Lise Poissant

The Impact of Electronic Health Records on Time Efficiency of Physicians and Nurses: A Systematic Review

A systematic review of the literature was performed to examine the impact of electronic health records (EHRs) on documentation time of physicians and nurses and to identify factors that may explain efficiency differences across studies. In total, 23 papers met our inclusion criteria; five were randomized controlled trials, six were posttest control studies, and 12 were one-group pretest-posttest designs. Most studies (58%) collected data using a time and motion methodology in comparison to work sampling (33%) and self-report/survey methods (8%). A weighted average approach was used to combine results from the studies. The use of bedside terminals and central station desktops saved nurses, respectively, 24.5% and 23.5% of their overall time spent documenting during a shift. Using bedside or point-of-care systems increased documentation time of physicians by 17.5%. In comparison, the use of central station desktops for computerized provider order entry (CPOE) was found to be inefficient, increasing the work time from 98.1% to 328.6% of physicians time per working shift (weighted average of CPOE-oriented studies, 238.4%). Studies that conducted their evaluation process relatively soon after implementation of the EHR tended to demonstrate a reduction in documentation time in comparison to the increases observed with those that had a longer time period between implementation and the evaluation process. This review highlighted that a goal of decreased documentation time in an EHR project is not likely to be realized. It also identified how the selection of bedside or central station desktop EHRs may influence documentation time for the two main user groups, physicians and nurses.

A Randomized Trial of the Effectiveness of On-demand versus Computer-triggered Drug Decision Support in Primary Care

OBJECTIVES Prescribing alerts generated by computerized drug decision support (CDDS) may prevent drug-related morbidity. However, the vast majority of alerts are ignored because of clinical irrelevance. The ability to customize commercial alert systems should improve physician acceptance because the physician can select the circumstances and types of drug alerts that are viewed. We tested the effectiveness of two approaches to medication alert customization to reduce prevalence of prescribing problems: on-physician-demand versus computer-triggered decision support. Physicians in each study condition were able to preset levels that triggered alerts. DESIGN This was a cluster trial with 28 primary care physicians randomized to either automated or on-demand CDDS in the MOXXI drug management system for 3,449 of their patients seen over the next 6 months. MEASUREMENTS The CDDS generated alerts for prescribing problems that could be customized by severity level. Prescribing problems included dosing errors, drug-drug, age, allergy, and disease interactions. Physicians randomized to on-demand activated the drug review when they considered it clinically relevant, whereas physicians randomized to computer-triggered decision support viewed all alerts for electronic prescriptions in accordance with the severity level they selected for both prevalent and incident problems. Data from administrative claims and MOXXI were used to measure the difference in the prevalence of prescribing problems at the end of follow-up. RESULTS During follow-up, 50% of the physicians receiving computer-triggered alerts modified the alert threshold (n = 7), and 21% of the physicians in the alert-on-demand group modified the alert level (n = 3). In the on-demand group 4,445 prescribing problems were identified, 41 (0.9%) were seen by requested drug review, and in 31 problems (75.6%) the prescription was revised. In comparison, 668 (10.3%) of the 6,505 prescribing problems in the computer-triggered group were seen, and 81 (12.1%) were revised. The majority of alerts were ignored because the benefit was judged greater than the risk, the interaction was known, or the interaction was considered clinically not important (computer-triggered: 75.8% of 585 ignored alerts; on-demand: 90% of 10 ignored alerts). At the end of follow-up, there was a significant reduction in therapeutic duplication problems in the computer-triggered group (odds ratio 0.55; p = 0.02) but no difference in the overall prevalence of prescribing problems. CONCLUSION Customization of computer-triggered alert systems is more useful in detecting and resolving prescribing problems than on-demand review, but neither approach was effective in reducing prescribing problems. New strategies are needed to maximize the use of drug decision support systems to reduce drug-related morbidity.

Incorporating the International Classification of Functioning, Disability, and Health (ICF) into an Electronic Health Record to Create Indicators of Function: Proof of Concept Using the SF-12

OBJECTIVE The purpose of this proof-of-concept study was to assess the feasibility of using a generic health measure to create coded functional status indicators and compare the characterization of a stroke population using coded functional indicators and using health-related quality-of-life summary measures alone. DESIGN Multiple raters assigned International Classification of Functioning, Disability, and Health (ICF) codes to the items of the 12-Item Short Form Health Survey (SF-12). Data for comparing the information from the SF-12 and from ICF codes were derived from the Montreal Stroke Cohort Study that was set up to examine the long-term impact of stroke. Available for analysis were data from 604 persons with stroke, average age 69 years, and 488 controls, average age 62 years. MEASUREMENT The SF-12 provides two summary scores, one for physical health and one for mental health. Domains of the ICF are coded to three digits, before the decimal; specific categorizations of impairments, activity limitations, and participation restrictions are coded to four digits before the decimal. RESULTS Persons with stroke scored, on average, approximately 10 points lower than controls on physical and mental health. The ICF coding indicated that this was attributed, not surprisingly, to greater difficulty in doing moderate activities including housework, climbing stairs, and working and was not attributed to differences in pain. Differences in mental health were attributed most strongly to greater fatigue (impairment in energy), but all areas of mental health were affected to some degree. CONCLUSION The ICF coding provided enhanced functional status information in a format compatible with the structure of administrative health databases.

Does the addition of functional status indicators to case-mix adjustment indices improve prediction of hospitalization, institutionalization, and death in the elderly?

Background:Case-mix adjustment is widely used in health services research to ensure that groups being compared are equivalent on variables predicting outcome. There has been considerable development and testing of comorbidity indices derived from diagnostic codes recorded in administrative databases, but increasingly, the benefit of clinical information and patient reported ratings of health and functional status is being recognized. One type of information that is highly valued but has so far not been captured by administrative health databases is functional status indicators (FSI). Objective:The purpose of this study was to estimate the extent to which prediction of health outcomes can be improved on by including information on functional status indicators (FSI). Research Design:The data for the current study was obtained from a clustered randomized trial evaluating computerized decision support for managing drug therapy in the elderly, conducted from 1997 to 1998. A total of 107 primary care physicians participated in this trial and 6465 of their patients (51%) completed a generic health status measure—the SF-12—before the intervention. C statistics and R2 were used to compare the predictive value of sociodemographic factors, 2 comorbidity indices, and 11 FSI predictor variables derived from the SF-12 and coded (possible for 8) using the International Classification of Functioning (ICF). Results:Using stepwise logistic regression, FSI, particularly limitation in stair climbing or doing moderate activities like housework, were found to be strong and independent predictors of all outcomes, even after controlling for sociodemographics and comorbidity. Conclusion:This study indicates that FSI provided as robust a prediction of health events as did complex comorbidity indices. Additionally, the ICF coding system provides a mechanism whereby information on FSI could be incorporated into administrative databases through the use of electronic health records that include a health or functional status measure.

Knowledge translation in physical therapy: from theory to practice

Abstract Purpose: Knowledge translation (KT) has emerged as a concept that can lead to a greater utilization of evidence-based research in systems of care. Despite a rise in KT research, the literature on KT in relation to physical therapy practice is scarce. This article provides physical therapists (PTs) with recommendations that can support the effective implementation of new knowledge and scientific evidence in clinical practice. Method: Recommendations are grounded in the Ottawa Model of Research Use and in the literature in KT in the health professions. Results: A well-established KT process, which is supported by a planning model, is essential to guide the implementation of scientific evidence. Consensus among all stakeholders about what evidence will be implemented must be reached. Context-related barriers and facilitators should be assessed and tailored active and multi-component interventions should be considered. Participation from individuals in intermediary positions (e.g. opinion leaders) supports implementation of KT interventions. Monitoring of the process and assessment of intended outcomes should be performed in order to assess the success of the implementation. Conclusion: Five major recommendations grounded in the Ottawa model are provided that can assist PTs with the complex task of implementing new knowledge in their clinical practice. Implications for Rehabilitation In order to support EBP, knowledge translation interventions can be used to support best practice. Implementation of new knowledge should be guided by a framework or a conceptual model. Consensus on the evidence must be reached and assessment of context-related factors should be done prior to the implementation of any KT intervention. Intervention strategies should be active, multi-component and include individuals with intermediary positions that can facilitate the KT process.

The development and preliminary validation of a Preference-Based Stroke Index (PBSI)

BackgroundHealth-related quality of life (HRQL) is a key issue in disabling conditions like stroke. Unfortunately, HRQL is often difficult to quantify in a comprehensive measure that can be used in cost analyses. Preference-based HRQL measures meet this challenge. To date, there are no existing preference-based HRQL measure for stroke that could be used as an outcome in clinical and economic studies of stroke. The aim of this study was to develop the first stroke-specific health index, the Preference-based Stroke Index (PBSI).MethodsThe PBSI includes 10 items; walking, climbing stairs, physical activities/sports, recreational activities, work, driving, speech, memory, coping and self-esteem. Each item has a 3-point response scale. Items known to be impacted by a stroke were selected. Scaling properties and preference-weights obtained from individuals with stroke and their caregivers were used to develop a cumulative score.ResultsCompared to the EQ-5D, the PBSI showed no ceiling effect in a high-functioning stroke population. Moderately high correlations were found between the physical function (r = 0.78), vitality (r = 0.67), social functioning (r = 0.64) scales of the SF-36 and the PBSI. The lowest correlation was with the role emotional scale of the SF-36 (r = 0.32). Our results indicated that the PBSI can differentiate patients by severity of stroke (p < 0.05) and level of functional independence (p < 0.0001).ConclusionsContent validity and preliminary evidence of construct validity has been demonstrated. Further work is needed to develop a multiattribute utility function to gather information on psychometric properties of the PBSI.

Clinicians' expectations of Web 2.0 as a mechanism for knowledge transfer of stroke best practices.

Background Health professionals are increasingly encouraged to adopt an evidence-based practice to ensure greater efficiency of their services. To promote this practice, several strategies exist: distribution of educational materials, local consensus processes, educational outreach visits, local opinion leaders, and reminders. Despite these strategies, gaps continue to be observed between practice and scientific evidence. Therefore, it is important to implement innovative knowledge transfer strategies that will change health professionals’ practices. Through its interactive capacities, Web 2.0 applications are worth exploring. As an example, virtual communities of practice have already begun to influence professional practice. Objective This study was initially developed to help design a Web 2.0 platform for health professionals working with stroke patients. The aim was to gain a better understanding of professionals’ perceptions of Web 2.0 before the development of the platform. Methods A qualitative study following a phenomenological approach was chosen. We conducted individual semi-structured interviews with clinicians and managers. Interview transcripts were subjected to a content analysis. Results Twenty-four female clinicians and managers in Quebec, Canada, aged 28-66 participated. Most participants identified knowledge transfer as the most useful outcome of a Web 2.0 platform. Respondents also expressed their need for a user-friendly platform. Accessibility to a computer and the Internet, features of the Web 2.0 platform, user support, technology skills, and previous technological experience were found to influence perceived ease of use and usefulness. Our results show that the perceived lack of time of health professionals has an influence on perceived behavioral intention to use it despite favorable perception of the usefulness of the Web 2.0 platform. Conclusions In conclusion, female health professionals in Quebec believe that Web 2.0 may be a useful mechanism for knowledge transfer. However, lack of time and lack of technological skills may limit their use of a future Web 2.0 platform. Further studies are required with other populations and in other regions to confirm these findings.

Estimating the information gap between emergency department records of community medication compared to on-line access to the community-based pharmacy records.

Objective Errors in community medication histories increase the risk of adverse events. The objectives of this study were to estimate the extent to which access to community-based pharmacy records provided more information about prescription drug use than conventional medication histories. Materials and methods A prospective cohort of patients with public drug insurance who visited the emergency departments (ED) in two teaching hospitals in Montreal, Quebec was recruited. Drug lists recorded in the patients’ ED charts were compared with pharmacy records of dispensed medications retrieved from the public drug insurer. Patient and drug-related predictors of discrepancies were estimated using general estimating equation multivariate logistic regression. Results 613 patients participated in the study (mean age 63.1 years, 59.2% women). Pharmacy records identified 41.5% more prescribed medications than were noted in the ED chart. Concordance was highest for anticoagulants, cardiovascular drugs and diuretics. Omissions in the ED chart were more common for drugs that may be taken episodically. Patients with more than 12 medications (OR 2.92, 95% CI 1.71 to 4.97) and more than one pharmacy (OR 3.85, 95% CI 1.80 to 6.59) were more likely to have omissions in the ED chart. Discussion The development of health information exchanges could improve the efficiency and accuracy of information about community medication histories if they enable automated access to dispensed medication records from community pharmacies, particularly for the most vulnerable populations with multiple morbidities. Conclusions Pharmacy records identified a substantial number of medications that were not in the ED chart. There is potential for greater safety and efficiency with automated access to pharmacy records.

Assessment of organizational readiness for e-health in a rehabilitation centre.

Purpose: The aims of this study were to assess organizational readiness for e-health among the staff of an out-patient rehabilitation centre and to identify the personal characteristics of potential users that may have influenced readiness. Methods: A cross-sectional study was conducted with 137 clinicians, 28 managers, and 47 nonclinical staff in a rehabilitation centre in Montreal, Quebec, Canada. All participants completed a self-administered questionnaire assessing organizational readiness for e-health. The measure contained three subscales: Individual, Organizational and Technological. Data were also collected on the users’ profile, use of technologies and typical response to new information. Results: Generally, participants considered themselves ready to adopt e-health in their work (X = 73.8%, SD = 8.5) and they also had a favorable view of the technologies in place (X 73.8%, SD = 7.2). However, they perceived the center as being only moderately ready (X 66.6%, SD = 9.8) for e-health changes. Perceived workload and position/duties in the organization were found to have an impact on readiness for e-health. Conclusions: These results underscore the importance of addressing organizational readiness for change as a multidimensional concept. Based on these results, implementation strategies tailored to the specific profile of a rehabilitation organization were identified. Implications for Rehabilitation The use of e-health, or the application of information and communications technologies (ICT) in the health sector, is growing in rehabilitation but its implementation can be challenging. Assessing a rehabilitation facility’s readiness for change reduces the risk of implementation failure of ICT. This study revealed personnel of an out-patient rehabilitation facility perceive themselves as being more ready than their organisation to adopt ICT. The influence of personal factors of potential users must be considered when planning and implementing ICT projects. ICT implementation requires strategies tailored to the organization and to the individuals who support it.

Maximizing post-stroke upper limb rehabilitation using a novel telerehabilitation interactive virtual reality system in the patient's home: study protocol of a randomized clinical trial

BACKGROUND Telerehabilitation (TR), or the provision of rehabilitation services from a distance using telecommunication tools such as the Internet, can contribute to ensure that patients receive the best care at the right time. This study aims to assess the effect of an interactive virtual reality (VR) system that allows ongoing rehabilitation of the upper extremity (UE) following a stroke, while the person is in their own home, with offline monitoring and feedback from a therapist at a distance. METHODS/DESIGN A single-blind (evaluator is blind to group assignment) two-arm randomized controlled trial is proposed, with participants who have had a stroke and are no longer receiving rehabilitation services randomly allocated to: (1) 4-week written home exercise program, i.e. usual care discharge home program or (2) a 4-week home-based TR exercise program using VR in addition to usual care i.e. treatment group. Motor recovery of the UE will be assessed using the Fugl-Meyer Assessment-UE and the Box and Block tests. To determine the efficacy of the system in terms of functional recovery, the Motor Activity Log, a self-reported measure of UE use will be used. Impact on quality of life will be determined using the Stroke Impact Scale-16. Lastly, a preliminary cost-effectiveness analysis will be conducted using costs and outcomes for all groups. DISCUSSION Findings will contribute to evidence regarding the use of TR and VR to provide stroke rehabilitation services from a distance. This approach can enhance continuity of care once patients are discharged from rehabilitation, in order to maximize their recovery beyond the current available services.