Development of a core competency framework for clinical informatics.

OBJECTIVES: Until this point there was no national core competency framework for clinical informatics in the UK. We report on the final two iterations of work carried out in the formation of a national core competency framework. This follows an initial systematic literature review of existing skills and competencies and a job listing analysis.MethodsAn iterative approach was applied to framework development. Using a mixed-methods design we carried out semi-structured interviews with participants involved in informatics (n=15). The framework was updated based on the interview findings and was subsequently distributed as part of a bespoke online digital survey for wider participation (n=87). The final version of the framework is based on the findings of the survey. RESULTS: Over 102 people reviewed the framework as part of the interview or survey process. This led to a final core competency framework containing 6 primary domains with 36 subdomains containing 111 individual competencies. CONCLUSIONS: An iterative mixed-methods approach for competency development involving the target community was appropriate for development of the competency framework. There is some contention around the depth of technical competencies required. Care is also needed to avoid professional burnout, as clinicians and healthcare practitioners already have clinical competencies to maintain. Therefore, how the framework is applied in practice and how practitioners meet the competencies requires careful consideration

Quality of medication use in primary care - mapping the problem, working to a solution: a systematic review of the literature

Background: The UK, USA and the World Health Organization have identified improved patient safety in healthcare as a priority. Medication error has been identified as one of the most frequent forms of medical error and is associated with significant medical harm. Errors are the result of the systems that produce them. In industrial settings, a range of systematic techniques have been designed to reduce error and waste. The first stage of these processes is to map out the whole system and its reliability at each stage. However, to date, studies of medication error and solutions have concentrated on individual parts of the whole system. In this paper we wished to conduct a systematic review of the literature, in order to map out the medication system with its associated errors and failures in quality, to assess the strength of the evidence and to use approaches from quality management to identify ways in which the system could be made safer. Methods: We mapped out the medicines management system in primary care in the UK. We conducted a systematic literature review in order to refine our map of the system and to establish the quality of the research and reliability of the system. Results: The map demonstrated that the proportion of errors in the management system for medicines in primary care is very high. Several stages of the process had error rates of 50% or more: repeat prescribing reviews, interface prescribing and communication and patient adherence. When including the efficacy of the medicine in the system, the available evidence suggested that only between 4% and 21% of patients achieved the optimum benefit from their medication. Whilst there were some limitations in the evidence base, including the error rate measurement and the sampling strategies employed, there was sufficient information to indicate the ways in which the system could be improved, using management approaches. The first step to improving the overall quality would be routine monitoring of adherence, clinical effectiveness and hospital admissions. Conclusion: By adopting the whole system approach from a management perspective we have found where failures in quality occur in medication use in primary care in the UK, and where weaknesses occur in the associated evidence base. Quality management approaches have allowed us to develop a coherent change and research agenda in order to tackle these, so far, fairly intractable problems

Alcohol Abuse in Older People – presentation and scope of the problem – a clinical review

Alcohol abuse is recognised as a serious problem in the UK and there is a strong correlation between average consumption, the prevalence of heavy drinking and associated harm. Alcohol abuse disorders are thought to be common in older people and associated with impairments in physical, psychological, social and cognitive wellbeing. The effects of co-morbidity, medication and age may exacerbate the risks of alcohol abuse. We conducted a review of published literature using a defined search strategy of electronic databases, including articles in English, between 1960-2004. This yielded 74 papers that matched the search criteria. Six papers were selected for detailed analysis. Alcohol abuse in older people has a prevalence of between 1-4% in the general population, rising to between 7-22% in inpatients and 23-44% for psychiatric inpatients. The health-related effects of alcohol use in older people are still uncertain. Neither screening for elderly alcohol abuse in a general population nor the use of validated tools such as the CAGE questionnaire may not be effective in the general population. However, for rapid assessment in a clinical setting, the CAGE questionnaire, with a cut-off score of >=2, will effectively discriminate older patients with a history of drinking problems from those without such a history. In the UK there has been little high-quality research reporting the prevalence, identification and treatment of alcohol use disorders in older people. There is a clear need for a specific research programme to address these issues in line with the government’s Alcohol Harm Reduction Strategy and the NSF for Older People

Systematic review of scope and quality of electronic patient record data in primary care

Objective: To systematically review measures of data quality in electronic patient records (EPRs) in primary care. Design: Systematic review of English language publications, 1980-2001. Data sources: Bibliographic searches of medical databases, specialist medical informatics databases, conference proceedings, and institutional contacts. Study selection: Studies selected according to a predefined framework for categorising review papers. Data extraction: Reference standards and measurements used to judge quality. Results: Bibliographic searches identified 4589 publications. After primary exclusions 174 articles were classified, 52 of which met the inclusion criteria for review. Selected studies were primarily descriptive surveys. Variability in methods prevented meta-analysis of results. Forty eight publications were concerned with diagnostic data, 37 studies measured data quality, and 15 scoped EPR quality. Reliability of data was assessed with rate comparison. Measures of sensitivity were highly dependent on the element of EPR data being investigated, while the positive predictive value was consistently high, indicating good validity. Prescribing data were generally of better quality than diagnostic or lifestyle data. Conclusion: The lack of standardised methods for assessment of quality of data in electronic patient records makes it difficult to compare results between studies. Studies should present data quality measures with dear numerators, denominators, and confidence intervals. Ambiguous terms such as "accuracy" should be avoided unless precisely defined.</p

Systematic review of scope and quality of electronic patient record data in primary care

Objective To systematically review measures of data quality in electronic patient records (EPRs) in primary care. Design Systematic review of English language publications, 1980-2001. Data sources Bibliographic searches of medical databases, specialist medical informatics databases, conference proceedings, and institutional contacts. Study selection Studies selected according to a predefined framework for categorising review papers. Data extraction Reference standards and measurements used to judge quality. Results Bibliographic searches identified 4589 publications. After primary exclusions 174 articles were classified, 52 of which met the inclusion criteria for review. Selected studies were primarily descriptive surveys. Variability in methods prevented meta-analysis of results. Forty eight publications were concerned with diagnostic data, 37 studies measured data quality, and 15 scoped EPR quality. Reliability of data was assessed with rate comparison. Measures of sensitivity were highly dependent on the element of EPR data being investigated, while the positive predictive value was consistently high, indicating good validity. Prescribing data were generally of better quality than diagnostic or lifestyle data. Conclusion The lack of standardised methods for assessment of quality of data in electronic patient records makes it difficult to compare results between studies. Studies should present data quality measures with clear numerators, denominators, and confidence intervals. Ambiguous terms such as “accuracy” should be avoided unless precisely defined