Electronic Health Record Research Research Articles

Identifying and mitigating biases in EHR laboratory tests

Electronic health record (EHR) data show promise for deriving new ways of modeling human disease states. Although EHR researchers often use numerical values of laboratory tests as features in disease models, a great deal of information is contained in the context within which a laboratory test is taken. For example, the same numerical value of a creatinine test has different interpretation for a chronic kidney disease patient and a patient with acute kidney injury. We study whether EHR research studies are subject to biased results and interpretations if laboratory measurements taken in different contexts are not explicitly separated. We show that the context of a laboratory test measurement can often be captured by the way the test is measured through time.We perform three tasks to study the properties of these temporal measurement patterns. In the first task, we confirm that laboratory test measurement patterns provide additional information to the stand-alone numerical value. The second task identifies three measurement pattern motifs across a set of 70 laboratory tests performed for over 14,000 patients. Of these, one motif exhibits properties that can lead to biased research results. In the third task, we demonstrate the potential for biased results on a specific example. We conduct an association study of lipase test values to acute pancreatitis. We observe a diluted signal when using only a lipase value threshold, whereas the full association is recovered when properly accounting for lipase measurements in different contexts (leveraging the lipase measurement patterns to separate the contexts).Aggregating EHR data without separating distinct laboratory test measurement patterns can intermix patients with different diseases, leading to the confounding of signals in large-scale EHR analyses. This paper presents a methodology for leveraging measurement frequency to identify and reduce laboratory test biases.

Implementing Unique Device Identification in Electronic Health Record Systems

The United States Food and Drug Administration (FDA) has proposed creating a unique device identification (UDI) system for medical devices to facilitate postmarket surveillance, quality improvement, and other applications. Although a small number of health care institutions have implemented initiatives comparable with the proposed UDI system by capturing data in electronic health record (EHR) systems, it is unknown whether institutions with fewer resources will be able to similarly implement UDI. This paper calls attention to organizational, workflow, and technological challenges in UDI system implementation by drawing from the literature on EHR and clinical research systems implementation. Organizational challenges for UDI system implementation include coordinating multiple stakeholders to define UDI attributes and characteristics for use in EHRs, guiding organizational change within individual institutions for integrating UDI with EHRs, and guiding organizational change for reusing UDI data captured in EHRs. Workflow challenges include capturing UDI data in EHRs using keyboard entry and barcode scanning. Technological challenges involve interfacing UDI data between EHRs and surgical information systems, transforming UDI and related patient data from EHRs for research, and applying data standards to UDI within and beyond EHRs. We provide recommendations for regulations, organizational sharing, and professional society engagement to raise awareness of and overcome UDI system implementation challenges. Implementation of the UDI system will require integration of people, process, and technology to achieve benefits envisioned by FDA, including improved postmarket device surveillance and quality of care.

What differentiates primary care physicians who predominantly prescribe diuretics for treating mild to moderate hypertension from those who do not? A comparative qualitative study

BackgroundThiazide diuretics are cost-effective for the treatment of mild to moderate hypertension, but physicians often opt for more expensive treatment options such as angiotensin II receptor blockers or angiotensin converting enzyme inhibitors. With escalating health care costs, there is a need to elucidate the factors influencing physicians' treatment choices for this highly prevalent chronic condition. The purpose of this study was to describe the characteristics of physicians' decision-making process regarding hypertension treatment choices.MethodsA comparative qualitative study was conducted in 2009 in the Canadian province of Quebec. Overall, 29 primary care physicians--who are also participating in an electronic health record research program--participated in a semi-structured interview about their prescribing decisions. Physicians were categorized into two groups based on their patterns of prescribing antihypertensive drugs: physicians who predominantly prescribe diuretics, and physicians who predominantly prescribe drug classes other than diuretics. Cases of hypertension that were newly started on antihypertensive therapy were purposely selected from each physician's electronic health record database. Chart stimulated recall interview, a technique utilizing patient charts to probe recall and provide context to physician decision-making during clinical encounters, was used to elucidate reasons for treatment choices. Interview transcripts were synthesized using content analysis techniques, and factors influencing physicians' decision making were inductively generated from the data.ResultsWe identified three themes that differentiated physicians who predominantly prescribe diuretics from those who predominantly prescribe other drug classes for the initial treatment of mild to moderate hypertension: a) perceptions about the efficacy of diuretics, b) preferred approach to hypertension management and, c) perceptions about hypertension guidelines. Specifically, physicians had differences in beliefs about the efficacy, safety and tolerability of diuretics, the most effective approach for managing mild to moderate hypertension, and in aggressiveness to achieve treatment targets. Marketing strategies employed by the pharmaceutical industry and practice experience appear to contribute to these differences in management approach.ConclusionsPhysicians preferring more expensive treatment options appear to have several misperceptions about the efficacy, safety and tolerability of diuretics. Efforts to increase physicians' prescribing of diuretics may need to be directed at overcoming these misperceptions.

Bias Associated with Mining Electronic Health Records

Large-scale electronic health record research introduces biases compared to traditional manually curated retrospective research. We used data from a community-acquired pneumonia study for which we had a gold standard to illustrate such biases. The challenges include data inaccuracy, incompleteness, and complexity, and they can produce in distorted results. We found that a naïve approach approximated the gold standard, but errors on a minority of cases shifted mortality substantially. Manual review revealed errors in both selecting and characterizing the cohort, and narrowing the cohort improved the result. Nevertheless, a significantly narrowed cohort might contain its own biases that would be difficult to estimate.

Design and implementation of a standards-based interoperable clinical decision support architecture in the context of the Korean EHR

Background In 2000 the Korean government initiated efforts to secure healthcare accessibility and efficiency anytime and anywhere via the nationwide healthcare information system by the end of 2010. According to the master plan, electronic health record (EHR) research and development projects were designed in 2005. One subproject was the design and implementation of standards-based interoperable clinical decision support (CDS) capabilities in the context of the EHR system. Objective The purpose of this study was to describe the challenges, process, and outcomes of defining and implementing a national CDS architecture to stimulate and motivate the widespread adoption of CDS services in Korea. Methods CDS requirements and design principles were established by conducting a selective literature review and a survey of clinicians, managers, and hospital and industrial health information technology engineers regarding issues related to CDS architectures. The previous relevant works of the American Medical Informatics Association, the Healthcare Information and Management Systems Society, and Health Level Seven were used to validate the scope and themes of the service architecture. The Arden Syntax, Standards-Based Sharable Active Guideline Environment, First DataBank, and SEBASTIAN approaches were used to assess the coverage of the application architecture thus defined. A CDS prototype of an outpatient hypertension management system was implemented and assessed in a simulated experimental setting to evaluate the feasibility of the proposed architecture. Results Four CDS service features were identified: knowledge application, knowledge management, audit and evaluation, and CDS and knowledge governance. Five core components of CDS application architecture were also identified: knowledge-execution component, knowledge-authoring component, data-interface component, knowledge repository, and service-interface component. The coverage and characteristics of the architecture identified herein were found to be comparable with those described previously. Two scenarios of deployment architecture were identified in the context of Korean healthcare. The preliminary feasibility test revealed that the architecture exhibited good performance and made it easy to integrate patient data. Conclusion We have described the efforts that have been made to realize CDS service features, core components, application, and deployment architectures in the context of the Korean EHR. These outcomes showed the potential to contribute to the adoption of CDS at the national level.

Scientific production of electronic health record research, 1991–2005

Purpose The increasing numbers of publications on electronic health record (EHR) indicate its increasing importance in the world. This study attempted to quantify the scientific production of EHR research articles, and how they have changed over time, in an effort to investigate changes in the trends cited in these critical evaluations. Method The articles were based on the science citation index (SCI) from 1991 to 2005. A descriptive study was performed using the 1803 documents published in the SCI from 39 countries in America, Europe, Africa, Asia, and Oceania. The evaluation was based on parameters including document type, language, first author's country of origin, number of citations and citations per publication. Results Of all publications, 1455 (80.7%) were articles, followed by meeting abstracts which represented about one-tenth of all types of EHR publications. Numbers of published articles have significantly increased when compared by each 5-year period. Most articles were published in English (98%) and were from the region of America (57%). The top 10 of the 374 journals accounted for 41% of the number of published articles. The US dominates publication production (57%) with a cumulative impact factor (IF) of 2227 and followed by the UK (8.5%, with a cumulative IF of 257.0) and the Netherlands (7.8%, with a cumulative IF of 211.1). An analysis of the number of articles related to population revealed a high publication output for relative small countries like Switzerland, the Netherlands, and Norway. Conclusions Research production in EHR showed a considerable increase during 1991–2005. The production was dominated by articles, those from the US, and those published in English. The production came from many countries, denoting the devotion to this field in different areas around the world.