Secondary use of data recorded in primary care: insights from human computer interaction field studies

Introduction: Electronic health records from primary care, are now aggregated in a number of large datasets from primary care settings, containing both coded data and free-text. Secondary users can easily undertake analyses using coded data. However although the balance of information between these codes and free text is variable, they rarely use the information contained in doctors’ free-text notes - because of their ‘messy’ nature and the costs of ensuring anonymity. Our epidemiological studies within the Patient Records Enhancement Project has demonstrated that free text contains important information, that is often ignored. Method: Human computer interaction (HCI) studies, using qualitative approaches, can help us understand the reasons for variability in the balance of coded and free text data. We undertook field studies in six GP surgeries which included observations of record use across the surgery, video analysis of real patient consultations and interviews with a range of surgery staff. We also undertook ‘simulated’ consultations, with two medical actors playing the part of the patient, allowing us to standarise the patient across doctors and software systems. Results: Preliminary results suggest several reasons for variation in data recording. Doctors create notes in order to best manage patients with little consideration for use by others, and reported limited awareness of secondary uses of the information. Doctors often record and “read” a picture painted by the overall record of a consultation or record symptoms and signs in free text notes, and choose not to code a definite diagnosis. If coding, they often choose a more general non specific code, even when they have inferred and acted on a clear diagnosis. These approaches reflect processes of progressing from differential to definite diagnosis, and the surgery’s administrative and consultation processes. Conclusion: Our findings may explain apparent delays in diagnosis often observed in epidemiological analyses. The picture portrayed within records may not be at all clear to researchers relying on coded data. Our results have implications for secondary users of data and assessment of data for quality of care. Follow on work might result in typologies of diseases liable to coded data deficits and support software development

Remote working: survey of attitudes to eHealth of doctors and nurses in rural general practices in the United Kingdom.

BACKGROUND: Health professionals in rural primary care could gain more from eHealth initiatives than their urban counterparts, yet little is known about eHealth in geographically isolated areas of the UK. OBJECTIVE: To elicit current use of, and attitudes towards eHealth of professionals in primary care in remote areas of Scotland. METHODS: In 2002, a questionnaire was sent to all general practitioners (n=154) in Scotland's 82 inducement practices, and to 67 nurses. Outcome measures included reported experience of computer use; access to, and experience of eHealth and quality of that experience; views of the potential usefulness of eHealth and perceived barriers to the uptake of eHealth. RESULTS: Response rate was 87%. Ninety-five percent of respondents had used either the Internet or email. The proportions of respondents who reported access to ISDN line, scanner, digital camera, and videoconferencing unit were 71%, 48%, 40% and 36%, respectively. Use of eHealth was lower among nurses than GPs. Aspects of experience that were rated positively were 'clinical usefulness', 'functioning of equipment' and 'ease of use of equipment' (76%, 74%, and 74%, respectively). The most important barriers were 'lack of suitable training' (55%), 'high cost of buying telemedicine equipment' (54%), and 'increase in GP/nurse workload' (43%). Professionals were concerned about the impact of tele-consulting on patient privacy and on the consultation itself. CONCLUSIONS: Although primary healthcare professionals recognize the general benefits of eHealth, uptake is low. By acknowledging barriers to the uptake of eHealth in geographically isolated settings, broader policies on its implementation in primary care may be informed

Comparing the content and quality of video, telephone, and face-to-face consultations: a non-randomised, quasi-experimental, exploratory study in UK primary care

Growing demands on primary care services have led to policymakers promoting video consultations (VCs) to replace routine face-to-face consultations (FTFCs) in general practice. AIM: To explore the content, quality, and patient experience of VC, telephone (TC), and FTFCs in general practice. DESIGN AND SETTING: Comparison of audio-recordings of follow-up consultations in UK primary care. METHOD: Primary care clinicians were provided with video-consulting equipment. Participating patients required a smartphone, tablet, or computer with camera. Clinicians invited patients requiring a follow-up consultation to choose a VC, TC, or FTFC. Consultations were audio-recorded and analysed for content and quality. Participant experience was explored in post-consultation questionnaires. Case notes were reviewed for NHS resource use. RESULTS: Of the recordings, 149/163 were suitable for analysis. VC recruits were younger, and more experienced in communicating online. FTFCs were longer than VCs (mean difference +3.7 minutes, 95% confidence interval [CI] = 2.1 to 5.2) or TCs (+4.1 minutes, 95% CI = 2.6 to 5.5). On average, patients raised fewer problems in VCs (mean 1.5, standard deviation [SD] 0.8) compared with FTFCs (mean 2.1, SD 1.1) and demonstrated fewer instances of information giving by clinicians and patients. FTFCs scored higher than VCs and TCs on consultation-quality items. CONCLUSION: VC may be suitable for simple problems not requiring physical examination. VC, in terms of consultation length, content, and quality, appeared similar to TC. Both approaches appeared less 'information rich' than FTFC. Technical problems were common and, though patients really liked VC, infrastructure issues would need to be addressed before the technology and approach can be mainstreamed in primary care.Chief Scientist Office for Scotlan

Achieving benefit for patients in primary care informatics: the report of a international consensus workshop at Medinfo 2007

Background Landmark reports suggest that sharing health data between clinical computer systems should improve patient safety and the quality of care. Enhancing the use of informatics in primary care is usually a key part of these strategies. Aim To synthesise the learning from the international use of informatics in primary care. Method The workshop was attended by 21 delegates drawn from all continents. There were presentations from USA, UK and the Netherlands, and informal updates from Australia, Argentina, and Sweden and the Nordic countries. These presentations were discussed in a workshop setting to identify common issues. Key principles were synthesised through a post-workshop analysis and then sorted into themes. Results Themes emerged about the deployment of informatics which can be applied at health service, practice and individual clinical consultation level: 1 At the health service or provider level, success appeared proportional to the extent of collaboration between a broad range of stakeholders and identification of leaders. 2 Within the practice much is currently being achieved with legacy computer systems and apparently outdated coding systems. This includes prescribing safety alerts, clinical audit and promoting computer data recording and quality. 3 In the consultation the computer is a 'big player' and may make traditional models of the consultation redundant. Conclusions We should make more efforts to share learning; develop clear internationally acceptable definitions; highlight gaps between pockets of excellence and real-world practice, and most importantly suggest how they might be bridged. Knowledge synthesis from different health systems may provide a greater understanding of how the third actor (the computer) is best used in primary care

TABLE (TABLE AND BED LABORATORY EXPERIMENT) TRIAL: A RANDOMIZED CONTROLLED TRIAL OF CONSULTATION ROOM LAYOUTS.

Abstract OBJECTIVE: The outpatient consultation room remains unchanged despite increasing use of technology mediated information sharing in the clinical encounter. The growth of outpatient medical care makes outpatient facilities the primary point of healthcare contact for many Americans. We propose implementing an adaptive design that supports a patient-centered approach to care. STUDY DESIGN: A randomized control trial conducted at the University of Kansas School of Medicine (KUSM) internal medicine resident clinic in Wichita, Kansas. METHODS: Fifty-nine patients were randomly assigned to consultation in a traditional room (n = 33) with a rectangular shaped examination table or in an experimental room (n = 26) with a round pedestal table. The care offered by the physician was not affected; however, room layouts and strategic placement of the laptop computer were different for both groups. Physicians did not have access to the survey. Patients completed a 5-point Likert scale post-visit questionnaire. The key features of this program were: a newly redesigned (experimental) consultation room featuring a round pedestal table in the experimental room allowing for a sitting style that enhances good proximity between the physician, patient and the computer screen used in information sharing during the visit; and a traditional room, featuring a rectangular padded examination table. All other features in the room layout were the same including room size, sink location, and number of seats in the room. Wilcoxon rank sum test was used to assess the combination score on each domain between the intervention and control group. The questionnaire was broken into domains with calculated response scores within each domain scaled from 0 to 100. RESULTS: A statistically significant difference in interpersonal-room interaction was found between the experimental room (65.24 ± 17.25) versus the traditional room (49.12 ± 22.35) scores (P = 0.0038). A higher percentage of participants in the experimental room reported their ability "to look at the information on the computer screen at any time they wanted" (24% vs. 12.9%) compared with the control group. More participants indicated that "provider shared information on the computer screen" for the experimental room (54.2% vs. 22.6%) than in the traditional room. Over half of subjects (72%) in the experimental room compared to the traditional room (40.6%) indicated complete agreement to "provider's engaging them in conversation about the information in the monitor". Patients reported that they were "able to look at the internet with the provider" with a total agreement response of 32% among the experimental room compared to 9.7% in the control group. There was no difference in patient satisfaction (P = 0.5524), mutual respect and communication quality (P = 0.8288), people-room interaction (P = 0.5892), or trust in physician (P = 0.5892). CONCLUSION: Changing the layout of a consultation room has the potential to improve information sharing. Clinicians who are interested in maximizing the benefits of their clinical encounter could consider changing the layout of their consultation room, especially the positioning of the computer screen

Acceptability, benefits, and challenges of video consulting: a qualitative study in primary care

Background People increasingly communicate online, using visual communication mediums such as Skype and FaceTime. Growing demands on primary care services mean that new ways of providing patient care are being considered. Video consultation (VC) over the internet is one such mode. Aim To explore patients’ and clinicians’ experiences of VC. Design and setting Semi-structured interviews in UK primary care. Method Primary care clinicians were provided with VC equipment. They invited patients requiring a follow-up consultation to an online VC using the Attend Anywhere web-based platform. Participating patients required a smartphone, tablet, or video-enabled computer. Following VCs, semi-structured interviews were conducted with patients (n = 21) and primary care clinicians (n = 13), followed by a thematic analysis. Results Participants reported positive experiences of VC, and stated that VC was particularly helpful for them as working people and people with mobility or mental health problems. VCs were considered superior to telephone consultations in providing visual cues and reassurance, building rapport, and improving communication. Technical problems, however, were common. Clinicians felt, for routine use, VCs must be more reliable and seamlessly integrated with appointment systems, which would require upgrading of current NHS IT systems. Conclusion The visual component of VCs offers distinct advantages over telephone consultations. When integrated with current systems VCs can provide a time-saving alternative to face-to-face consultations when formal physical examination is not required, especially for people who work. Demand for VC services in primary care is likely to rise, but improved technical infrastructure is required to allow VC to become routine. However, for complex or sensitive problems face-to-face consultations remain preferable

Chest pain in primary care: is the localization of pain diagnostically helpful in the critical evaluation of patients? - A cross sectional study

BACKGROUND: Chest pain is a common complaint and reason for consultation in primary care. Traditional textbooks still assign pain localization a certain discriminative role in the differential diagnosis of chest pain. The aim of our study was to synthesize pain drawings from a large sample of chest pain patients and to examine whether pain localizations differ for different underlying etiologies. METHODS: We conducted a cross-sectional study including 1212 consecutive patients with chest pain recruited in 74 primary care offices in Germany. Primary care providers (PCPs) marked pain localization and radiation of each patient on a pictogram. After 6 months, an independent interdisciplinary reference panel reviewed clinical data of every patient, deciding on the etiology of chest pain at the time of patient recruitment. PCP drawings were entered in a specially designed computer program to produce merged pain charts for different etiologies. Dissimilarities between individual pain localizations and differences on the level of diagnostic groups were analyzed using the Hausdorff distance and the C-index. RESULTS: Pain location in patients with coronary heart disease (CHD) did not differ from the combined group of all other patients, including patients with chest wall syndrome (CWS), gastro-esophageal reflux disease (GERD) or psychogenic chest pain. There was also no difference in chest pain location between male and female CHD patients. CONCLUSIONS: Pain localization is not helpful in discriminating CHD from other common chest pain etiologies

Doctor-patient interaction in Finnish primary health care as perceived by first year medical students

BACKGROUND: In Finland, public health care is the responsibility of primary health care centres, which render a wide range of community level preventive, curative and rehabilitative medical care. Since 1990's, medical studies have involved early familiarization of medical students with general practice from the beginning of the studies, as this pre-clinical familiarisation helps medical students understand patients as human beings, recognise the importance of the doctor-patient relationship and identify practicing general practitioners (GPs) as role models for their professional development. Focused on doctor-patient relationship, we analysed the reports of 2002 first year medical students in the University of Kuopio. The students observed GPs' work during their 2-day visit to primary health care centres. METHODS: We analysed systematically the texts of 127 written reports of 2002, which represents 95.5% of the 133 first year pre-clinical medical students reports. The reports of 2003 (N = 118) and 2004 (N = 130) were used as reference material. RESULTS: Majority of the students reported GPs as positive role models. Some students reported GPs' poor attitudes, which they, however, regarded as a learning opportunity. Students generally observed a great variety of responsibilities in general practice, and expressed admiration for the skills and abilities required. They appreciated the GPs' interest in patients concerns. GPs' communication styles were found to vary considerably. Students reported some factors disturbing the consultation session, such as the GP staring at the computer screen and other team members entering the room. Working with marginalized groups, the chronically and terminally ill, and dying patients was seen as an area for development in the busy Finnish primary health care centres. CONCLUSION: During the analysis, we discovered that medical students' perceptions in this study are in line with the previous findings about the importance of role model (good or bad) in making good doctors. Therefore, medical students' pre-clinical primary health care centre visits may influence their attitudes towards primary health care work and the doctor-patient relationship. We welcome more European studies on the role of early pre-clinical general practice exposure on medical students' primary care specialty choice

A study of general practitioners' perspectives on electronic medical records systems in NHS Scotland

<b>Background</b> Primary care doctors in NHSScotland have been using electronic medical records within their practices routinely for many years. The Scottish Health Executive eHealth strategy (2008-2011) has recently brought radical changes to the primary care computing landscape in Scotland: an information system (GPASS) which was provided free-of-charge by NHSScotland to a majority of GP practices has now been replaced by systems provided by two approved commercial providers. The transition to new electronic medical records had to be completed nationally across all health-boards by March 2012. <p></p><b> Methods</b> We carried out 25 in-depth semi-structured interviews with primary care doctors to elucidate GPs' perspectives on their practice information systems and collect more general information on management processes in the patient surgical pathway in NHSScotland. We undertook a thematic analysis of interviewees' responses, using Normalisation Process Theory as the underpinning conceptual framework. <p></p> <b>Results</b> The majority of GPs' interviewed considered that electronic medical records are an integral and essential element of their work during the consultation, playing a key role in facilitating integrated and continuity of care for patients and making clinical information more accessible. However, GPs expressed a number of reservations about various system functionalities - for example: in relation to usability, system navigation and information visualisation. <b>Conclusion </b>Our study highlights that while electronic information systems are perceived as having important benefits, there remains substantial scope to improve GPs' interaction and overall satisfaction with these systems. Iterative user-centred improvements combined with additional training in the use of technology would promote an increased understanding, familiarity and command of the range of functionalities of electronic medical records among primary care doctors

Electronic Consultations Between Primary and Specialty Care Clinicians: Early Insights

Outlines how e-consultation enables clinicians and specialists to communicate more easily and reduce the need for in-person referrals; experiences for patients, clinicians, and health systems; benefits such as continuity of care; and barriers to adoption