Morgan Price

A review on systematic reviews of health information system studies

The purpose of this review is to consolidate existing evidence from published systematic reviews on health information system (HIS) evaluation studies to inform HIS practice and research. Fifty reviews published during 1994-2008 were selected for meta-level synthesis. These reviews covered five areas: medication management, preventive care, health conditions, data quality, and care process/outcome. After reconciliation for duplicates, 1276 HIS studies were arrived at as the non-overlapping corpus. On the basis of a subset of 287 controlled HIS studies, there is some evidence for improved quality of care, but in varying degrees across topic areas. For instance, 31/43 (72%) controlled HIS studies had positive results using preventive care reminders, mostly through guideline adherence such as immunization and health screening. Key factors that influence HIS success included having in-house systems, developers as users, integrated decision support and benchmark practices, and addressing such contextual issues as provider knowledge and perception, incentives, and legislation/policy.

Impact of electronic medical record on physician practice in office settings: a systematic review

BackgroundIncreased investments are being made for electronic medical records (EMRs) in Canada. There is a need to learn from earlier EMR studies on their impact on physician practice in office settings. To address this need, we conducted a systematic review to examine the impact of EMRs in the physician office, factors that influenced their success, and the lessons learned.ResultsFor this review we included publications cited in Medline and CINAHL between 2000 and 2009 on physician office EMRs. Studies were included if they evaluated the impact of EMR on physician practice in office settings. The Clinical Adoption Framework provided a conceptual scheme to make sense of the findings and allow for future comparison/alignment to other Canadian eHealth initiatives.In the final selection, we included 27 controlled and 16 descriptive studies. We examined six areas: prescribing support, disease management, clinical documentation, work practice, preventive care, and patient-physician interaction. Overall, 22/43 studies (51.2%) and 50/109 individual measures (45.9%) showed positive impacts, 18.6% studies and 18.3% measures had negative impacts, while the remaining had no effect. Forty-eight distinct factors were identified that influenced EMR success. Several lessons learned were repeated across studies: (a) having robust EMR features that support clinical use; (b) redesigning EMR-supported work practices for optimal fit; (c) demonstrating value for money; (d) having realistic expectations on implementation; and (e) engaging patients in the process.ConclusionsCurrently there is limited positive EMR impact in the physician office. To improve EMR success one needs to draw on the lessons from previous studies such as those in this review.

Conditions potentially sensitive to a Personal Health Record (PHR) intervention, a systematic review

BackgroundPersonal Health Records (PHRs) are electronic health records controlled, shared or maintained by patients to support patient centered care. The potential for PHRs to transform health care is significant; however, PHRs do not always achieve their potential. One reason for this may be that not all health conditions are sensitive to the PHR as an intervention. The goal of this review was to discover which conditions were potentially sensitive to the PHR as an intervention, that is, what conditions have empirical evidence of benefit from PHR-enabled management.MethodsA systematic review of Medline and CINAHL was completed to find articles assessing PHR use and benefit from 2008 to 2014 in specific health conditions. Two researchers independently screened and coded articles. Health conditions with evidence of benefit from PHR use were identified from the included studies.Results23 papers were included. Seven papers were RCTs. Ten health conditions were identified, seven of which had documented benefit associated with PHR use: asthma, diabetes, fertility, glaucoma, HIV, hyperlipidemia, and hypertension. Reported benefits were seen in terms of care quality, access, and productivity, although many benefits were measured by self-report through quasi-experimental studies. No study examined morbidity/mortality. No study reported harm from the PHR.ConclusionThere is a small body of condition specific evidence that has been published. Conditions with evidence of benefit when using PHRs tended to be chronic conditions with a feedback loop between monitoring in the PHR and direct behaviours that could be self-managed. These findings can point to other potentially PHR sensitive health conditions and guide PHR designers, implementers, and researchers. More research is needed to link PHR design, features, adoption and health outcomes to better understand how and if PHRs are making a difference to health outcomes.

Using the Clinical Document Architecture as Open Data Exchange Format for Interfacing EMRs with Clinical Decision Support Systems

Clinical decision support systems (CDSS) can significantly increase the quality of care while decreasing cost and effort. They are difficult to develop and most existing systems are proprietary, tightly integrated with specific electronic medical record (EMR) systems, and expensive to own. EGADSS is an open-source CDSS that has been developed as a standalone, standards-based, re-usable component to make decision-support available for any EMR. In order to realize this vision, the EGADSS team has had to develop an open interface for medical data exchange, which maximizes interoperability, simplicity and standard-conformance. This paper reports on a solution to this challenge based on the HL7 clinical document architecture (CDA) and the electronic medical summary standard. CDA-based medical summaries are used to encapsulate virtual medical records about patients that serve the DSS component as temporary databases. We show how these temporary databases can be queried from within Arden syntax-based guidelines in a standard query language. Moreover, we show how the CDA can be used to communicate CDSS alerts and recommendations back to the EMR. We report on our evaluation with a prototype implementation and compare it with alternative approaches

Provider connectedness and communication patterns: extending continuity of care in the context of the circle of care.

BackgroundContinuity is an important aspect of quality of care, especially for complex patients in the community. We explored provider perceptions of continuity through a system’s lens. The circle of care was used as the system.MethodsSoft systems methodology was used to understand and improve continuity for end of life patients in two communities. Participants: Physicians, nurses, pharmacists in two communities in British Columbia, involved in end of life care. Two debates/discussion groups were completed after the interviews and initial analysis to confirm findings. Interview recordings were qualitatively analyzed to extract components and enablers of continuity.Results32 provider interviews were completed. Findings from this study support the three types of continuity described by Haggerty and Reid (information, management, and relationship continuity). This work extends their model by adding features of the circle of care that influence and enable continuity: Provider Connectedness the sense of knowing and trust between providers who share care of a patient; a set of ten communication patterns that are used to support continuity across the circle of care; and environmental factors outside the circle that can indirectly influence continuity.ConclusionsWe present an extended model of continuity of care. The components in the model can support health planners consider how health care is organized to promote continuity and by researchers when considering future continuity research.

Assessing accuracy of an electronic provincial medication repository

BackgroundJurisdictional drug information systems are being implemented in many regions around the world. British Columbia, Canada has had a provincial medication dispensing record, PharmaNet, system since 1995. Little is known about how accurately PharmaNet reflects actual medication usage.MethodsThis prospective, multi-centre study compared pharmacist collected Best Possible Medication Histories (BPMH) to PharmaNet profiles to assess accuracy of the PharmaNet profiles for patients receiving a BPMH as part of clinical care. A review panel examined the anonymized BPMHs and discrepancies to estimate clinical significance of discrepancies.Results16% of medication profiles were accurate, with 48% of the discrepant profiles considered potentially clinically significant by the clinical review panel. Cardiac medications tended to be more accurate (e.g. ramipril was accurate >90% of the time), while insulin, warfarin, salbutamol and pain relief medications were often inaccurate (80–85% of the time). 1215 sequential BPMHs were collected and reviewed for this study.ConclusionsThe PharmaNet medication repository has a low accuracy and should be used in conjunction with other sources for medication histories for clinical or research purposes. This finding is consistent with other, smaller medication repository accuracy studies in other jurisdictions. Our study highlights specific medications that tend to be lower in accuracy.

The clinical adoption meta-model: a temporal meta-model describing the clinical adoption of health information systems

Health information systems (HISs) hold the promise to transform health care; however, their adoption is challenged. We have developed the Clinical Adoption Meta-Model (CAMM) to help describe processes and possible challenges with clinical adoption. The CAMM, developed through an action research study to evaluate a provincial HIS, is a temporal model with four dimensions: availability, use, behaviour changes, and outcome changes. Seven CAMM archetypes are described, illustrating classic trajectories of adoption of HISs over time. Each archetype includes an example from the literature. The CAMM and its archetypes can support HIS implementers, evaluators, learners, and researchers.

Software engineering in health care: is it really different? and how to gain impact

Over the last several years, software engineering (SE) has given birth to several communities and venues related to research on SE in the context of health care systems. By and large, the interest in this topic has been spurred by alarming failures of software-intensive systems that have been deployed to address some of the challenges faced in current health care environments. Today, the software engineering in health care (SERC) community faces several challenges. It needs to justify the significance of its existence towards the general SE community and towards the medical/health informatics community. The purpose of this paper is to explore some of the fundamental challenges pertaining to SERC, to consider whether these challenges require a dedicated community-based effort and to generate recommendations on how to strengthen its impact. We argue that the community should adopt a conceptual model of knowledge translation (KT) analogous those used in the medical domain to position its research and maximize its impact.

Engineering Medical Information Systems: Architecture, Data and Usability & Security

There has been increasing pressure on the health care sector to adopt information technologies to rationalize service delivery and increase service quality. Medical information systems need to be highly interoperable and effectively manage complex information of great sensitivity. Moreover, they have to be optimized for usability in a highly complex knowledge base and agile work environment. This tutorial introduces key concepts, methods and techniques essential for engineering clinical information systems, in particular electronic medical records. It targets participants with basic software engineering knowledge who are or will be involved in development, maintenance, evolution or research of medical software.

SCOOP - The Social Collaboratory for Outcome Oriented Primary Care

Many primary care clinics have transitioned from paper-based record keeping to computer-based Electronic Medical Record (EMR) systems. This transition provides opportunities for computer-based data analytics in support of practice improvement and more evidence-based clinical research. Unfortunately, the data in primary care EMRs is often not readily accessible to researchers, who often have to overcome significant political, organizational and technical hurdles before gaining access to such data. As a consequence, knowledge discovery and translation has been slow and burdensome in this area. Primary care research networks (PCRN) have been proposed as a way to addressing these limitations. This paper reports on the development of a PCRN in British Columbia, referred to as SCOOP (The Social Collaboratory for Outcome Oriented Primary Care). We describe its technical architecture and draw comparisons to related and previous initiatives.