Computer-based Patient Record System Research Articles

The impact of first wave of COVID-19 on the nursing-sensitive and rehabilitation outcomes of patients undergoing hip fracture surgery: a single centre retrospective cohort study

BackgroundDuring the COVID-19 pandemic, the care of hip fracture patients remains a clinical priority. To date, there is limited empirical knowledge about the impact of pandemic on the care of patients surgically treated for hip fracture, affected or not by COVID-19.ObjectiveTo investigate the effects of the COVID-19 pandemic on the nursing-sensitive and rehabilitation outcomes of frail patients undergoing hip fracture surgery.MethodsA retrospective cohort study was conducted in an Italian Orthopaedic Research Institute. All patients aged ≥ 65 years admitted with fragility hip fractures between 1st March and 30th June in 2019 (group PP: pre-pandemic) and in the same period in 2020 (group P: pandemic), were compared. In the P group, COVID-19 positive patients were excluded due to the presence of a specific treatment pathway. Data on patient demographics and baseline characteristics, and peri-operative care factors were obtained from the Institute’s computer-based patient-record system. The primary outcome was the incidence of any stage hospital-acquired pressure ulcers (PUs). The secondary outcome was time to first static verticalization and to first ambulation.ResultsThree-hundred and sixty patients were included in the study, which comprised 108 patients in PP group and 252 patients in P group. Overall PUs incidence was significantly higher in the P-group (21.8%) than in the PP-group (10.2%) (p = 0.009). Specifically, the incidence of sacral PUs was significantly lower in P-group (38.1%) vs PP-group (91%) (p = 0.004); on the contrary, the incidence of PUs localized to the heels or other body sites were significantly higher in P-group (30.9% and 30.9%, respectively) vs PP-group (0% and 9%, respectively) (p = 0.004).No significant between groups differences were found for all the secondary outcomes.ConclusionIn the pandemic period, nursing and rehabilitation care provided to patients with fragility hip fracture maintained high standards comparable to the pre-pandemic period. The increase in PUs incidence in the pandemic period was probably due to the older age of the patients admitted to hospital. The qualitative evaluation of the care administered and the emotional impact of the pandemic on the patients are very interesting topic which would deserve further investigation.

The Association Between Hyperparathyroidism and Ischemic Stroke Subtypes

Background: Up to date, a substantial amount of research has remarked on the potential role of parathormone (PTH) in the development of subclinical and clinical vascular diseases. However, the association between the hyperparathyroidism and cerebrovascular disease has rather been underestimated in the literature. Herein, we aimed to investigate the association between serum PTH levels and ischemic stroke. Methods: Serum PTH levels were measured in all patients with ischemic stroke who were hospitalized in the Yozgat City Hospital between January 1, 2017 and January 1, 2019. Clinical and demographic findings were retrospectively evaluated via computer-based patient record system of Yozgat City Hospital (AKGUN). Results: Overall, 158 patients with ischemic stroke with a median age of 71.5 ± 11.5 were enrolled in this study. Parathyroid hormone was found to be high in 31 of the patients (19.6%). The stroke subtype of extracranial atherosclerosis was found to be more common in the group of patients with a high level of PTH (12%/3%; P = 0.008). Remarkably, logistic regression analyses also confirmed that high PTH level was a significant variable in the determination of the stroke subtype of extracranial atherosclerosis (P = 0.024). Conclusions: We have found a high rate of hyperparathyroidism in our group of patients with ischemic stroke. Remarkably, the elevation of PTH was found to be significantly associated with the ischemic stroke subtype of extracranial atherosclerosis. Clarification of these results in the future large-scale studies may provide crucial perspectives regarding our understanding of the pathophysiology of some subtypes of ischemic stroke and potentially lead to a large public health implication in this area. J Neurol Res. 2020;10(1):7-12 doi: https://doi.org/10.14740/jnr564

Incidence and prevalence of lupus in Buenos Aires, Argentina: a 11-year health management organisation-based study

ObjectivesStudies regarding the epidemiology of systemic lupus erythematosus (SLE) are lacking in Argentina. Our purpose was to estimate the incidence and prevalence of SLE in a university hospital-based health management...

Incidence and prevalence of psoriatic arthritis in Buenos Aires, Argentina: a 6-year health management organization-based study

Studies regarding epidemiology of PsA are lacking in Latin America. We estimated the incidence and prevalence of PsA in a University Hospital-based Health Management Organization in Buenos Aires [Hospital Italiano Medical Care Program (HIMCP)]. for incidence calculation, the population at risk was all adult members of the HIMCP, with continuous affiliation for at least 1 year from January 2000 to January 2006. Each person was followed until he/she voluntarily left the HIMCP, death or finalization of the study (final dates) contributing time at risk since January 2000 or enrolment date (whichever occurred later) to that final date. Case ascertainment: medical records of all patients with the problem psoriasis and/or PsA in the HIMCP problem-oriented computer-based patient record system, or registered in rheumatologists and/or dermatologists databases, were revised. Patients fulfilling CASPAR criteria were included. incidence rate (IR) was calculated with 95% CIs. Cumulative prevalence was estimated on 1 January 2006 (denominator population ==88,112). In the study period, 138,288 persons contributed a total of 558,878 person-years, of whom 35 developed PsA (IR 6.26; 95% CI 4.2, 8.3 cases per 100,000 person-years). There were 12 females: IR 3.64 (95% CI 1.6, 5.7) cases per 100,000 person-years; and 23 males: IR 10.02 (95% CI 5.9, 14.1) cases per 100,000 person-years. On 1 January 2006, 65 prevalent cases were identified: prevalence 74 (95% CI 57, 94) cases per 100,000 members. The incidence and prevalence of PsA in this Latin American country was similar to that reported in other studies from Europe and the USA.

The impact of electronic medical record systems on outpatient workflows: A longitudinal evaluation of its workflow effects

Context The promise of the electronic medical record (EMR) 1 1 The electronic medical record (EMR) is defined as a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information. Such systems may be limited in their scope to a single area of clinical information (e.g., laboratory data), or they may be comprehensive and cover virtually every facet of clinical information pertinent to patient care (e.g., computer-based patient record systems). An ideal EMR's usually encompasses (i) a longitudinal collection of electronic health information for and about person; (ii) electronic access to person- and population-level information by authorized users. lies in its ability to reduce the costs of health care delivery and improve the overall quality of care – a promise that is realized through major changes in workflows within the health care organization. Yet little systematic information exists about the workflow effects of EMRs. Moreover, some of the research to-date points to reduced satisfaction among physicians after implementation of the EMR and increased time, i.e., negative workflow effects. A better understanding of the impact of the EMR on workflows is, hence, vital to understanding what the technology really does offer that is new and unique. Objective (i) To empirically develop a physician centric conceptual model of the workflow effects of EMRs; (ii) To use the model to understand the antecedents to the physicians’ workflow expectation from the new EMR; (iii) To track physicians’ satisfaction overtime, 3 months and 20 months after implementation of the EMR; (iv) To explore the impact of technology learning curves on physicians’ reported satisfaction levels. Design The current research uses the mixed-method technique of concept mapping to empirically develop the conceptual model of an EMR's workflow effects. The model is then used within a controlled study to track physician expectations from a new EMR system as well as their assessments of the EMR's performance 3 months and 20 months after implementation. Setting The research tracks the actual implementation of a new EMR within the outpatient clinics of a large northeastern research hospital. Participants The pre-implementation survey netted 20 physician responses; post-implementation Time 1 survey netted 22 responses, and Time 2 survey netted 26 physician responses. Intervention The implementation of the actual EMR served as the intervention. Since the study was conducted within the same setting and tracked a homogenous group of respondents, the overall study design ensured against extraneous influences on the results. Main outcome measures Outcome measures were derived empirically from the conceptual model. They included 85 items that measured physician perceptions of the EMR's workflow effect on the following eight issues: (1) administration, (2) efficiency in patient processing, (3) basic clinical processes, (4) documentation of patient encounter, (5) economic challenges and reimbursement, (6) technical issues, (7) patient safety and care, and (8) communication and confidentiality. The items were used to track expectations prior to implementation and they served as retrospective measures of satisfaction with the EMR in post-implementation Time 1 and Time 2. Results The findings suggest that physicians conceptualize EMRs as an incremental extension of older computerized provider order entries (CPOEs) rather than as a new innovation. The EMRs major functional advantages are seen to be very similar to, if not the same as, those of CPOEs. Technology learning curves play a statistically significant though minor role in shaping physician perceptions. Conclusions The physicians’ expectations from the EMR are based on their prior beliefs rather than on a rational evaluation of the EMR's fit, functionality, or performance. Their decision regarding the usefulness of the EMR is made very early, within the first few months of use of the EMR. These early perceptions then remain stable and become the lens through which subsequent experience with the EMR is interpreted. The findings suggest a need for communication based interventions aimed at explaining the value, fit, and usefulness of EMRs to physicians early in the pre- and immediate post-EMR implementation stages.

A usability evaluation of four commercial dental computer-based patient record systems

The usability of dental computer-based patient record (CPR) systems has not been studied, despite early evidence that poor usability is a problem for dental CPR system users at multiple levels. The authors conducted formal usability tests of four dental CPR systems by using a purposive sample of four groups of five novice users. The authors measured task outcomes (correctly completed, incorrectly completed and incomplete) in each CPR system while the participants performed nine clinical documentation tasks, as well as the number of usability problems identified in each CPR system and their potential relationship to task outcomes. The authors reviewed the software application design aspects responsible for these usability problems. The range for correctly completed tasks was 16 to 64 percent, for incorrectly completed tasks 18 to 38 percent and for incomplete tasks 9 to 47 percent. The authors identified 286 usability problems. The main types were three unsuccessful attempts, negative affect and task incorrectly completed. They also identified six problematic interface and interaction designs that led to usability problems. The four dental CPR systems studied have significant usability problems for novice users, resulting in a steep learning curve and potentially reduced system adoption. The significant number of data entry errors raises concerns about the quality of documentation in clinical practice.

Installing and Implementing a Computer-based Patient Record System in Sub-Saharan Africa: The Mosoriot Medical Record System

The authors implemented an electronic medical record system in a rural Kenyan health center. Visit data are recorded on a paper encounter form, eliminating duplicate documentation in multiple clinic logbooks. Data are entered into an MS-Access database supported by redundant power systems. The system was initiated in February 2001, and 10,000 visit records were entered for 6,190 patients in six months. The authors present a summary of the clinics visited, diagnoses made, drugs prescribed, and tests performed. After system implementation, patient visits were 22% shorter. They spent 58% less time with providers (p<0.001) and 38% less time waiting (p=0.06). Clinic personnel spent 50% less time interacting with patients, two thirds less time interacting with each other, and more time in personal activities. This simple electronic medical record system has bridged the “digital divide.” Financial and technical sustainability by Kenyans will be key to its future use and development.

PKI-based secure mobile access to electronic health services and data

Recent research works examine the potential employment of public-key cryptography schemes in e-health environments. In such systems, where a Public Key Infrastructure (PKI) is established beforehand, Attribute Certificates (ACs) and public key enabled protocols like TLS, can provide the appropriate mechanisms to effectively support authentication, authorization and confidentiality services. In other words, mutual trust and secure communications between all the stakeholders, namely physicians, patients and e-health service providers, can be successfully established and maintained. Furthermore, as the recently introduced mobile devices with access to computer-based patient record systems are expanding, the need of physicians and nurses to interact increasingly with such systems arises. Considering public key infrastructure requirements for mobile online health networks, this paper discusses the potential use of Attribute Certificates (ACs) in an anticipated trust model. Typical trust interactions among doctors, patients and e-health providers are presented, indicating that resourceful security mechanisms and trust control can be obtained and implemented. The application of attribute certificates to support medical mobile service provision along with the utilization of the de-facto TLS protocol to offer competent confidentiality and authorization services is also presented and evaluated through experimentation, using both the 802.11 WLAN and General Packet Radio Service (GPRS) networks.

Information Technologies Relevant to Pharmacy Practice in Hospitals: Results of a Statewide Survey

Purpose To evaluate the extent that Florida hospitals are utilizing a variety of pharmacy-related information technology (IT) applications and contrast these results with nationwide studies regarding IT. Methods Chief Information Officers of Florida acute care hospitals were surveyed from May through October 2003. Facilities were questioned on the utilization of clinical and other IT applications, priorities, and barriers. The results of the questionnaire along with differences between small and large hospitals were examined. Results Overall, few hospitals have adopted computerized physician order entry (CPOE) and bar coded medication management (15.8% and 12.6% respectively), and only slightly more than half (50.5%) have adopted a computer-based patient record (CPR) system. Although utilization of these did not differ between small and large hospitals, larger hospitals were more likely to have a pharmacy information system (100% vs 69.6%, P = 0.004) and an automated pharmacy dispensing system (82.6% vs 30.4%, P &lt; 0.001). Larger hospitals were also more likely to utilize most medical information retrieval services. Implementing technology to reduce medical errors and promote patient safety was cited by facilities as their number one IT priority, and lack of adequate financial support was cited as the single most important barrier to implementing IT. These results were comparable with other nationwide studies. Conclusions Florida hospitals, similar to previous hospitals studied nationwide, were found to have a slow rate of adoption of pharmacy-related IT. As a result, pharmacists are encouraged to play a more active role in collaborating with hospital leaders in order to implement these technologies at their facilities in an effort to reduce medication errors and improve the quality of care delivered to patients.

A systematic review of computer-based patient record systems and quality of care: more randomized clinical trials or a broader approach?

To analyse the impact of computer-based patient record systems (CBPRS) on medical practice, quality of care, and user and patient satisfaction. Manual and electronic search of the Medline, Cochrane, and Embase databases. Selected articles were published from 2000 to March 2003. CBPRS was defined as computer software designed to be used by clinicians as a direct aid in clinical decision making. To be included, the systems should have recorded patient characteristics and offered online advice, or information or reminders specific to clinicians during the consultation. Keywords used for the search were: electronic record, informatic record, electronic medical record, electronic patient record, patient order entry, computer-based patient system, clinical decision support systems, and evaluation. Twenty-six articles were selected. Use of a CBPRS was perceived favourably by physicians, with studies of satisfaction being mainly positive. A positive impact of CBPRS on preventive care was observed in all three studies where this criterion was examined. The 12 studies evaluating the impact on medical practice and guidelines compliance showed that positive experiences were as frequent as experiences showing no benefit. None of the six studies analysing the impact of CBPRS on patient outcomes reported any benefit. CBPRS increased user and patient satisfaction, which might lead to significant improvements in medical care practices. However, the studies on the impact of CBPRS on patient outcomes and quality of care were not conclusive. Alternative approaches considering social, cultural, and organizational factors may be needed to evaluate the usefulness of CBPRS.

Computer-based Patient Record System and Pediatric Surgery

Computer-based Patient Record System and Pediatric Surgery

A randomized, controlled trial of clinical information shared from another institution

Study Objective: Emergency physicians often must deliver medical care with minimal access to historical clinical information. We demonstrate the feasibility and potential value of increased access to patients’ clinical information from another hospital while they are receiving care in the emergency department. Methods: We conducted a pilot randomized, controlled trial of providing information from a large, longitudinal, computer-based patient record system of clinical data from an urban hospital to emergency physicians at either of 2 urban EDs. We randomized patients seen at either ED to have the information from the computer-based patient record system provided to their physician or to not have the information provided. We delivered information to the emergency physician both as a printed abstract and by means of online access to the computer-based patient record. We assessed charges, hospital admissions, repeat visits to EDs, and the emergency physicians’ satisfaction with the information. Results: Under certain assumptions, the intervention was estimated to decrease charges for ED care by approximately $26 per encounter (P =.03) at 1 hospital, but there was no effect on charges at the other hospital. This result was likely because of marked differences in the workflows and information access at these 2 EDs. We demonstrated no differences in admission rates or repeat visits to the ED. Emergency physicians identified that remembering their passwords and the time required to search for the information were significant barriers to accessing clinical information online. Conclusion: Our pilot study is the first to demonstrate the feasibility of sharing clinical information between different health care systems. We observed a trend toward cost savings at 1 of 2 hospitals and no differences in the quality measures we studied. Our experience underscores the difficulties inherent in studying the effects of community-wide health care interventions on cost and quality of ED care. [Overhage JM, Dexter PR, Perkins SM, Cordell WH, McGoff J, McGrath R, McDonald CJ. A randomized, controlled trial of clinical information shared from another institution. Ann Emerg Med. January 2002;39:14-23.]

How the past teaches the future: ACMI distinguished lecture.

More than 30 years of experience in developing a computer-based patient record system, The Medical Record (TMR), in multiple settings, in multiple specialty groups, and at multiple sites has taught us many lessons. Lessons related to computer-based patient records include the importance of a data model in which input, storage, and planned use are independent; separation of patient-specific data from metadata; a modular design to localize the program code that deals with a set of data; redundant storage to optimize tasks and response time; and integration of decision support into work process. Lessons related to medical informatics include the importance of a clinical-technical partnership, control of tools at the leading edge, and rapid prototyping in the real world. Finally, changes in technology move the challenges but do not eliminate them.

History and trends in clinical information systems in the United States.

To provide a synopsis of issues about clinical information systems for nurses not schooled in nursing informatics. The past, present, and future of clinical computing, including major factors resulting in the early hospital information systems (HIS) and decision support systems (DSS) in the United States, current advances and issues in managing clinical information, and future trends and issues. Literature review and analysis. The first HIS and DSS were used in the late 1960s and were focused on applications for acute care. The change from fee-for-service to managed care required a change in the design of clinical information systems toward more patient-centered systems that span the care continuum, such as the computer-based patient record (CPR). Current difficulties with CPR systems include lack of systems integration, data standardization, and implementation. Increased advances in information and technology integration and increased use of the Internet for health information will shape the future of clinical information systems.

Computer-based patient record systems.

To provide oncology nurses with an overview of computer-based patient record (CPR) systems, a key infrastructure requirement in information management that is essential to maintaining a scientific basis for health care. Published articles, research studies, and review articles pertaining to CPR systems. Progress in hardware development, software applications, and interfaces combine to bring us multimedia patient record systems. Many obstacles have been overcome as standards have emerged and technologies conform to those standards. However, there has been limited success in implementation of such systems. Early acceptance of structured data and problem-oriented documentation set the framework for charting in the electronic record. Oncology clinicians and cancer patients alike will realize greater efficiencies and increased quality in health care when the CPR is fully implemented.

Health informatics and oncology nursing.

To provide an overview of the essential role of health and nursing informatics in meeting the 21st century call to provide state-of-the-art oncology care. Published articles, research studies, and documents relating to informatics. Health and nursing informatics encompass the pivotal roles of data and information; identifying and documenting essential data using nursing vocabularies; ensuring adequate computer-based patient record systems; accessing and building knowledge; using telecommunications to support care delivery; empowering the consumer through health informatics; transforming education; and enhancing decision making in oncology nursing through national research agendas. The information age calls us to explore digital and information technologies as extensions of human capacity. Oncology nursing practice is especially positioned to contribute to the health of our population.

Impact of a computer-based patient record system on data collection, knowledge organization, and reasoning.

To assess the effects of a computer-based patient record system on human cognition. Computer-based patient record systems can be considered "cognitive artifacts," which shape the way in which health care workers obtain, organize, and reason with knowledge. Study 1 compared physicians' organization of clinical information in paper-based and computer-based patient records in a diabetes clinic. Study 2 extended the first study to include analysis of doctor-patient-computer interactions, which were recorded on video in their entirety. In Study 3, physicians' interactions with computer-based records were followed through interviews and automatic logging of cases entered in the computer-based patient record. Results indicate that exposure to the computer-based patient record was associated with changes in physicians' information gathering and reasoning strategies. Differences were found in the content and organization of information, with paper records having a narrative structure, while the computer-based records were organized into discrete items of information. The differences in knowledge organization had an effect on data gathering strategies, where the nature of doctor-patient dialogue was influenced by the structure of the computer-based patient record system. Technology has a profound influence in shaping cognitive behavior, and the potential effects of cognition on technology design needs to be explored.

IMPLEMENTING A COMPREHENSIVE COMPUTERIZED PATIENT RECORD Lessons for the Individual Practitioner and the Organization

The conversion from a paper medical record system to a computer-based patient record (CPR) system is a complex process. There are many factors to consider; advantages and disadvantages vary depending on the nature of a practice. This article introduces the reader to those issues that must be addressed in bringing information technology into office-based medical records. A number of software programs are available; however, introducing CPR into a practice is far more complex than just selecting a software vendor. The transition to CPR, even using off-the-shelf software, is at least a year-long project and, in most cases, takes several years. In the following discussion, computer terminology is kept at a minimum. Even someone who has never used a computer should be able to understand the principles discussed here. A very basic understanding of personal computers (PCs), however, will deepen the reader's understanding of certain technical aspects of this discussion. There is a growing appreciation for the advantages of CPR. Even 10 years ago the penetration of computers into medical record keeping was less than 1% for office-based practices. The decrease in the cost of computer power, combined with the increased demands for documentation, has fueled a growing interest in CPR. In 1992 the Computer-Based Record Institute 2 (CPRI) was formed to facilitate the implementation of computer-based patient records to improve health care quality, cost, and access. The first step in implementing CPR into an ophthalmology practice is to review the advantages and disadvantages of computer-based records. This step is more than a formality; understanding the advantages of adding CPR to your practice is the basis for all the decisions you will make. For example, perhaps you are considering using voice-recognition software in your practice. If your primary goal is to reduce overhead cost, then voice recognition may help a lot. If, on the other hand, your primary goal is to see more patients, voice recognition may actually slow you down. It is only by having a clear understanding of your goals that you will make the correct decisions about all the various options available in CPR. Determining the advantages and disadvantages of CPR in your practice can help to answer the first question, Should I implement CPR in my practice now?

Enhancing the expressiveness of structured reporting systems.

The overall goal of this research is to build a structured reporting system that reduces the cost, delays, and inconvenience associated with conventional dictation and speech recognition systems. We have implemented such a structured reporting system for radiology that replaces current dictation and transcription processes by allowing radiologists and other imaging professionals to select imaging findings from a medical lexicon. The system uses an imaging-specific information model, called a "description set,' to organize selected terms in a relational database. Unique features of the knowledge representation that enhance its expressiveness include its ability to codify uncertainty about an imaging observation and to represent explicitly the logical relationships among imaging findings. In addition, the system does not require the user to fill in "blanks' in a static text template. Instead, it allows entry of terms in arbitrary order and uses automated text-generation techniques to create a text report that referring physicians are accustomed to receiving. In parallel, the system also produces a multimedia report that the referring physician can use as a quick reference. Unlike the results of conventional dictation or speech recognition, each finding is coded in a relational database for later information processing. Thus, the structured report database can be used to index images by content, to provide real-time decision support, to enhance radiologists' performance, to conduct exploratory clinical research, and to transmit imaging report data to computer-based patient record systems.

CIS6/413: Design of a Computer-Based Patient Record System (ARISTOPHANES) for Medical Departments: Implementation for Surgery Wards

IntroductionToday, the demand for computer-based patient records to improve the quality of patient care and to reduce costs in health services is generally recognized. The new electronic patient record system (ARISTOPHANES) is based on a self-developed relational data model with a star-shaped topology. An hierarchical structure has been chosen for the user interface. ARISTOPHANES has been developed for use in clinical workstations taking into account varied requirements, user acceptance, and future extension.MethodsFor the design of the electronic patient records was used the software "Oracle Forms 5.0". An Oracle database has been generated and loaded with test data. The designed forms are currently being implemented using "SQL*Plus 8.0" by Oracle.ResultsWe used a self-developed star-shaped relational data model, which is highly flexible with regard to the modification and extension of the data structure. The design of the electronic patient records has taken into account the varied demands of the medical partners in order to guarantee user acceptance. The hierarchical topology that has been chosen renders the designed electronic patient record system flexible and efficient, such that further departments and regulatory changes can be integrated within a short time. General functions required by all departments are contained in the main menu. These include patient data, case details, medical documentation, care documentation, personnel details, and business partners. Specific functions are included at lower levels for the demands of the surgery departments, such as anaesthesia record, operation record, present status record.DiscussionThe complexity of user acceptance is reflected by (i) the different groups of users of Electronic Healthcare Record systems (physicians, nurses, managers, researchers) together with their various requirements, and (ii) the different contexts of use (e.g., support in normal or emergency situations, access for research, and mobile access). Commercial providers have developed electronic patient record systems, that often turn out to be too inflexible for the requirements of a university setting and need to be customized considerably. To ensure user acceptance, we analyzed the demands together with clinical partners from the surgery departments. It is expected that the ARISTOPHANES system will also be attractive to other medical departments in light of the overall advantages such as paperless documentation, reliable patient data transfer, improved settlement of accounts, and easing the burden on care personnel.