Informatics in Primary Care最新文献

Background: High levels of funding have been invested in health information technologies, especially electronic health records (EHRs), in an effect to coordinate and organize patient health data. However, the effect of EHRs in the exam room on doctor-patient communication has not been sufficiently explored. Objective The purpose of this systematic review was to determine how physician use of EHRs in medical consultations affects doctor-patient communication, both in terms of patient perceptions and actual physician behaviours.

Method: The reviewer conducted a comprehensive online database search in March 2013 of EMBASE, MEDLINE, and SCOPUS, using a combination of synonyms of the terms "patient", "doctor", "communication", and "EHR" or "computing". For inclusion in this review, articles had to be published in English, take place in an outpatient setting and demonstrate an empirical investigation into whether EHR affects doctor-patient communication. The reviewer then analysed 13 articles that met the inclusion criteria.

Results: Studies showed EHR use encouraged biomedical questioning of the patient, and encouraged patient-led questioning and doctor-led information provision. EHR-related behaviours such as keyboarding and screen gaze impaired relationships with patients, by reducing eye contact, rapport, and provision of emotional support. EHRs negatively affected physician-led patient-centred communication. Computer use may have amplified existing physician behaviours regarding medical record use.

Conclusion: We noted both positive and negative effects of EHR use. This review highlights the need for increased EHR-specific communication training to mitigate adverse effects and for continued acknowledgement of patient perspectives.

Background: This paper explores the scope of malaria-susceptibility modelling to predict malaria occurrence in an area.

Objective: An attempt has been made in Varanasi district, India, to evaluate the status of malaria disease and to develop a model by which malaria-prone zones could be predicted using five classes of relative malaria susceptibility, i.e.very low, low, moderate, high and very high categories. The information value (Info Val) method was used to assess malaria occurrence and various time-were used as the independent variables. A geographical information system (GIS) is employed to investigate associations between such variables and distribution of different mosquitoes responsible for malaria transmission. Accurate prediction of risk depends on a number of variables, such as land use, NDVI, climatic factors, population, distance to health centres, ponds, streams and roads etc., all of which have an influence on malaria transmission or reporting. Climatic factors, particularly rainfall, temperature and relative humidity, are known to have a major influence on the biology of mosquitoes. To produce a malaria-susceptibility map using this method, weightings are calculated for various classes in each group. The groups are then superimposed to prepare a Malaria Susceptibility Index (MSI) map.

Results: We found that 3.87% of the malaria cases were found in areas with a low malaria-susceptibility level predicted from the model, whereas 39.86% and 26.29% of malaria cases were found in predicted high and very high susceptibility level areas, respectively.

Conclusions: Malaria susceptibility modelled using a GIS may have a role in predicting the risks of malaria and enable public health interventions to be better targeted.

Background: Telehealth has been promoted as an adjunct to managing patients with long-term conditions. It has been used in various settings and for different disease groups. However, robust evidence for the efficacy of telehealth is currently lacking.

Objectives: To evaluate the impact of a telehealth service on emergency admissions and emergency department (ED) attendances.

Methods: We evaluated a telehealth service providing supported self-management to patients that was implemented in Nottingham City. Two groups of patients ('graduates' of the Nottingham telehealth service and service 'decliners') were compared for two periods; 2009 (pre-service implementation) and 2011. Eighty-nine pairs of graduates and decliners were identified who were matched for age and sex. The number and cost of emergency admissions and ED attendances for these patients were then collated and analysed.

Results: Graduates had significantly fewer emergency admissions and ED attendances compared with decliners in 2011. However, differences of a similar magnitude in emergency admissions and ED attendances were found in 2009. Telehealth service users were likely to be qualitatively different from decliners, reflecting a degree of self-selection. This suggests that decliners were more likely to have a confounding reason for not engaging with telehealth, such as greater disease severity.

Conclusions: This service review found no evidence that the Nottingham telehealth service has had a significant impact on secondary care utilisation in the short term. Longer term follow up is needed to establish conclusively whether telehealth initiatives like the Nottingham telehealth service does lead to tangible patient benefits and provide value for money.

Purpose: Historically, parents have demonstrated poor understanding of adolescent healthcare laws. This study assessed US parents' current knowledge and opinions about technology facilitated physician-adolescent communication and applicable laws to enhance transition to adult health care.

Methods: A brief survey in two low-income academic paediatric clinics asked parents about their knowledge of health care and laws, and their opinions about technology facilitated contact between physicians and adolescents.

Results: Almost all parents (96.7%) have internet access at home, work or via a mobile device. Only 44.1% approved of having a physician directly contact their child about annual examinations, immunisations or to discuss issues of sexuality. Half (55.4%) were aware that adolescents could receive confidential sexuality information and treatment without parents' permission. Only one-third (32.2%) approved of a specific technology for direct communication.

Conclusions: Parents are divided about direct physician-adolescent contact. Future plans to engage adolescents to understand their health will require parental education and involvement on the value of physician-adolescent communication.

Background: The prevalence of diabetes is increasing with growing levels of obesity and an aging population. New practical guidelines for diabetes provide an applicable classification. Inconsistent coding of diabetes hampers the use of computerised disease registers for quality improvement, and limits the monitoring of disease trends.

Objective: To develop a consensus set of codes that should be used when recording diabetes diagnostic data.

Methods: The consensus approach was hierarchical, with a preference for diagnostic/disorder codes, to define each type of diabetes and non-diabetic hyperglycaemia, which were listed as being completely, partially or not readily mapped to available codes. The practical classification divides diabetes into type 1 (T1DM), type 2 (T2DM), genetic, other, unclassified and non-diabetic fasting hyperglycaemia. We mapped the classification to Read version 2, Clinical Terms version 3 and SNOMED CT.

Results: T1DM and T2DM were completely mapped to appropriate codes. However, in other areas only partial mapping is possible. Genetics is a fastmoving field and there were considerable gaps in the available labels for genetic conditions; what the classification calls 'other' the coding system labels 'secondary' diabetes. The biggest gap was the lack of a code for diabetes where the type of diabetes was uncertain. Notwithstanding these limitations we were able to develop a consensus list.

Conclusions: It is a challenge to develop codes that readily map to contemporary clinical concepts. However, clinicians should adopt the standard recommended codes; and audit the quality of their existing records.

Background: The electronic medical records software of the Catalan Institute of Health has recently incorporated an electronic version of clinical practice guidelines (e-CPGs). This study aims to assess the impact of the implementation of e-CPGs on the diagnosis, treatment, control and management of hypercholesterolaemia, diabetes mellitus type 2 and hypertension.

Methods: Eligible study participants are those aged 35-74 years assigned to family practitioners (FPs) of the Catalan Institute of Health. Routinely collected data from electronic primary care registries covering 80% of the Catalan population will be analysed using two approaches: (1) a cross-sectional study to describe the characteristics of the sample before e-CPG implementation; (2) a controlled before-and-after study with 1-year follow-up to ascertain the effect of e-CPG implementation. Patients of FPs who regularly use the e-CPGs will constitute the intervention group; the control group will comprise patients assigned to FPs not regularly using the e-CPG. The outcomes are: (1) suspected and confirmed diagnoses, (2) control of clinical variables, (3) requests for tests and (4) proportions of patients with adequate drug prescriptions.

Results: This protocol should represent a reproducible process to assess the impact of the implementation of e-CPGs. We anticipate reporting results in late 2013.

Conclusion: This project will assess the effectiveness of e-CPGs to improve clinical decisions and healthcare procedures in the three disorders analysed. The results will shed light on the use of evidence-based medicine to improve clinical practice of FPs.

Background: This is a study of the epidemiology of acute and chronic episodes of care (EoCs) in the Transition Project in three countries. We studied the duration of EoCs for acute and chronic health problems and the relationship of incidence to prevalence rates for these EoCs.

Method: The Transition Project databases collect data on all elements of the doctor-patient encounter in family medicine. Family doctors code these elements using the International Classification of Primary Care. We used the data from three practice populations to study the duration of EoCs and the ratio of incidence to prevalence for common health problems.

Results: We found that chronic health problems tended to have proportionately longer duration EoCs, as expected, but also a lower incidence to prevalence rate ratio than acute health problems. Thus, the incidence to prevalence index could be used to define a chronic condition as one with a low ratio, below a defined threshold.

Conclusions: Chronic health problems tend to have longer duration EoCs, proportionately, across populations. This result is expected, but we found important similarities and differences which make defining a problem as chronic on the basis of time rather difficult. The ratio of incidence to prevalence rates has potential to categorise health problems into acute or chronic categories, at different ratio thresholds (such as 20, 30 or 50%). It seems to perform well in this study of three family practice populations, and is proposed to the scientific community for further evaluation.

Background: A study is reported that examines the use of electronic health record (EHR) systems in two UK local health communities.

Objective: These systems were developed locally and the aim of the study was to explore how well they were supporting the coordination of care along healthcare pathways that cross the organisational boundaries between the agencies delivering health care.

Results: The paper presents the findings for two healthcare pathways; the Stroke Pathway and a pathway for the care of the frail elderly in their own homes. All the pathways examined involved multiple agencies and many locally tailored EHR systems are in use to aid the coordination of care. However, the ability to share electronic patient information along the pathways was patchy. The development of systems that did enable effective sharing of information was characterised by sociotechnical system development, i.e. associating the technical development with process changes and organisational changes, with local development teams that drew on all the relevant agencies in the local health community and on evolutionary development, as experience grew of the benefits that EHR systems could deliver.

Conclusions: The study concludes that whilst there may be a role for a national IT strategy, for example, to set standards for systems procurement that facilitate data interchange, most systems development work needs to be done at a 'middle-out' level in the local health community, where joint planning between healthcare agencies can occur, and at the local healthcare pathway level where systems can be matched to specific needs for information sharing.

Background: Demand is increasing for primary care to deliver effective weight management services to patients, but research suggests that staff feel inadequately resourced for such a role. Supporting service delivery with a free and effective web-based weight management programme could maximise primary care resource and provide cost-effective support for patients. However, integration of e-health into primary care may face challenges.

Objectives: To explore primary care staff experiences of delivering weight management services and their perceptions of a web-based weight management programme to aid service delivery.

Methods: Focus groups were conducted with primary care physicians, nurses and healthcare assistants (n = 36) involved in delivering weight loss services. Data were analysed using inductive thematic analysis.

Results: Participants thought that primary care should be involved in delivering weight management, especially when weight was aggravating health problems. However, they felt under-resourced to deliver these services and unsure as to the effectiveness of their input, as routine services were not evaluated. Beliefs that current services were ineffective resulted in staff reluctance to allocate more resources. Participants were hopeful that supplementing practice with a web-based weight management programme would enhance patient services and promote service evaluation.

Conclusions: Although primary care staff felt they should deliver weight loss services, low levels of faith in the efficacy of current treatments resulted in provision of under-resourced and 'ad hoc' services. Integration of a web-based weight loss programme that promotes service evaluation and provides a cost-effective option for supporting patients may encourage practices to invest more in weight management services.

Background: The system informs the nurse about levels of physical activity in the daily living of patients who are using the It's LiFe! tool. The tool consists of an accelerometer that transfers data to a smartphone, which is subsequently connected to a server. Nurses can monitor patients' physical activity via a secured website. Physical activity levels are measured in minutes per day compared with pre-set activity goals, which are set in dialogue with the patient.

Objective: To examine user requirements and to evaluate the usability of the secured website, in order to increase the probability of effective use by nurses.

Method: The needs and preferences of nurses towards the system were determined through qualitative research. The usability of the system was evaluated in a laboratory situation and during a three-month pilot study.

Results: A monitoring and feedback system to support patients in their intention to be more active was developed in a systematic way. Automatically generated feedback messages were defined based on the requirements of nurses. The results from the usability tests gave insights into how to improve the structure and quality of the information provided. Nurses were positive about the features and ease of use of the system, but made critical remarks about the time that its use entails.

Conclusion: The system supports nurses when performing physical activity counselling in a structured and profound way. The opportunity to support self-management of patients in between regular consultations needs further investigation, and adaptation into the clinical workflow of the nurses.