). Forty-nine TECLS patients and 50 NTECLS patients were compared. The TECLS patients were significantly younger [49.9 years 16.6–86.2 vs. 57.1 (21.4–78.6); p = 0.007] and had lower body mass indices (BMIs) [27.7 kg/m² (20–37) vs. 32.5 (19–88.5); p = 0.001] than the NTECLS patients. The intensive care unit (ICU) survival rate [n = 34 (69.4%) vs. n = 13 (26%); p ≤ 0.001] and the hospital survival rate [n = 32 (65.3%) vs. n = 13 (26%); p ≤ 0.001] were significantly higher for the TECLS cohort than for the NTECLS cohort. The lengths of stay (LOSs) in the ICU [24 days (4.8–71.1) vs. 11.3 (0–88.6); p = 0.001] and in the hospital [46.6 days (2.9–197.6) vs. 21 (0.1–213.8); p = 0.001] were significantly longer for the TECLS patients than for the NTECLS patients.     

Benefits and drawbacks of preimplantation genetic diagnosis (PGD) for reciprocal translocations: lessons from a prospective cohort study

Preimplantation genetic diagnosis (PGD) using fluorescence in situ hybridisation probes was carried out for 59 couples carrying reciprocal translocations. Before treatment, 85% of pregnancies had resulted in spontaneous miscarriage and five couples had achieved a healthy live-birth delivery. Following treatment, 33% of pregnancies failed and 21of 59 couples had a healthy live-born child. The accuracy of diagnosis was 92% (8% false abnormal and 0% false normal results). The overall incidence of 2:2 alternate segregation products was 44% however, products consistent with 2:2 adjacent segregation were ∼twice as likely from male heterozygotes, and those with 3:1 disjunction were three times more likely from female heterozygotes. Our results indicate that up to three stimulation cycles per couple would give an ∼50% chance of a successful live birth, with the risk of miscarriage reduced to the level found in the general population. In our study, 87% of all normal/balanced embryos available were identified as being suitable for transfer. We conclude that PGD provides benefit for couples with high-risk translocations by reducing the risk of miscarriage and avoiding a pregnancy with an unbalanced form of the translocation; however, for fertile carriers of translocations with a low risk of conceiving a chromosomally unbalanced offspring, natural conception may be a more viable option.     

Onychomycosis in Morocco: experience of the parasitology and medical mycology laboratory from Rabat children hospital (1982-2003)

Cases of onychomycosis diagnosed by mycological examination in the parasitology and mycology laboratory (Children Hospital, Rabat, Marocco) over the 22-year period, between 1982 and 2003, have been reviewed. 17,177 dermatophytes have been isolated in 4,940 patients. Dermatophytes presented 61.46% of onychomycosis, yeasts Candida albicans were responsible in 25.5%, moulds in 1.53% and for 12% fungi identification was not determined (positive direct examination or negative direct examination and culture despite typical clinical aspect). The most frequent dermatophyte was Trichophyton rubrum (83.6%), followed by Trichophyton violaceum var. glabrum (9%) and Trichophyton mentagrophytes var. interdigitale (6.9%). Candida albicans was the prevalent yeast. Moulds were mainly Fusarium spp. (47%), followed Scopulariopsis brevicaulis (16%) and Aspergillus spp. (12%). Dermatophytes and moulds most commonly infected the toenails, yeasts the fingernails.     

Intelligence and cognitive profile in the fra(X) syndrome: a longitudinal study in 18 fra(X) boys.

A longitudinal study of IQ and cognitive profile in 18 fra(X) positive boys is reported. At the time of diagnosis, four of the boys were mildly retarded, seven were moderately retarded, and five were severely mentally retarded. Intelligence was borderline in one child and normal in another. A decline in intellectual performance with age in the fra(X) syndrome indicated in previous studies was not confirmed and we review the reported data on this subject.     

Preliminary criteria for the definition of allergic rhinitis: a systematic evaluation of clinical parameters in a disease cohort (II)

BACKGROUND: This study is a development of the work done in 'Preliminary criteria for the definition of allergic rhinitis: a systematic evaluation of clinical parameters in a disease cohort (I)'. OBJECTIVE: We sought to develop criteria which could be routinely used to define allergic rhinitis. METHODS: A total of 47 allergic rhinitis and 23 normal subjects were evaluated with a detailed questionnaire and history, physical examination, serum total immunoglobulin (Ig) E, skin prick tests and serum EAST's. RESULTS: Based on this data, we developed a preliminary scoring system by which a reliable diagnosis of allergic rhinitis can be made, which is based on the prevalence adjusted strength of association delta ( partial differential) rank values described in this report. Cumulative frequency histograms were constructed for allergic rhinitis and normal subjects in a variety of configurations. CONCLUSION: A simple scoring system which can be used to diagnose allergic rhinitis on a routine basis was developed in this study.