A structured registration program can be validly used for quality assessment in general practice

ABSTRACT: BACKGROUND: Patient information, medical history, clinical outcomes and demographic information, can be registered in different ways in registration programs. For evaluation of diabetes care, data can easily be extracted from a structured registration program (SRP). The usability of data from this source depends on the agreement of this data with that of the usual data registration in the electronic medical record (EMR). Aim of the study was to determine the comparability of data from an EMR and from an SRP, to determine whether the use of SRP data for quality assessment is justified in general practice. METHODS: We obtained 196 records of diabetes mellitus patients in a sample of general practices in the Netherlands. We compared the agreement between the two programs in terms of laboratory and non-laboratory parameters. Agreement was determined by defining accordance between the programs in absent and present registrations, accordance between values of registrations, and whether the differences found in values were also a clinically relevant difference. RESULTS: No differences were found in the occurrence of registration (absent/present) in the SRP and EMR for all the laboratory parameters. Smoking behaviour, weight and eye examination were registered significantly more often in the SRP than in the EMR. In the EMR, blood pressure was registered significantly more often than in the SRP. Data registered in the EMR and in the SRP had a similar clinical meaning for all parameters (laboratory and non-laboratory). CONCLUSIONS: Laboratory parameters showed good agreement and non-laboratory acceptable agreement of the SRP with the EMR. Data from a structured registration program can be used validly for research purposes and quality assessment in general practice

Costs of shoulder pain and resource use in primary health care: a cost-of-illness study in Sweden

<p>Abstract</p> <p>Background</p> <p>Painful shoulders pose a substantial socioeconomic burden. A prospective cost-of-illness study was performed to assess the costs associated with healthcare use and loss of productivity in patients with shoulder pain in primary health care in Sweden.</p> <p>Methods</p> <p>The study was performed in western Sweden, in a region with 24 000 inhabitants. Data were collected during six months from electronic patient records at three primary healthcare centres in two municipalities. All patients between 20 and 64 years of age who presented with shoulder pain to a general practitioner or a physiotherapist were included. Diagnostic codes were used for selection, and the cases were manually controlled. The cost for sick leave was calculated according to the human capital approach. Sensitivity analysis was used to explore uncertainty in various factors used in the model.</p> <p>Results</p> <p>204 (103 women) patients, mean age 48 (SD 11) years, were registered. Half of the cases were closed within six weeks, whereas 32 patients (16%) remained in the system for more than six months. A fifth of the patients were responsible for 91% of the total costs, and for 44% of the healthcare costs. The mean healthcare cost per patient was €326 (SD 389) during six months. Physiotherapy treatments accounted for 60%. The costs for sick leave contributed to 84% of the total costs. The mean annual total cost was €4139 per patient. Estimated costs for secondary care increased the total costs by one third.</p> <p>Conclusions</p> <p>The model applied in this study provides valuable information that can be used in cost evaluations. Costs for secondary care and particularly for sick leave have a major influence on total costs and interventions that can reduce long periods of sick leave are warranted.</p

The general practitioners perspective regarding registration of persistent somatic symptoms in primary care: a survey

BackgroundPersistent somatic symptoms (PSS) are common in primary care and often accompanied by an increasing disease burden for both the patient and healthcare. In medical practice, PSS is historically considered a diagnosis by exclusion or primarily seen as psychological. Besides, registration of PSS in electronic health records (EHR) is ambiguous and possibly does not reflect classification adequately. The present study explores how general practitioners (GPs) currently register PSS, and their view regarding the need for improvements in classification, registration, and consultations.MethodDutch GPs were invited by email to participate in a national cross-sectional online survey. The survey addressed ICPC-codes used by GPs to register PSS, PSS-related terminology added to free text areas, usage of PSS-related syndrome codes, and GPs’ need for improvement of PSS classification, registration and care.ResultsGPs (n = 259) were most likely to use codes specific to the symptom presented (89.3%). PSS-related terminology in free-text areas was used sparsely. PSS-related syndrome codes were reportedly used by 91.5% of GPs, but this was primarily the case for the code for irritable bowel syndrome. The ambiguous registration of PSS is reported as problematic by 47.9% of GPs. Over 56.7% of GPs reported needing additional training, tools or other support for PSS classification and consultation. GPs also reported needing other referral options and better guidelines.ConclusionsRegistration of PSS in primary care is currently ambiguous. Approximately half of GPs felt a need for more options for registration of PSS and reported a need for further support. In order to improve classification, registration and care for patients with PSS, there is a need for a more appropriate coding scheme and additional training.Stress-related psychiatric disorders across the life spa

Using electronic data from primary care to inform decision making for hypertension in the elderly

Hypertension is a major risk factor for cardiovascular disease and the main risk factor for stroke. Previous research has demonstrated that treatment of hypertension significantly reduces cardiovascular risk and the incidence of cardiovascular events. Since the prevalence of hypertension increases with age, so the absolute reduction in risk associated with treatment and its resultant benefits are greater in the elderly population. Despite this, a situation known as the rale of halves has been shown to exist. This indicates that half of the hypertensive population are not known, half of those known are not treated and half of those treated are not controlled. Addressing this anomaly requires information on all potentially at risk patients and accessing the large amounts of data held in general practice computer systems is one of the best ways of generating such information. However, whilst practitioners can access the information required to inform management of individual patients, the data required to inform strategic decision making are not as readily available. The research described in this thesis evaluates the provision of different levels of feedback, developed from computerized data, on identification, treatment and control of hypertension in the elderly. This was done by means of a randomised controlled trial. Fifty two Scottish general practices were recruited and randomised to three groups. A Control group which received no intervention, an Audit group which received feedback of audit data and a Strategic group which received audit feedback plus data prioritising patients by absolute risk of death from stroke. Electronic data on demography, morbidity and prescribing were extracted from practice computer systems annually from 1999-2001 and used to develop feedback. Participants represented both urban and rural practice and a range of practice size, list size and deprivation level. The data presented demonstrate that over the period of study, the proportion of 65-79 years olds with a blood pressure recorded increased, with the largest improvement seen in the Audit group. At the outset, 30-40% of the patients whose blood pressure was 160/90 mm Hg had been identified as being hypertensive. This improved in all three groups, the improvement made in the Audit and Control groups being two to three times that made in the Strategic group. The majority of diagnosed hypertensives were initially receiving treatment and this increased to more than 90% in all three groups. The greatest improvement was seen in the Strategic group. Around 40% of treated patients in each group had controlled high blood pressure at the outset of the study and this rose by around 10%. The lowest mean systolic blood pressure was found in the Strategic group, whilst the greatest proportions of controlled hypertensive patients were found in the Strategic and Control groups. However, after adjusting for clustering, patient and practice effects, there was a significant difference in the level of control in the Strategic group compared with the other two groups. Absolute risk was reduced for between 10-20% of patients in each group, with the largest reduction found in the Strategic group. More than 80% of the patients in that group had their blood pressure record updated compared with only half of the patients in the Audit and Control groups. In addition, twice as many patients in the Strategic group had their record changed to reflect that they did not smoke and fewer patients in that group were newly recorded as smokers. There was no significant difference in the numbers of patients in each group who had a stroke during the study period. Improvements were demonstrated in all aspects of the rule of halves, a finding supported by other studies in this area. Whilst 60%> of all hypertensive patients and 40% of treated hypertensives were still not controlled at the end of the study, the results suggest that providing practices with patient specific, strategic feedback can impact on identification and management of hypertension in the elderly, producing a consequent increase in blood pressure control. The study also demonstrates the utility of electronic primary care data and highlights the importance of practice organisation in the management of chronic disease

The quantitative epidemiology of canine neoplastic disease: risk factor identification using diagnostic histopathology data

Research was undertaken to investigate the risk factors for neoplasia in two canine biopsy populations, the first originating fi-om the Canine Infectious Diseases Research Unit (CIDRU) diagnostic histopathology service, based at the University of Glasgow Veterinary School (GUVS), and the second from the diagnostic histopathology service operated by a commercial organisation. Both provide histopathology reports to veterinary practitioners located throughout the United Kingdom and occasionally overseas. The studies were undertaken to determine the feasibility of using these data sources for meaningful epidemiological analyses of host-related risk factors for canine neoplasia. The analytical scope was expanded to explore the effect of submitting practice as a risk factor for canine neoplasia. Finally, spatial and spatio-temporal epidemiological techniques were applied to the CIDRU data to explore the significance of its geographical origin upon an outcome of neoplasia in a canine biopsy. Records pertaining to canine biopsy submissions were extracted from both histopathology databases. The records were subjected to a hierarchical and iterative data cleaning process, which focused upon the main host-related variables of age, gender and breed of dog, when available, and biopsy site of origin. This procedure highlighted a number of important quality assurance issues in both datasets. The coding system used in the CIDRU database was found to be adequate for assisting data preparation, although there were issues relating to the lack of integral data checks and the use of free text input. The extensive use of free text input for the commercial dataset limited the amount of data content that could be prepared fi-om this database for subsequent analysis. Following establishment of data integrity, case-control studies of the cleaned datasets were performed. Multivariable logistic regression was used to assess the effect of the host- related risk factors of age, gender and breed of dog, when available, and site of biopsy, on the outcome of neoplasia in a biopsy submitted to the histopathology service. Similar results were produced in analyses of both datasets. The grouping of data by submitting veterinary practice was considered to cause violation of the assumption of independence for individual biopsies because of unknown practice-related factors associated with biopsy submission. Following the application of inclusion criteria to the data, a practice variable was entered into the host related multivariable models first as a fixed-effect term, then as a random- effect term. The introduction of a variable for practice verified that group effects due to practice were significant in the data from both histopathology services. Spatial and space-time analyses were conducted on the CIDRU dataset using spatial and space-time scan statistics. Graphical display of the results with a Geographical Information System (GIS) illustrated a trend for clusters with low risk of neoplasia diagnosis in biopsies submitted from the north of the UK compared to high risk clusters located in the south of the country. A number of individual practices caused significant subclusters within the main clusters, leading to the proposal of conducting practice-based research to investigate practice-related factors that influence tissue biopsy submission. It was concluded that the histopathology databases provided data suitable for the epidemiological analysis of host-related risk factors for canine neoplasia. The findings of the studies suggest that future research should focus upon identification of factors within individual practices which directly influence the procurement of tissue for histopathological analysis, to accurately ascertain their effect upon the diagnosis of neoplasia in canine biopsies. Practice-based research may also provide insight into differences in geographical occurrence of canine neoplasia, which may lead to the generation of hypotheses regarding possible environmental factors contributing to the aetiology of canine neoplastic disease

Clinical foundations and information architecture for the implementation of a federated health record service

Clinical care increasingly requires healthcare professionals to access patient record information that may be distributed across multiple sites, held in a variety of paper and electronic formats, and represented as mixtures of narrative, structured, coded and multi-media entries. A longitudinal person-centred electronic health record (EHR) is a much-anticipated solution to this problem, but its realisation is proving to be a long and complex journey. This Thesis explores the history and evolution of clinical information systems, and establishes a set of clinical and ethico-legal requirements for a generic EHR server. A federation approach (FHR) to harmonising distributed heterogeneous electronic clinical databases is advocated as the basis for meeting these requirements. A set of information models and middleware services, needed to implement a Federated Health Record server, are then described, thereby supporting access by clinical applications to a distributed set of feeder systems holding patient record information. The overall information architecture thus defined provides a generic means of combining such feeder system data to create a virtual electronic health record. Active collaboration in a wide range of clinical contexts, across the whole of Europe, has been central to the evolution of the approach taken. A federated health record server based on this architecture has been implemented by the author and colleagues and deployed in a live clinical environment in the Department of Cardiovascular Medicine at the Whittington Hospital in North London. This implementation experience has fed back into the conceptual development of the approach and has provided "proof-of-concept" verification of its completeness and practical utility. This research has benefited from collaboration with a wide range of healthcare sites, informatics organisations and industry across Europe though several EU Health Telematics projects: GEHR, Synapses, EHCR-SupA, SynEx, Medicate and 6WINIT. The information models published here have been placed in the public domain and have substantially contributed to two generations of CEN health informatics standards, including CEN TC/251 ENV 13606

ERP implementation methodologies and frameworks: a literature review

Enterprise Resource Planning (ERP) implementation is a complex and vibrant process, one that involves a combination of technological and organizational interactions. Often an ERP implementation project is the single largest IT project that an organization has ever launched and requires a mutual fit of system and organization. Also the concept of an ERP implementation supporting business processes across many different departments is not a generic, rigid and uniform concept and depends on variety of factors. As a result, the issues addressing the ERP implementation process have been one of the major concerns in industry. Therefore ERP implementation receives attention from practitioners and scholars and both, business as well as academic literature is abundant and not always very conclusive or coherent. However, research on ERP systems so far has been mainly focused on diffusion, use and impact issues. Less attention has been given to the methods used during the configuration and the implementation of ERP systems, even though they are commonly used in practice, they still remain largely unexplored and undocumented in Information Systems research. So, the academic relevance of this research is the contribution to the existing body of scientific knowledge. An annotated brief literature review is done in order to evaluate the current state of the existing academic literature. The purpose is to present a systematic overview of relevant ERP implementation methodologies and frameworks as a desire for achieving a better taxonomy of ERP implementation methodologies. This paper is useful to researchers who are interested in ERP implementation methodologies and frameworks. Results will serve as an input for a classification of the existing ERP implementation methodologies and frameworks. Also, this paper aims also at the professional ERP community involved in the process of ERP implementation by promoting a better understanding of ERP implementation methodologies and frameworks, its variety and history

Perceptions of nurses with regard to the use of computer information technology at primary health care clinics in the eastern part of Ekurhuleni

M.Cur. (Nursing Management)Information technology is the management of a computer-based information system, particularly software applications and computer hardware, which are used to handle all aspects of information storage, retrieval, transmittal, protection, and processing information securely. The lack of reliable health information is one of the major obstacles to the effective planning of the health services in South Africa. The existing information systems are fragmented and incompatible; most systems are manually driven with minimal computerisation which results in inadequate analysis, interpretation and the use of data at PHC level. The use of computer information technology in the health facilities will improve service delivery; reduce the cost of providing health care; and enhance the management and control of service. Yet, it seems that nurses are insufficiently using computer information technology at the PHC clinics in the eastern part of Ekurhuleni. It has been observed that nurses do not use Computer Information Technology (CIT) to the benefit of the clients. It was unclear what the perceptions of PHC professional nurses about CIT were. The purpose of this study was to explore and describe the perceptions of primary health care nurses with regard to the use of Computer Information Technology (CIT) with the purpose of recommending the actions to be taken by the nurse manager about computer information technology. In this study a quantitative, exploratory and descriptive design was used in order to obtain factual reasoning and information from professional nurses working at five (5) primary health clinics in the eastern part of Ekurhuleni. The total sample of professional nurses was n = 150. The method of data collection was a self-administered and structured survey- questionnaire that took 30 minutes to complete. Descriptive statistics were compiled by using the Statistical Package of the Social Sciences (SPSS) Version 20 software program. Validity and reliability were ensured by the judgments of the researcher and experts about whether the research instrument had covered the comprehensive set of facets that encompassed the concepts (the use of information technology at primary health care clinics). It also included pre-testing of the instrument to establish the consistency with which participants understood, interpreted and responded to all the carefully formulated questions in the survey-questionnaire. Ethical principles and standards for nurse researchers were adhere to. The findings indicated that there were aspects that need to be addressed in respect of the use of information technology in primary health care clinics. Limitations of study and the recommendations for nursing practice, management and research were discussed. This study determined the perceptions of nurses with regard to the use of computer information technology at the PHC clinics that lead to recommendations on the actions to be taken by the nurse managers about the use of computer information technology at PHC clinics