Development of functional requirements for electronic health communication: preliminary results from the ELIN project

Background User participation is important for developing a functional requirements specification for electronic communication. General practitioners and practising specialists, however, often work in small practices without the resources to develop and present their requirements. It was necessary to find a method that could engage practising doctors in order to promote their needs related to electronic communication. Materials and methods Qualitative research methods were used, starting a process to develop and study documents and collect data from meetings in project groups. Triangulation was used, in that the participants were organised into a panel of experts, a user group, a supplier group and an editorial committee. Results The panel of experts created a list of functional requirements for electronic communication in health care, consisting of 197 requirements, in addition to 67 requirements selected from an existing Norwegian standard for electronic patient records (EPRs). Elimination of paper copies sent in parallel with electronic messages, optimal workflow, a common electronic 'envelope' with directory services for units and end-users, and defined requirements for content with the possibility of decision support were the most important requirements. Conclusions The results indicate that we have found a method of developing functional requirements which provides valid results both for practising doctors and for suppliers of EPR systems

Expectations for the next generation of electronic patient records in primary care: a triangulated study

Background Although primary care physicians are satisfied users of electronic patient records (EPRs) in Norway today, EPR systems may not have reached their full potential. We studied primary care physicians' needs and experiences in relation to EPRs and analysed potential improvements for today's EPR systems. Respondents and methods This is a triangulatedstudy that compares qualitative and quantitative data from focus groups, observations of primary care encounters and a questionnaire survey. Results General practioners (GPs) were not satisfied with the level of availability of information within EPR systems. They were especially concerned about follow-up for chronic disease and dealing with patients with multiple conditions. Many expressed a desire for reminders and easier access to clinical guidelines under normal working conditions, as well as the possibility of consultations with specialists from their EPR systems. GPs placed importance on the ability to communicate electronically with patients. Conclusions Progress toward a problem-oriented EPR system based on episodes of care that includes decision support is necessary to satisfy the needs expressed by GPs. Further research could solve the problem of integration of functionality for consultation with specialists and integration with patient held records. Results from this study could contribute to further development of the next generation of EPRs in primary care, as well as inspire the application of EPRs in other parts of the health sector

GPs’ prescription routines and cooperation with other healthcare personnel before and after implementation of multidose drug dispensing

Beskriver en survey hvor hensikten var å undersøke fastlegers holdninger til og erfaringer med multidose, og deres erfaringer knyttet til hvordan multidose påvirker foreskriving og rutiner for kommunikasjon med hjemmeboende pasienter.Background: this study addresses GPs’ attitudes towards multidose drug dispensing before and after implementation and their perceived experience of how multidose drug dispensing affects prescription and communication routines for patients in the home care services. This study contributes to a method triangulation with two other studies on the introduction of multidose drug dispensing in Trondheim. Methods: a controlled before-and-after study carried out in Trondheim (intervention) and Tromsø (control). A questionnaire was distributed to all GPs in the two towns in 2005 with a followup questionnaire in 2008. Results: the GPs in Trondheim showed a positive attitude to multidose drug dispensing both before and after the implementation. Increased workload was reported, but still the GPs wanted the system to be continued. Most of the GPs reported a better overview of the patients’ medication and a supposed reduction in medication errors. The GPs’ prescription- and communication routines were changed only for the multidose drug users and not for the other patients in the home care services. Conclusions: the study supports the results presented in two previous publications according to GPs’ positive attitude towards multidose drug dispensing, their better overview of the patients’ medications, and improved cooperation with the pharmacy. This study adds to our understanding of prescription routines among GPs and the use of the medication module in the electronic health record

Development of a patient-centred care pathway across healthcare providers: a qualitative study

BACKGROUND: Different models for care pathways involving both specialist and primary care have been developed to ensure adequate follow-up after discharge. These care pathways have mainly been developed and run by specialist care and have been disease-based. In this study, primary care providers took the initiative to develop a model for integrated care pathways across care levels for older patients in need of home care services after discharge. Initially, the objective was to develop pathways for patients diagnosed with heart failure, COPD and stroke. The aim of this paper is to investigate the process and the experiences of the participants in this developmental work. The participants were drawn from three hospitals, six municipalities and patient organizations in Central Norway. METHODS: This qualitative study used focus group interviews, written material and observations. Representatives from the hospitals, municipalities and patient organizations taking part in the development process were chosen as informants. RESULTS: The development process was very challenging because of the differing perspectives on care and different organizational structures in specialist care and primary care. In this study, the disease perspective, being dominant in specialist care, was not found to be suitable for use in primary health care because of the need to cover a broader perspective including the patient’s functioning, social situation and his or her preferences. Furthermore, managing several different disease-based care pathways was found to be unsuitable in home care services, as well as unsuitable for a population characterized by a substantial degree of comorbidity. The outcome of the development process was a consensus that outlined a single, common patient-centred care pathway for transition from hospital to follow-up in primary care. The pathway was suitable for most common diseases and included functional and social aspects as well as disease follow-up, thus merging the differing perspectives. The disease-based care pathways were kept for use within the hospitals. CONCLUSIONS: Disease-based care pathways for older patients were found to be neither feasible nor sustainable in primary care. A common patient-centred care pathway that could meet the needs of multi- morbid patients was recommended

Can Electronic Tools Help Improve Nursing Home Quality?

Background. Nursing homes face challenges in the coming years due to the increased number of elderly. Quality will be under pressure, expectations of the services will rise, and clinical complexity will grow. New strategies are needed to meet this situation. Modern clinical information systems with decision support may be part of that. Objectives. To study the impact of introducing an electronic patient record system with decision support on the use of warfarin, neuroleptics and weighing of patients, in nursing homes. Methods. A prevalence study was performed in seven nursing homes with 513 subjects. A before-after study with internal controls was performed. Results. The prevalence of atrial fibrillation in the seven nursing homes was 18.8%. After intervention, the proportion of all patients taking warfarin increased from 3.0% to 9.8% (P = 0.0086), neuroleptics decreased from 33.0% to 21.5% (P = 0.0121), and the proportion not weighed decreased from 72.6% to 16.0% (P < 0.0001). The internal controls did not change significantly. Conclusion. Statistics and management data can be continuously produced to monitor the quality of work processes. The electronic health record system and its system for decision support can improve drug therapy and monitoring of treatment policy

Multidose drug dispensing and discrepancies between medication records

Beskriver en kontrollert studie hvor hensikten var å undersøke om innføring av multidose hos hjemmeboende påvirker grad av samstemt legemiddelinformasjon hos fastlege og hjemmesykepleien.Background: the objective of this study was to investigate whether implementation of multidose drug dispensing (MDD) for elderly outpatients is associated with a change in the number of discrepancies in the medication record at the general practitioners (GPs) and at the community home-care services. Methods: a controlled follow-up study with paired design of patients’ medication records was performed during implementation of MDD. Medication records from the home care units and from the GPs were reviewed, and the discrepancies were noted. The discrepancies were rated into four classes based upon the potential harm, and a risk score system was applied, giving the potentially most harmful discrepancies the highest score. Results: medication records from 59 patients with a mean age of 80 years were included. The number of discrepancies was reduced from 203 to 133 (p<0.001), and the total risk score decreased from 308 to 181 (p<0.001) after the implementation of MDD. For both drugs subject to MDD and drugs not suitable for MDD, the reductions in discrepancies were significant (39% and 31% reduction respectively). Conclusions: calculated health risk due to discrepancies between the medication records from the home-care service and from the GPs decreased during the time of implementation of the MDD system. It seems likely that most of the positive effect was caused by the change in routines and enhanced focus on the medication process rather than by MDD per se

Hospital Admissions from Nursing Homes: Rates and Reasons

Hospital admissions from nursing homes have not previously been investigated in Norway. During 12 months all hospital admissions (acute and elective) from 32 nursing homes in Bergen were recorded via the Norwegian ambulance register. The principal diagnosis made during the stay, length of stay, and the ward were sourced from the hospital's data register and data were merged. Altogether 1,311 hospital admissions were recorded during the 12 months. Admissions from nursing homes made up 6.1% of the total number of admissions to medical wards, while for surgical wards they made up 3.8%. Infections, fractures, cardiovascular and gastri-related diagnoses represented the most frequent admission diagnoses. Infections accounted for 25.0% of admissions, including 51.0% pneumonias. Of all the admissions, fractures were the cause in 10.2%. Of all fractures, hip fractures represented 71.7. The admission rate increased as the proportion of short-term beds increased, and at nursing homes with short-term beds, admissions increased with increasing physician coverage. Potential reductions in hospitalizations for infections from nursing homes may play a role to reduce pressure on medical departments as may fracture prevention. Solely increasing physician coverage in nursing homes will probably not reduce the number of hospitalizations

Helhetlige pasientforløp – gjennomføring i primærhelsetjenesten

Et av hovedmålene i samhandlingsreformen har vært at kommuner i samarbeid med sykehus skal kunne tilby helhetlige og integrerte tjenester før og etter sykehusopphold, basert på sammenhengende pasientforløp. Kommuner og foretak er derfor i den nye helse- og omsorgsloven blitt pålagt å inngå forpliktende samarbeidsavtaler om innleggelse og utskrivning av pasienter. Vi har fulgt noen sykehus og kommuner som sammen har forsøkt å utvikle helhetlige pasientforløp for KOLS, hjertesvikt, slag og hoftebrudd som også omfattet oppfølging i kommunen. Vi finner at spesialisering av tjenester og personell i primærhelsetjenesten for oppfølging av spesifikke diagnoser hverken er bærekraftig eller funksjonelt. I tillegg vil det å forlenge diagnosespesifikke forløp fra sykehus ut i kommunen bidra til fragmentering av tjenestene til eldre og kronisk syke. I noen av kommunene ble det utviklet og tatt i bruk generisk diagnoseuavhengige forløp. Det fungerte for disse kommunene og framstår som en mer bærekraftig modell. Nøkkelord: Samhandling, behandlingslinje, kommunehelsetjeneste, hjemmesykepleie, utskrivningsklare pasienter, multisyke pasienter.Helhetlige pasientforløp – gjennomføring i primærhelsetjenestenpublishedVersio

Instant availability of patient records, but diminished availability of patient information: A multi-method study of GP's use of electronic patient records

<p>Abstract</p> <p>Background</p> <p>In spite of succesful adoption of electronic patient records (EPR) by Norwegian GPs, what constitutes the actual benefits and effects of the use of EPRs in the perspective of the GPs and patients has not been fully characterized. We wanted to study primary care physicians' use of electronic patient record (EPR) systems in terms of use of different EPR functions and the time spent on using the records, as well as the potential effects of EPR systems on the clinician-patient relationship.</p> <p>Methods</p> <p>A combined qualitative and quantitative study that uses data collected from focus groups, observations of primary care encounters and a questionnaire survey of a random sample of general practitioners to describe their use of EPR in primary care.</p> <p>Results</p> <p>The overall availability of individual patient records had improved, but the availability of the information within each EPR was not satisfactory. GPs' use of EPRs were efficient and comprehensive, but have resulted in transfer of administrative work from secretaries to physicians. We found no indications of disturbance of the clinician-patient relationship by use of computers in this study.</p> <p>Conclusion</p> <p>Although GPs are generally satisfied with their EPRs systems, there are still unmet needs and functionality to be covered. It is urgent to find methods that can make a better representation of information in large patient records as well as prevent EPRs from contributing to increased administrative workload of physicians.</p

Assessment of ePrescription quality: an observational study at three mail-order pharmacies

<p>Abstract</p> <p>Background</p> <p>The introduction of electronic transfer of prescriptions (ETP) or ePrescriptions in ambulatory health care has been suggested to have a positive impact on the prescribing and dispensing processes. Thereby, implying that ePrescribing can improve safety, quality, efficiency, and cost-effectiveness. In December 2007, 68% of all new prescriptions were transferred electronically in Sweden. The aim of the present study was to assess the quality of ePrescriptions by comparing the proportions of ePrescriptions and non-electronic prescriptions necessitating a clarification contact (correction, completion or change) with the prescriber at the time of dispensing.</p> <p>Methods</p> <p>A direct observational study was performed at three Swedish mail-order pharmacies which were known to dispense a large proportion of ePrescriptions (38–75%). Data were gathered on all ePrescriptions dispensed at these pharmacies over a three week period in February 2006. All clarification contacts with prescribers were included in the study and were classified and assessed in comparison with all drug prescriptions dispensed at the same pharmacies over the specified period.</p> <p>Results</p> <p>Of the 31225 prescriptions dispensed during the study period, clarification contacts were made for 2.0% (147/7532) of new ePrescriptions and 1.2% (79/6833) of new non-electronic prescriptions. This represented a relative risk (RR) of 1.7 (95% CI 1.3–2.2) for new ePrescriptions compared to new non-electronic prescriptions. The increased RR was mainly due to 'Dosage and directions for use', which had an RR of 7.6 (95% CI 2.8–20.4) when compared to other clarification contacts. In all, 89.5% of the suggested pharmacist interventions were accepted by the prescriber, 77.7% (192/247) as suggested and an additional 11.7% (29/247) after a modification during contact with the prescriber.</p> <p>Conclusion</p> <p>The increased proportion of prescriptions necessitating a clarification contact for new ePrescriptions compared to new non-electronic prescriptions indicates the need for an increased focus on quality aspects in ePrescribing deployment. ETP technology should be developed towards a two-way communication between the prescriber and the pharmacist with automated checks of missing, inaccurate, or ambiguous information. This would enhance safety and quality for the patient and also improve efficiency and cost-effectiveness within the health care system.</p