Clinical Computer Systems Research Articles

Assessing the feasibility of the GOTT (Gabapentinoid and Opioid Tapering Toolkit) in a primary care setting in North-East England.

To assess the feasibility and possible impacts of implementation of systematic non-pharmacological interventions to reduce the level of prescribing of opioid and gabapentinoid analgesics for chronic non-cancer pain (CNCP), particularly high-dose prescriptions, through a proof-of-concept study in a deprived area (second lowest decile) primary care practice in North-East England. Twenty-five primary care staff (clinical and non-clinical) of which 18 clinicians received the intervention. All clinicians received an educational skills programme to support patient pain self-management, tailored on the clinicians' self-assessment of their learning needs, embedding both clinician skill learning and patient self-care resources for rapid access within consultations into a GP clinical management computer system. Clinical staff completed questionnaires before and after the GOTT intervention to assess levels of knowledge and confidence in their own skills to support chronic pain self-management across several domains. Prescription data were used to measure changes in opioid and gabapentinoid prescribing at the practice across the 12-month intervention and 30-month follow-up period. Prescribing of opioid and gabapentinoid/pregabalin decreased substantially in the practice across the intervention period (c. 90% in high-dose opioid [p = .0118], and 15% gabapentin/pregabalin prescriptions, respectively), over a one-year period during the COVID-19 pandemic. Follow-up analysis showed 100% and c.50% reductions, respectively, in December 2022. The questionnaire data showed an increase in clinician confidence in skills to enable self-management over the intervention period, overall (p = .044) and, specifically across three of the five domains measured: supporting behavioural change (p = .028), supporting self-care (p = .008), and managing difficult consultations (p = .011). The GOTT intervention program provided some initial evidence of a proof-of-concept for the implementation of a systematic non-pharmacological pain management skills and resources programme addressing lack of confidence in skills to introduce and support self-management and reduce use of strong opioids and gabapentinoids.

CÁLCULO DE MEDICAMENTOS EM NEONATOS E PEDIATRIA: DESENVOLVIMENTO E VALIDAÇÃO DE APLICATIVO MÓVEL

ABSTRACT Objective: to describe the process of developing and validating a mobile application for medication dosing in neonatal and pediatric services. Method: a methodological study based on the instructional design model with 5 stages: analysis, design, development, implementation, and evaluation. The first 3 phases of development were conducted by a computer engineer. The content and appearance validity index were measured by clinical nurses (n=20) and computer systems engineers (n=18), respectively, and the usability was evaluated with nursing students (n=61). Results: after the development phase, the MATYMAR V 1.0 mobile app was made available on a free platform to use on the Android system. The content validity index was 1.0, while the appearance index showed variations. The usability evaluation of the app, conducted by 61 nursing students, was positive for medication dose calculations in neonatal and pediatric services. Conclusions: the model used proved effective for developing the app, which received positive evaluations from clinical nurses and systems engineers in terms of content and appearance through the concordance index validation, as well as from nursing students in the usability evaluation. It is a useful and functional app for dose calculation, transitioning from a conventional method to a technological system, making the dosing process safer, more reliable, and time-efficient.

Digitally deployed, GP remote consultation video intervention that aims to reduce opioid prescribing in primary care: protocol for a mixed-methods evaluation

IntroductionOpioid prescribing rates are disproportionately high in the North of England. In addition to patients’ complex health needs, clinician prescribing behaviour is also a key driver. Although strategies have been...

Interaction Time with Electronic Health Records: A Systematic Review.

The amount of time that health care clinicians (physicians and nurses) spend interacting with the electronic health record is not well understood. This study aimed to evaluate the time that health care providers spend interacting with electronic health records (EHR). Data are retrieved from Ovid MEDLINE(R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations and Daily, (Ovid) Embase, CINAHL, and SCOPUS. Peer-reviewed studies that describe the use of EHR and include measurement of time either in hours, minutes, or in the percentage of a clinician's workday. Papers were written in English and published between 1990 and 2021. All physicians and nurses involved in inpatient and outpatient settings. A narrative synthesis of the results, providing summaries of interaction time with EHR. The studies were rated according to Quality Assessment Tool for Studies with Diverse Designs. Out of 5,133 de-duplicated references identified through database searching, 18 met inclusion criteria. Most were time-motion studies (50%) that followed by logged-based analysis (44%). Most were conducted in the United States (94%) and examined a clinician workflow in the inpatient settings (83%). The average time was nearly 37% of time of their workday by physicians in both inpatient and outpatient settings and 22% of the workday by nurses in inpatient settings. The studies showed methodological heterogeneity. This systematic review evaluates the time that health care providers spend interacting with EHR. Interaction time with EHR varies depending on clinicians' roles and clinical settings, computer systems, and users' experience. The average time spent by physicians on EHR exceeded one-third of their workday. The finding is a possible indicator that the EHR has room for usability, functionality improvement, and workflow optimization.

Prevalence of thromboembolic (VTE) events in a South London District hospital: a retrospective study

Introduction: Venous thromboembolism (VTE) has been defined by many professionals as the term to describe deep vein thrombosis (DVT) and pulmonary embolism (PE). It is a condition where a thrombus (blood clot) forms in the deep veins usually the lower limbs. DVT can often propagate to the lungs causing PE which can result in significant health complications including instant fatality. The disease occurs in 1 in 20 people in the United Kingdom (UK) at some point during their life time Purpose: To investigate the prevalence of VTE in a South London hospital over a period of 3 years. The objectives of the study were to explore the characteristics of VTE by examining potential correlations with demographic variables of gender, age and ethnicity. Another objective was to distinguish between hospital-associated VTE and community-associated VTE and to identify prevalent types of VTE. Materials and methods: This was a retrospective, quantitative study using convenience sampling. Records of 1728 patients diagnosed with VTE between 1st January 2014 and 31st December 2017 were selected. The data was collected using a clinical computer system to gather patient demographics and identify whether the episode of VTE was related to a hospital admission. Data was analysed using SPSS 23 in order to create descriptive statistics. Spearman’s correlation test was carried out to assess potential correlations between incidences of VTE with age. Jonckheere trend tests were used to assess the significance of trends. Results: The highest incidence of VTE was among the white population n=1470 (85.1%). The average age of the participants in the study was 66.96 years (standard deviation 17.8), There was a positive correlation between incidence of VTE and age (r=0.078, p=0.001). There were more females diagnosed with VTE, n=895 (51.8%) than males n=833 (48.2%). This trend was significant at 0.05. Conclusion: VTE is a concern for the general population and is a major health problem affecting 99 people per 100,000 of the population each year. This common disease is prevalent among all individuals irrespective of age, ethnicity or gender and is not always related to episodes of hospitalization. Further research is needed to examine risk factors and rates of VTE and to establish whether individual events are triggered by transient or acquired influences and causal relationships

The Evidence-Based Development of an Intervention to Improve Clinical Health Literacy Practice.

Low health literacy is an issue with high prevalence in the UK and internationally. It has a social gradient with higher prevalence in lower social groups and is linked with higher rates of long-term health conditions, lower self-rated health, and greater difficulty self-managing long-term health conditions. Improved medical services and practitioner awareness of a patient’s health literacy can help to address these issues. An intervention was developed to improve General Practitioner and Practice Nurse health literacy skills and practice. A feasibility study was undertaken to examine and improve the elements of the intervention. The intervention had two parts: educating primary care doctors and nurses about identifying and enhancing health literacy (patient capacity to get hold of, understand and apply information for health) to improve their health literacy practice, and implementation of on-screen ‘pop-up’ notifications that alerted General Practitioners (GPs) and nurses when seeing a patient at risk of low health literacy. Rapid reviews of the literature were undertaken to optimise the intervention. Four General Practices were recruited, and the intervention was then applied to doctors and nurses through training followed by alerts via the practice clinical IT system. After the intervention, focus groups were held with participating practitioners and a patient and carer group to further develop the intervention. The rapid literature reviews identified (i) key elements for effectiveness of doctors and nurse training including multi-component training, role-play, learner reflection, and identification of barriers to changing practice and (ii) key elements for effectiveness of alerts on clinical computer systems including ‘stand-alone’ notification, automatically generated and prominent display of advice, linkage with practitioner education, and use of notifications within a targeted environment. The findings from the post-hoc focus groups indicated that practitioner awareness and skills had improved as a result of the training and that the clinical alerts reminded them to incorporate this into their clinical practice. Suggested improvements to the training included more information on health literacy and how the clinical alerts were generated, and more practical role playing including initiating discussions on health literacy with patients. It was suggested that the wording of the clinical alert be improved to emphasise its purpose in improving practitioner skills. The feasibility study improved the intervention, increasing its potential usefulness and acceptability in clinical practice. Future studies will explore the impact on clinical care through a pilot and a randomised controlled trial.

Capturing pharmacists\u2019 impact in general practice: an e-Delphi study to attempt to reach consensus amongst experts about what activities to record

BackgroundIn the UK, there is ongoing integration of pharmacists into general practice as a new healthcare service in primary care. Evaluation of the service involves national measures that require pharmacists to record their work, on the general practice clinical computer systems, using electronic activity codes. No national agreement, however, has been established on what activities to record. The purpose of this study was to attempt to reach consensus on what activities general practice-based pharmacists should record.MethodsThe e-Delphi method was chosen as it is an excellent technique for achieving consensus. The study began with an initial stage in which screening of a general practice clinical computer system and discussion groups with pharmacists from two ‘pharmacists in general practice’ sites identified 81 codes potentially relevant to general practice-based pharmacists’ work. Twenty-nine experts (pharmacists and pharmacy technicians from the two sites along with experts recruited through national committees) were then invited by e-mail to participate as a panel in three e-Delphi questionnaire rounds. In each round, panellists were asked to grade or rank codes and justify their choices. In every round, panellists were provided with anonymised feedback from the previous round which included their individual choices along with their co-panellists’ views. Final consensus (in Round 3) was defined as at least 80% agreement. Commentaries on the codes from all e-Delphi rounds were pooled together and analysed thematically.ResultsTwenty-one individual panellists took part in the study (there were 12 responses in Round 1, 18 in Round 2 and 16 in Round 3). Commentaries on the codes included three themes: challenges and facilitators; level of detail; and activities related to funding. Consensus was achieved for ten codes, eight of which related to activities (general and disease specific medication reviews, monitoring of high-risk drugs and medicines reconciliation) and two to patient outcomes (presence of side effects and satisfactory understanding of medication).ConclusionsA formal consensus method revealed general practice-based pharmacists’ preferences for activity coding. Findings will inform policy so that any future shaping of activity coding for general practice-based pharmacists takes account of pharmacists’ actual needs and preferences.

Assessing Concordance With Watson for Oncology, a Cognitive Computing Decision Support System for Colon Cancer Treatment in Korea.

IBM Watson for Oncology (WFO) is a clinical decision-support computing system that provides oncologists with evidence-based treatment recommendations for a variety of cancer diagnoses. The evidence-based supported treatment recommendations are presented in three categories: Recommended, representing the Memorial Sloan Kettering Cancer Center (MSKCC) preferred approach; For Consideration, evidence-based alternative treatments; and Not Recommended, alternative therapies that may be unacceptable. We examined the absolute concordance of treatment options with that of the recommendations of a multidisciplinary team of oncologists from Gachon University, Gil Medical Centre, Incheon, South Korea. We enrolled 656 patients with stage II, III, and IV colon cancer between 2009 and 2016. Cases were processed using WFO and, using retrospective clinical data, outputs were compared with the actual treatment the patient received. Absolute concordance was defined as an alignment of recommendation in the Recommended MSKCC preferred-approach category. Treatment recommendations that were represented in the For Consideration category were not the focus of this study. The absolute concordance between the WFO-derived MSKCC preferred approach and Gil Medical Centre treatment recommendations was 48.9%. The percentage of cases found to be acceptable was 65.8% (432 of 656) and the stage-specific concordance rate was 32.5% for patients with stage II disease who had risk factors and 58.8% for patients with stage III disease. Patients 70 years of age and older had a concordance rate of only 20.2%, whereas younger patients had a concordance rate of 63.8% ( P = .0001). The main reasons attributed to the low concordance rate were age, reimbursement plan, omitting chemotherapy after liver resection, and not recommending biologic agents (ie, cetuximab and bevacizumab).

Spatial distribution of clinical computer systems in primary care in England in 2016 and implications for primary care electronic medical record databases: a cross-sectional population study

ObjectivesUK primary care databases (PCDs) are used by researchers worldwide to inform clinical practice. These databases have been primarily tied to single clinical computer systems, but little is known about...

Role of the homograft bypass in extremity inferior's reconstructions

Vascular homografts are used for limb salvage in cases of graft infection after previous reconstructive vascular surgery or inadequate autologous veins. During multi-organ donation the thoracic aorta segment, aortic bifurcation, iliac arteries, femoral arteries, popliteal arteries, femoral veins and greater saphenous veins can be harvested. Our aim was to optimize the use of homografts by analyzing the results of previous procedures. The patient information was processed retrospectively, using the clinical computer system. 162 procedures were performed on 144 patients between 2007 and 2014. The short- and long-term patency, hemorrhagic complication rate, amputation rate and mortality was examined in our study. The location, graft type and length of cryopreservation were taken into consideration. Aortoiliac and femoropopliteal reconstructions with arterial and venous homografts were examined. The mean age of the patients was 63.6 ± 10.7 years, the mean follow-up period was 36 ± 28 months. The primary patency rates at the postoperative 1, 3 and 6 months were 83.7%, 75.0% and 63.4%. In this study the arterial and deep venous homografts had better primary patency rates compared to the superficial venous homografts: at the postoperative 1, 3, 6 months the arterial homograft results were 85.6%, 78.6% and 74.3%, the greater saphenous vein homograft results were 81.4%, 70.4% and 47.7% in the same intervals. The reconstructive surgical procedures in septic area mean serious challenge for the vascular surgeons. The AB0 compatibility of the graft and the recipient did not result better long-term outcomes compared to the non-compatible grafts. According to our data the ideal choice of homogenous graft is an arterial homograft which was not cryopreserved longer than 6 months.

Dynamic Volume Computed Tomography Imaging of the Upper Airway in Obstructive Sleep Apnea.

To describe a dynamic three-dimensional (3D) computed tomography (CT) technique for the upper airway and compare the required radiation dose to that used for common clinical studies of a similar anatomical area, such as for subjects undergoing routine clinical facial CT. Dynamic upper-airway CT was performed on eight subjects with persistent obstructive sleep apnea, four of whom were undergoing magnetic resonance imaging and an additional four subjects who had a contraindication to magnetic resonance imaging. This Health Insurance Portability and Accountability Act-compliant study was approved by our institutional review board, and informed consent was obtained. The control subjects (n = 41) for comparison of radiation dose were obtained from a retrospective review of the clinical picture-archiving computer system to identify 10 age-matched patients per age-based control group undergoing facial CT. Dynamic 3D CT can be performed with an effective radiation dose of less than 0.38 mSv, a dose that is less than or comparable to that used for clinical facial CT. The resulting data- set is a uniquely complete, dynamic 3D volume of the upper airway through a full respiratory cycle that can be processed for clinical and modeling analyses. A dynamic 3D CT technique of the upper airway is described that can be performed with a clinically reasonable radiation dose and sets a benchmark for future use.

Understanding the epidemiology of avoidable significant harm in primary care: protocol for a retrospective cross-sectional study

IntroductionMost patient safety research has focused on specialist-care settings where there is an appreciation of the frequency and causes of medical errors, and the resulting burden of adverse events. There...

Using a clinical computer system to assess student anatomical knowledge and understanding: A pilot

Introduction: Although anatomy is baseline knowledge for radiation therapists, students often do not see its clinical relevance. Radiation therapists need to interpret the anatomy visualised on computed tomography (CT) images for planning and treatment verification purposes. The Bachelor of Radiation Therapy at the University of Otago combines anatomy with imaging concepts in a first-year academic paper. Teaching includes using a treatment planning system (TPS), which permits students to make the connection between textbook anatomy and CT images. This project explored the use of a TPS as an assessment tool for anatomy. Method: The anatomical knowledge of two small cohorts of first- and second-year radiation therapy students was assessed using a treatment planning system. Semi-structured focus groups were conducted with each cohort to capture the students’ experience of the assessment. Results: Students performed no worse in this assessment compared with a similar traditional assessment. In addition, the assessment promoted student engagement with the material. Students could demonstrate their knowledge and understanding in a manner reflective of clinical practice. Concerns regarding lack of familiarity in using the planning system and fear of technological failure on the assessment day were identified, as well as a general discomfort with the absence of a “correct answer” for certain scenarios. Conclusions: This study shows that a TPS can be used to teach and assess anatomical knowledge. Students found the TPS assessment to be more clinically relevant and were able to make connections between topics and clinical experience. Future assessments utilising a TPS should ensure students are familiar with the system prior to those assessments.

Backdating of events in electronic primary health care data: should one censor at the date of last data collection.

Studies using primary care databases often censor follow-up at the date data are last collected from clinical computer systems (last collection date (LCD)). We explored whether this results in the selective exclusion of events entered in the electronic health records after their date of occurrence, that is, backdated events. We used data from The Health Improvement Network (THIN). Using two versions of the database, we identified events that were entered into a later (THIN14) but not an earlier version of the database (THIN13) and investigated how the number of entries changed as a function of time since LCD. Times between events and the dates they were recorded were plotted as a function of time since the LCD in an effort to determine appropriate points at which to censor follow-up. There were 356 million eligible events in THIN14 and 355 million eligible events in THIN13. When comparing the two data sets, the proportion of missing events in THIN13 was highest in the month prior to the LCD (9.6%), decreasing to 5.2% at 6 months and 3.4% at 12 months. The proportion of missing events was largest for events typically diagnosed in secondary care such as neoplasms (28% in the month prior to LCD) and negligible for events typically diagnosed in primary care such as respiratory events (2% in the month prior to LCD). Studies using primary care databases, particularly those investigating events typically diagnosed outside primary care, should censor follow-up prior to the LCD to avoid underestimation of event rates.

Cutaneous Oncology: From Research to Diagnosis and Management

Cutaneous Oncology: From Research to Diagnosis and Management

Service users with diabetes in an acute inpatient setting

This article aimes to review eight of the nine care processes reviewed in 2011/2012 in an acute psychiatric inpatient setting with standards derived from National Institute for Health and Care Excellence guidelines. Data were collected from the electronic records system for all the inpatients admitted in one week of December 2013 against the selected audit standards. Sixty-six service users were identified out of a total of 508 inpatients. Ninety-five percent of the service users had their HbA1c levels documented (a significant improvement from 64% in the previous audit). There was a slight improvement in the number of service users having their total cholesterol levels documented. Serum creatinine levels were documented in all service users, as compared to 82% in the previous audit. The documentation of blood pressure increased from 82% in the previous audit to 97%, and 38% had evidence of an eye check in the previous 12 months. This is a huge improvement on the previous audit (8%). Foot assessments with documentation of pulses checked in (33%) and vibration in (23%) was an improvement from the (11%) in the previous audit. Improvements continued to be seen in screening for diabetes, weight, body mass index and care planning. The assessment tool needs to be integrated into the clinical computer system to improve the collection and recording of data. Staff education regarding the importance of foot care and eye screening and ongoing training in diabetes care, medications and insulin is also important.

Development and validation of risk prediction algorithms to estimate future risk of common cancers in men and women: prospective cohort study

ObjectiveTo derive and validate a set of clinical risk prediction algorithm to estimate the 10-year risk of 11 common cancers.DesignProspective open cohort study using routinely collected data from 753 QResearch...

Relationship between quality of care and choice of clinical computing system: retrospective analysis of family practice performance under the UK's quality and outcomes framework

ObjectivesTo investigate the relationship between performance on the UK Quality and Outcomes Framework pay-for-performance scheme and choice of clinical computer system.DesignRetrospective longitudinal study.SettingData for 2007–2008 to 2010–2011, extracted from the...

Providing the right dose instructions

The General Medical Council -funded PRACtICe study investigated the prevalence and causes of prescribing errors in general practices. The results showed that around one in three of the prescribing errors detected were associated with incomplete information on the prescription whilst around one in 10 involved giving a medicine at the wrong time. In this article we focus on achieving clear and unambiguous dosing instructions including how clinical computer systems can help to alleviate the problem. We also look at the cautionary and advisory labels added during the dispensing process. The article gives the reader opportunities to reflect upon different scenarios, and there are also suggestions for additional continuing professional development activities.

Independent external validation of QCancer (Ovarian)

We read Collins and Altman's excellent validation of QCancer® (Ovarian) with particular interest (Collins & Altman 2012). While Collins and Altman reported that the algorithm was well calibrated across all tenths of risk, we note that they found some overprediction in the older age groups. In the original study (Hippisley-Cox & Coupland 2012), the outcome for ovarian cancer was defined as a diagnosis of ovarian cancer recorded either in the general practitioner (GP) record or in the linked cause of death record. As described in the paper (Hippisley-Cox & Coupland 2012), using both GP and Office of National Statistics death data sources for the definition of the outcome increased the ascertainment of cases by around 10–12% on the derivation and validation samples. The independent external validation reported by Collins and Altman is based on a separate database (THIN). The THIN database is not linked to cause of death data so the outcome for ovarian cancer in the Collins study is necessarily based solely on the data recorded in the GP record. This is therefore likely to result in a lower incidence rate of ovarian cancer in the THIN database compared with QResearch. Table 1 compares the incidence of ovarian cancer in the QResearch validation database using two definitions: (1) ovarian cancer recorded in either GP or deaths data as in the original study; and (2) ovarian cancer only recorded in the GP data. The table also shows the percentage of ovarian cancer cases identified only on the GP data in QResearch and how the ascertainment falls with increasing age. When a direct comparison of the incidence of ovarian cancer is made using identical case definitions, the rates are much closer. Since the incidence rate of the outcome will affect the predictive algorithm, we hypothesised therefore that the apparent overprediction of QCancer® when applied to THIN particularly at older ages is likely to reflect the under-ascertainment of ovarian cancer in the THIN database. Figure 1 shows the calibration of QCancer® by age group in the original QResearch validation cohort based on the original case definition. Figure 2 shows the calibration by age in QResearch when only diagnoses recorded on the GP record are included in the validation cohort. The graph shows a similar pattern to that in the Collins paper with apparent over prediction at older ages. We believe these results show that rather than QCancer® overpredicting, the discrepancy is mainly due to a lower incidence of the ovarian cancer in THIN since it does not include additional cases recorded on death data. Calibration of QCancer in QResearch based on the original definition of ovarian cancer, that is, recorded in either the general practitioner (GP) or Office of National Statistics (ONS) death record. Calibration of QCancer in QResearch based on the amended definition of ovarian cancer, that is, recorded solely in the general practitioner (GP) records. J.H.-C. is professor of clinical epidemiology at the University of Nottingham and co-director of QResearch® – a not-for-profit organisation, which is a joint partnership between the University of Nottingham and EMIS (leading commercial supplier of IT for 60% of general practices in the UK). J.H.-C. is also a paid director of ClinRisk Ltd, which produces software to ensure the reliable and updatable implementation of clinical risk algorithms within clinical computer systems to help improve patient care. C.C. is associate professor of Medical Statistics at the University of Nottingham and a paid consultant statistician for ClinRisk Ltd. This work and any views expressed within it are solely those of the co-authors and not of any affiliated bodies or organisations.