Local Electronic Medical Record Research Articles

Assessment of multiple-opinion referrals and consults at the BC Children’s Hospital Allergy Clinic

BackgroundAllergic disease is on the rise. Waitlists for specialists are long, and many referred patients have already received prior allergic assessment, either by a certified Allergist, Primary Care Provider, or other Specialist. It is important to understand the prevalence and motivating factors for multiple-opinion referrals, to deliver timely assessment for patients with allergic disease.MethodsA retrospective chart review of demographic information, number of previous consultations, and motivation for new consults and multiple-opinion referrals, of pediatric patients aged 8 months–17 years to BC Children’s Hospital Allergy Clinic from September 1, 2016–August 31, 2017, was performed. Referral data including reason for referral or multiple-opinion, primary allergic concerns, and others, from referral forms and consult notes were accessed through local Electronic Medical Records and subsequently analyzed for trends in categorical variables to assess the rationale for and impact of multiple-opinion referrals to our clinic.ResultsOf 1029 new referrals received, 210 (20.4%) were multiple-opinion referrals. Food allergy was the predominant allergic concern prompting further opinion (75.7%). The main rationale for seeking further opinions was wanting an assessment by a certified allergist in cases where prior consultation was performed by non-allergist specialist, primary care provider, or alternative health care provider. Of second-opinion referrals generated, 70 (33.3%) initial consultations were performed by an Allergist, whereas 140 (66.7%) were performed by a non-allergist.ConclusionsMany new consults at the BCCH Allergy Clinic are multiple-opinion assessments, contributing to long waitlists. Advocacy at the systems level through standardized referral guidelines, centralized triaging systems, and stronger support for Primary Care Providers is needed to provide better access in Canada for children needing a specialized Allergist.Trial registration UBC/BCCH Research Ethics Board

A Digital Solution for an Advanced Breast Tumor Board: Pilot Application Cocreation and Implementation Study

Cancer treatment is constantly evolving toward a more personalized approach based on clinical features, imaging, and genomic pathology information. To ensure the best care for patients, multidisciplinary teams (MDTs) meet regularly to review cases. Notwithstanding, the conduction of MDT meetings is challenged by medical time restrictions, the unavailability of critical MDT members, and the additional administrative work required. These issues may result in members missing information during MDT meetings and postponed treatment. To explore and facilitate improved approaches for MDT meetings in France, using advanced breast cancers (ABCs) as a model, Centre Léon Bérard (CLB) and ROCHE Diagnostics cocreated an MDT application prototype based on structured data. In this paper, we want to describe how an application prototype was implemented for ABC MDT meetings at CLB to support clinical decisions. Prior to the initiation of cocreation activities, an organizational audit of ABC MDT meetings identified the following four key phases for the MDT: the instigation, preparation, execution, and follow-up phases. For each phase, challenges and opportunities were identified that informed the new cocreation activities. The MDT application prototype became software that integrated structured data from medical files for the visualization of the neoplastic history of a patient. The digital solution was assessed via a before-and-after audit and a survey questionnaire that was administered to health care professionals involved in the MDT. The ABC MDT meeting audit was carried out during 3 MDT meetings, including 70 discussions of clinical cases before and 58 such discussions after the implementation of the MDT application prototype. We identified 33 pain points related to the preparation, execution, and follow-up phases. No issues were identified related to the instigation phase. Difficulties were grouped as follows: process challenges (n=18), technological limitations (n=9), and the lack of available resources (n=6). The preparation of MDT meetings was the phase in which the most issues (n=16) were seen. A repeat audit, which was undertaken after the implementation of the MDT application, demonstrated that (1) the discussion times per case remained comparable (2 min and 22 s vs 2 min and 14 s), (2) the capture of MDT decisions improved (all cases included a therapeutic proposal), (3) there was no postponement of treatment decisions, and (4) the mean confidence of medical oncologists in decision-making increased. The introduction of the MDT application prototype at CLB to support the ABC MDT seemed to improve the quality of and confidence in clinical decisions. The integration of an MDT application with the local electronic medical record and the utilization of structured data conforming to international terminologies could enable a national network of MDTs to support sustained improvements to patient care.

COVID-19 Impact on Australian Patients with Substance Use Disorders: Emergency Department Admissions in Western Sydney before Vaccine Roll Out.

Background: In this study, we determined the impact of the COVID-19 pandemic on Western Sydney patients with substance use disorders (SUD) by comparing emergency department (ED) admission rates before and after the onset of the COVID-19 pandemic and before the rollout of COVID-19 vaccination. Methods: ED admission data for patients with SUD were retrieved from the local electronic medical record (eMR) on the hospital central database. ED data collected from 25 January to 25 July 2019 (before the COVID-19 pandemic) were compared with data from 25 January to 25 July 2020 (early pandemic). ED admission reasons were categorised based on the presenting complaints and ED diagnoses. Results: Despite an overall reduction in ED admissions during the early pandemic, compared to the pre-pandemic period, admissions for patients with SUD increased significantly (1.7% to 3.4%, p < 0.01). ED admission rates related to infection (0.05% to 0.12%, p < 0.01), local infection (0.02% to 0.05%, p < 0.01), trauma (0.06% to 0.12%, p < 0.01), alcohol (0.01% to 0.03%, p < 0.05), and other issues (0.06% to 0.10%, p < 0.05) increased significantly among Indigenous patients with SUD. ED admission rates related to drugs (0.12% to 0.39%, p < 0.01), infection (0.21% to 0.34%, p < 0.01), local infection (0.07% to 0.18%, p < 0.01), gastrointestinal (0.15% to 0.23%, p < 0.05), trauma (0.14% to 0.25%, p < 0.01), alcohol (0.36% to 0.74%, p < 0.01), and ‘other’ issues (0.47% to 0.91%, p < 0.01) increased significantly among non-Indigenous patients with SUD. Four cases of COVID-19 were reported among these patients. Conclusions: There was an increase in ED admissions for patients with SUD in the initial six months of the COVID-19 pandemic (before vaccine rollout), mainly for drugs, systemic infection, local infection, trauma, and alcohol-related reasons. Now that most people in New South Wales have been vaccinated against COVID-19, a further study is needed to quantify the effect of the pandemic on patients with SUD in the post-vaccine era.

Agreement among sources of adult influenza vaccination in the age of immunization information systems

IntroductionMany vaccination studies rely on self-reported vaccination status, with its inherent biases. Accuracy of influenza vaccination self-report has been evaluated periodically, typically using the medical record as the gold standard. The burgeoning of electronic medical records (EMRs) and immunization information systems (IISs) and the rise of adult vaccine administration in community pharmacies suggest the need for a reevaluation of self-reported vaccination status. MethodsVaccination data from self-report, the state IIS, the health system EMR and other sources were compared for participants in outpatient and inpatient influenza vaccine effectiveness studies for four seasons (2016–2017 to 2019–2020). Agreement among the sources was calculated along with sensitivity and specificity. Tests for trend assessed changes in completeness of the Pennsylvania - Statewide IIS (PA-SIIS) data over time. ResultsWith self-report as the gold standard, agreement with the local EMR, PA-SIIS, and all sources was 62%, 77% and 85%, respectively. Sensitivity of the EMR was 42% (95% CI = 41, 43) and specificity was 91% (90, 92). With PA-SIIS-as the gold standard, agreement with the local EMR and all sources was 77% and 78%, respectively. Sensitivity of all sources combined was 96% (95, 97) and specificity was (63% (62, 64). Capture of influenza vaccinations in the IIS has not consistently improved over time, with a significant increase among children (P = 0.001), no change among working-age adults and a decrease among older adults (P = 0.004). However, PA-SIIS provided the largest percentage of verified vaccines (69.3%) compared with EMR (43.3%) and other sources (12.4%). ConclusionBoth self-report and PA-SIIS are good estimates of actual vaccine uptake. When high accuracy data are required, such as for vaccine effectiveness studies, triangulation using multiple sources should be conducted.

Substitution and complementarity in the use of health information exchange and electronic medical records

ABSTRACT While considerable literature has addressed the separate use of health information systems, limited research has examined how the use of one system changes following the implementation of another. We address this gap in the literature by developing and testing hypotheses about substitution and complementarity in physicians’ use of health information exchange (HIE), which merges patient data from multiple sources, following the implementation of a local electronic medical record (EMR) system. The hypotheses are anchored in theories foundational to understanding the motivation for information seeking behaviour. The hypotheses are tested with unique data, recorded in system log files, that describe HIE use by physicians in an emergency department before and after EMR implementation. The findings confirm that system use is characterised by substitution when it is defined dichotomously as whether the system is accessed or not (lower HIE access rates after EMR implementation) and by complementarity when it is defined as the extent of system use (higher volume and duration of HIE use after EMR implementation). Our findings suggest that the information seeking literature has underestimated the explanatory value of the cost-benefit approach and the occurrence of complementarity in system use because of its overreliance on a narrow definition of use.

1286-P: Identification of Atypical Pediatric Diabetes Using Electronic Medical Records (EMR)

We aimed to identify cases of rare or atypical pediatric diabetes who may be candidates for studies to understand their etiology and pathogenesis. We tested two strategies in a large pediatric hospital in Southwestern USA. STRATEGY 1: We designed a questionnaire that would allow a health-care provider to rule out typical diabetes types by manual EMR review. This questionnaire was first applied to the EMR of 50 youth (0-21 years old [y/o]) consecutively seen in the diabetes outpatient clinic, then modified to address problems identified, and tested in a second iteration, and on 50 additional cases (n=100). STRATEGY 2: In collaboration with local EMR analysts, we built three queries to generate periodic, automated reports of possible pediatric atypical diabetes cases: unknown type, type 2 diabetes (T2D) diagnosed &amp;lt;10 y/o, and autoantibody-negative type 1 diabetes (T1D). Diabetes type (i.e., unknown, T1D or T2D) was determined by the treating pediatric endocrinologist, through a customized flowchart embedded in the EMR. STRATEGY 1: We found 6 cases (6%) of atypical diabetes (mean age at diagnosis 11 y/o [SD 2.64], 16.6% male, 33% non-Hispanic White [NHW] and 66.6% Hispanic [Hisp]). STRATEGY 2: Unknown diabetes type: 67 cases (15, out of 6676 total diabetes cases), with mean age at diagnosis 12.6 y/o (SD 3.3), 32.8% male, 23.8% NHW, 47.6% Hisp, 25.4% African-American (AA), 3.2% other. Out of 1142 children with T2D, 64 (6.6%) cases were diagnosed &amp;lt;10 y/o, with mean age at diagnosis 8.6 y/o (SD 1.6), 20.3% male, 4.7% NHW, 65.6% Hisp, 28.1% AA, 1.6% other. Out of 680 cases of new onset T1D, 38 (5.6%) were negative for islet autoantibodies (IAA, GAD, IA-2), with mean age at diagnosis 11.3 y/o (SD3.8); 57.9% male, 50% NHW, 19.4% Hisp, 22.3% AA, 8.3% other. In sum, we designed and tested two strategies that use EMR to identify possible atypical pediatric diabetes cases for further studies that may shed light on the heterogeneity of pediatric diabetes, possibly opening new opportunities for diagnosis, treatment and prevention. Disclosure M. Astudillo: None. M. Tosur: None. A.F. Siller: None. A. Balasubramanyam: None. M.J. Redondo: None.

Cuidado compartilhado de pessoas vivendo com HIV/AIDS na Atenção Primária

Introdução: Buscando instituir ações para prevenir e reduzir a transmissão, melhorar o acesso ao tratamento e a qualidade de vida das pessoas vivendo com HIV/AIDS (PVHIV), a rede municipal de saúde de Florianópolis implantou entre 2015 e 2016 uma nova forma de suporte em Infectologia para a Atenção Primária a Saúde (APS). Objetivo: Descrever os resultados encontrados no município no processo de descentralização e cuidado compartilhado de pessoas vivendo com HIV/AIDS (PVHIV) com a APS de Florianópolis. Métodos: Trata-se de um estudo observacional, transversal e descritivo. Os dados foram obtidos de relatórios do prontuário eletrônico local e a partir de questionário estruturado aplicado junto aos médicos da APS de Florianópolis. Resultados: Entre 2014 e 2018, o número de atendimentos na APS relacionados ao cuidado de PVHIV teve um aumento expressivo, sobretudo após 2016, acompanhado de uma redução de 45,7% na proporção de encaminhamentos para infectologia após a implantação do apoio matricial em infectologia. Aliada à redução da taxa de encaminhamento evidenciou-se a habilidade na prescrição de Terapia Antirretroviral (TARV) por 100% dos médicos da APS entrevistados. Em relação à situação de acompanhamento de PVHIV, exclusivamente sob cuidados da APS, foi encontrada diferença estatisticamente significante entre os médicos que fazem preceptoria em ensino na graduação e residência e os que são residentes ou tem formação específica em medicina de família e comunidade (MFC) em relação aos médicos sem formação específica. A proporção de médicos que se sentem seguros e confiantes em realizar esse tipo de atendimento na APS também foi significativamente maior entre os médicos que fazem preceptoria e são médicos de família e comunidade. Conclusões: A implantação do Apoio Matricial da Infectologia para a APS trouxe grande avanço para o município de Florianópolis, no que tange ao acesso e qualificação do cuidado das pessoas vivendo com HIV/AIDS. Os resultados foram mais significativos para os profissionais envolvidos com atividades de preceptoria e formação específica em MFC, o que reforça o papel da educação permanente na qualificação da coordenação do cuidado pela APS.

Emergency management of SCD pain crises: Current practices and playing variables

Introduction/ObjectivesAcute pain episode is a common reason for patients with sickle cell disease to present to the Emergency Room. This study is designed to assess the role of multiple factors that might affect the time from Emergency Department triage to the administration of the first opiate pain medication and its dosage, to compare current practices with the American Pain Society Guideline for the Management of Acute and Chronic Pain in Sickle-Cell Disease in the Emergency Department. By identifying and recognizing some of the factors that delay or affect the proper dosing of the pain medications, we aim to implement suitable and plausible changes to ensure better emergency care for these sickle cell disease patients. MethodologyThis is a cross-sectional retrospective descriptive study that relied on collecting non-identifiable data from the local Electronic Medical Record to assess for possible relationship between the proposed set of factors/variables and the time to administration of the 1st pain medication and it's dosage. The population in question includes the entire sickle cell disease patients' population (HB-SS, HB-SC, HB-SD, HB-SB+ and HB-SB0) that are under the care of our Pediatric Hematology-Oncology clinic with the age range of 1 day–21 years. The factors include age, gender, pain assessment/scale, time of presentation, mode of arrival, presence or absence of IV access at presentation, and ESI acuity. ResultsThere were 259 patient Emergency Room visits with 148 unique patients. Mean (SD) age of the entire study population was 15.98 (±4.08) years and 61.8% of the patients were females. Average time to 1st opiate pain medication was 120.27 min (SD ± 78.4) and average doses of Morphine and Hydromorphone were 0.067 mg/kg and 0.053 mg/kg respectively. Longer waiting time to 1st opiate pain medication were found in females with a mean difference of 25.5 min (95% CI 20–80.5 P value 0.027), older patients and patients with least severity ESI score (correlation coefficient of 0.214 & 0.134 (p values of 0.001 and 0.031) respectively). On the other hand, there seems to be a negative correlation between the time to 1st opiate and the pain score with a negative correlation coefficient of −0.22 (p value of <0.001). ConclusionOverall, patients with acute SCD pain experienced significant delays when seeking pain relief in the Emergency Department. The following patients experienced the longest delays: those assigned a lower triage priority level, female patients, patients with lower pain score and older patients.

PRM47 - Navigating Real World Evidence in Oncology – Where to Go and Why

Utilizing real world evidence (RWE) of disease burden and how therapies are used and perform in clinical practice settings is increasingly a focus of the healthcare industry. Companies can specifically set up primary data sources to collect the required data but can require significant time and resource investment. Alternatively, there are a plethora of existing data sources in many countries that can be potentially leveraged but the publically-available information on the quality of these data sources is limited. This research aims to identify and evaluate existing registries used for RWE within oncology. EMBASE searches were conducted for any observational study in oncology (2001-2017) using existing real-world data. These were then subject to text mining to identify the data sources. 526 sources of oncology data were identified across 31 different cancer types. These were across 133 countries, including 69 in the USA, 31 in China, 34 in Italy, 22 in France, 17 in Spain, 15 in UK, 14 in Japan, and 11 in Germany. These encompassed a mix of national and regional registries, local electronic medical record systems and administrative databases. Most registries are not specific for a certain type of cancer although some are restricted to, for example, childhood cancers or solid tumors. We have identified over 500 oncology data sources worldwide that can be potentially leveraged to, for example, quantify the local unmet need, analyse real-world clinical practice and potentially measure performance of a therapy and support validation of the economic assessment of a health technology. Nevertheless, when selecting countries to conduct a real world study, there are many more important factors to consider than the number of data sources. These include the quality and representativeness of the data collected, clinical setting, accessibility of the data, and scope of the registry (geography, follow-up, patients and cancers included).

Evaluation of an ICD logging system to supplement an EMR in a Sub-Saharan country

Adoption of electronic medical records (EMRs) has been spotty and sluggish in the world, including the United States, despite the multiple benefits of medical technology and informatics. Though there are difficulties in establishing and maintaining an EMR system in a developing country, it is not impossible. The International Classification of Diseases (ICD) Logger, called CREDO (Clinical Rotation Evaluation and Documentation Organizer), developed by Edward Via College of Osteopathic Medicine (VCOM), provides a straightforward, economical EMR system to use in a developing country, such as Ghana. However, with a recently established EMR system developed locally and being used at the target new hospital, Healthwise Medical Center, the aim of the study was to use the common medical documentation language of the World Health Organization (WHO) ICD-10 codes to add value to the local EMR. This demonstration enabled the comparison of medical encounters in Ghana to those in the United States, specifically in Appalachia where VCOM students typically do their clinical rotations. We also evaluated the issues and tested the CREDO ICD Logger as a simple, stand-alone EMR system. Therefore, by collecting ICD data twice weekly from Ghana, a data point in Sub-Saharan Africa, it became possible to compare a public health snapshot of developing countries and sites in the United States.

Gemcitabine plus nab-paclitaxel use in metastatic pancreatic cancer: A study of 40 patients.

498 Background: Metastatic pancreatic adenocarcinoma (mPDAC) carries a dismal prognosis, with often a poor response to treatment (Tx). Although gemcitabine with nab-paclitaxel (GnP) is now a standard 1st-line (1L) Tx in mPDAC, provincial policies limit its use. To understand the implications of the restriction, this real-life study was conducted. Methods: A historical prospective data was compiled using the local electronic medical record (Endovault Oncology v3.0, NY) at the Jewish General Hospital-McGill. All patients (pts) diagnosed with mPDAC that received GnP from 2013-2016 were identified. Demographics and Tx data was obtained. Primary objective was to evaluate tolerability in all lines of Tx [grade &gt;2 CTCAE v4.03, mean Tx delay (mTxd)]. Secondary objectives were Tx attrition and outcomes [RECIST 1.1, complete response (CR), stable disease (SD) and progression disease (PD)]. Results: Of the 40 pts (female 60%, median age 64.3), 25 (62.5%) had primary at the head of the pancreas and 30 (75%) liver metastasis. 1L Tx: GnP 24 (60%), FOLFIRINOX 10 (FFX, 25%), Gemcitabine 5 (Gc, 12.5%) and FOLFOX 1 (2.5%). 70% of both FFX and Gc pts had grade 2 peripheral neuropathy (PN), neutropenia (NEUT) and fatigue. Half GnP pts had grade 2 NEUT and fatigue. mTxd in GnP, FFX and Gc were 7, 14 and 7 days. All FFX and Gc pts had PD. GnP cohort had 1 CR and 7 SD. 2L Tx was in 22 (55%): GnP 13 (59.5%), FFX 3 (13.5%), Capecitabine 2 (9%), FOLFOX 2 (9%) and Gc (9%). FFX pts 66.6% had grade 3 fatigue. GnP pts had grade 2 NEUT, PN and fatigue in 53.8%, 15.3% and 46.2%. mTxd were GnP 14 days and FFX 14 days. Except 1 SD, all FFX pts had PD. GnP pts had 1 CR, 6 SD, and 6 PD. All pts on Capecitabine, FOLFOX and Gc had PD. 3L Tx was in 6 (15%): 3 GnP (50%) and 3 on clinical trials (50%). All pts had PD and &lt; 3 cycles. In 1L FFX pts, 7/10 and 3/6 went on to receive GnP in 2L and 3L. All 1L Gc pts had 2L GnP. Only 3 pts and 1 pt from 1L GnP pts went on to receive 2L and 3L Tx. Conclusions: Due to access limitations to GnP, its use was likely reserved for poor performance status pts. Instead, 1L FFX was used when possible. 1L FFX pts received more Tx lines due to initial pt selection. Further studies are needed in broader populations to evaluate optimal 1L Tx selection accounting for expected attrition and overall survival.

Lessons learned from adapting a generic narrative diabetic-foot guideline to an institutional decision-support system.

Clinical guidelines usually need to be adapted to fit local practice before they can be actually used by clinicians. Reasons for adaptation include variations of institution setting such as type of practice and location, availability of resources, differences in patient populations, local policies, and practice patterns. When a guideline is implemented for clinical decision support and integrated with an institution's clinical information system, the data model of the local electronic medical record (EMR) and the data actually collected and stored in it also influence the guideline's adaptation. The purpose of this work is: (1) to characterize a tool-supported process for guideline encoding that addresses local adaptation and EMR integration, and (2) to identify the types of changes in guideline encoding during the local adaptation process.

Utility of linking primary care electronic medical records with Canadian census data to study the determinants of chronic disease: an example based on socioeconomic status and obesity.

BackgroundElectronic medical records (EMRs) used in primary care contain a breadth of data that can be used in public health research. Patient data from EMRs could be linked with other data sources, such as a postal code linkage with Census data, to obtain additional information on environmental determinants of health. While promising, successful linkages between primary care EMRs with geographic measures is limited due to ethics review board concerns. This study tested the feasibility of extracting full postal code from primary care EMRs and linking this with area-level measures of the environment to demonstrate how such a linkage could be used to examine the determinants of disease. The association between obesity and area-level deprivation was used as an example to illustrate inequalities of obesity in adults.MethodsThe analysis included EMRs of 7153 patients aged 20 years and older who visited a single, primary care site in 2011. Extracted patient information included demographics (date of birth, sex, postal code) and weight status (height, weight). Information extraction and management procedures were designed to mitigate the risk of individual re-identification when extracting full postal code from source EMRs. Based on patients’ postal codes, area-based deprivation indexes were created using the smallest area unit used in Canadian censuses. Descriptive statistics and socioeconomic disparity summary measures of linked census and adult patients were calculated.ResultsThe data extraction of full postal code met technological requirements for rendering health information extracted from local EMRs into anonymized data. The prevalence of obesity was 31.6 %. There was variation of obesity between deprivation quintiles; adults in the most deprived areas were 35 % more likely to be obese compared with adults in the least deprived areas (Chi-Square = 20.24(1), p < 0.0001). Maps depicting spatial representation of regional deprivation and obesity were created to highlight high risk areas.ConclusionsAn area based socio-economic measure was linked with EMR-derived objective measures of height and weight to show a positive association between area-level deprivation and obesity. The linked dataset demonstrates a promising model for assessing health disparities and ecological factors associated with the development of chronic diseases with far reaching implications for informing public health and primary health care interventions and services.

Database: A New Article Type in CPT: Pharmacometrics & Systems Pharmacology.

Database: A New Article Type in CPT: Pharmacometrics & Systems Pharmacology.

Customization of a Severity of Illness Score Using Local Electronic Medical Record Data.

Severity of illness (SOI) scores are traditionally based on archival data collected from a wide range of clinical settings. Mortality prediction using SOI scores tends to underperform when applied to contemporary cases or those that differ from the case-mix of the original derivation cohorts. We investigated the use of local clinical data captured from hospital electronic medical records (EMRs) to improve the predictive performance of traditional severity of illness scoring. We conducted a retrospective analysis using data from the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC-II) database, which contains clinical data from the Beth Israel Deaconess Medical Center in Boston, Massachusetts. A total of 17 490 intensive care unit (ICU) admissions with complete data were included, from 4 different service types: medical ICU, surgical ICU, coronary care unit, and cardiac surgery recovery unit. We developed customized SOI scores trained on data from each service type, using the clinical variables employed in the Simplified Acute Physiology Score (SAPS). In-hospital, 30-day, and 2-year mortality predictions were compared with those obtained from using the original SAPS using the area under the receiver-operating characteristics curve (AUROC) as well as the area under the precision-recall curve (AUPRC). Test performance in different cohorts stratified by severity of organ injury was also evaluated. Most customized scores (30 of 39) significantly outperformed SAPS with respect to both AUROC and AUPRC. Enhancements over SAPS were greatest for patients undergoing cardiovascular surgery and for prediction of 2-year mortality. Custom models based on ICU-specific data provided better mortality prediction than traditional SAPS scoring using the same predictor variables. Our local data approach demonstrates the value of electronic data capture in the ICU, of secondary uses of EMR data, and of local customization of SOI scoring.

Development and pilot feasibility study of a health information technology tool to calculate mortality risk for patients with asymptomatic carotid stenosis: the Carotid Risk Assessment Tool (CARAT).

BackgroundPatients with no history of stroke but with stenosis of the carotid arteries can reduce the risk of future stroke with surgery or stenting. At present, a physicians’ ability to recommend optimal treatments based on an individual’s risk profile requires estimating the likelihood that a patient will have a poor peri-operative outcomes and the likelihood that the patient will survive long enough to gain benefit from the procedure. We describe the development of the CArotid Risk Assessment Tool (CARAT) into a 2-year mortality risk calculator within the electronic medical record, integrating the tool into the clinical workflow, training the clinical team to use the tool, and assessing the feasibility and acceptability of the tool in one clinic setting.MethodsWe modified an existing clinical flowsheet with the local electronic medical record for the CARAT risk model. To understand how CARAT would fit into the existing clinical workflow, we observed the clinic and talked with the clinical staff to develop a process map for the existing clinical workflow. CARAT was completed by the clinic nurse for patients identified on the clinic schedule as having carotid narrowing. We analyzed post-implementation assessment in two ways: quantifying the proportion of eligible patients with whom CARAT was utilized, and surveying surgeons to understand the impact of CARAT on decision-making and clinical workflow.ResultsWith minimum investment of institutional resources, we were able to produce a workable tool and pilot the tool in our clinic within a 6 month time period. Over 4 months, 287 patients were seen in the clinic with carotid narrowing, and clinic staff completed CARAT for 195 (68%). Per-surgeon completion rates ranged from 29 to 81%. Most patients (191 of 195, 98%) patients had a low 2-year calculated mortality risk. Most surgeons believed the risk assessment aligned with their expectations of patient predicted risk.ConclusionsWe successfully integrated CARAT into the existing electronic medical record and have preliminary evidence that CARAT can be a valuable tool for evaluating mortality risk for patients with diseased carotid arteries. Accuracy of the risk calculations must be evaluated in larger, multi-center studies.

Prescription of Ocular ??-Blockers in??Patients with Obstructive Pulmonary Disease

Topical beta-blockers are contraindicated in obstructive pulmonary diseases (OPDs). In this study we aimed to evaluate through central or local electronic medical records (EMRs) the prescription patterns for topical ocular beta-blockers for patients with glaucoma and OPD treated by ophthalmologists. The study was carried out at the Leumit Health Maintenance Organisation (HMO) in Israel. The physicians at the HMO all work with an EMR, either a central EMR incorporating data from primary-care physicians and consultants, or a local one. The study population included all HMO members who filled at least one prescription for antiglaucoma medications in 2004. The patients were divided into two groups: those with a previous diagnosis of OPD (ICD-9 codes 493) and those with no known diagnosis of OPD. 7481 patients consumed topical antiglaucoma medications during the study period, and 14.5% had a diagnosis of OPD. 798 OPD patients were treated by ophthalmologists, and of the 61.8% who were treated with topical beta-blockers, only 38 received betaxolol. In comparison with glaucoma patients without OPD, OPD patients received fewer beta-blockers (p < 0.001), more selective beta-blockers (p < 0.0001) and less timolol (p < 0.001). Of the OPD patients treated by ophthalmologists with a central EMR, 59.5% received beta-blockers in comparison with 66.4% treated by ophthalmologists with a local EMR (p = 0.06). OPD patients treated by ophthalmologists with a central EMR received more non-beta-blockers in comparison with patients treated by ophthalmologists with a local EMR (p = 0.02). Most patients with OPD and glaucoma continued to receive topical beta-blockers, mostly noncardioselective beta-blockers. A central EMR with a comprehensive and highly available medical history reduced the prescription of beta-blockers to OPD patients, but rates remained unacceptably high.

Electronic Medical Records: Saving Trees, Saving Lives

CONSIDER THIS IRONY OF MODERN LIFE: IN A MEDICAL CRISIS, EMERGENCY physicians would have an easier time accessing a patient’s bank account using his or her automatic teller machine card than they would finding critical medical history using his or her medical insurance card. Medical records, including crucial electrocardiograms, drug allergies, or medical conditions, are typically stored on paper and are often inaccessible in emergencies. The ability to access medical charts electronically, in emergency situations or in routine medical settings, has not paralleled the growth of financial networks or indeed of the Internet. Although several commercial sites are now selling space for individuals to put their medical records online and numerous institutions have local electronic medical records (EMRs) in place, most clinical records are still kept in paper charts that are stored at a single location. The challenge of building an integrated EMR system has proved to be more than technological; 25 years of attempts to formalize the terms and concepts of medical practice has exposed some fascinating philosophical conundrums. What belongs in a medical record, and how should medical conditions or ideas be encoded? Which tasks are best performed by physicians, and which by the computer? Is it possible to encapsulate the medical encounter in digital form? A number of centers have had local EMRs available for decades, providing evidence that thoughtfully implemented EMRs improve medical care through adjunct technology like error checking and allow easier study of trends in a clinic population. New links are being forged between individual patient data and the information in digital libraries or the tools of computerized decision support. While the potential for ease of access and error reduction seems obvious, new technologies should be held to the same standards of evidence as new treatments are. Research in this field has started to look not only at efficiency and institutional satisfaction but also at health outcomes and impact on the patient-physician relationship. As researchers measure the gains made by using EMRs, they should also consider potential losses. Will physicians rely too heavily on the safety nets of automatic warning systems, losing the ability to think through the problem—just as many who rely on calculators cannot compute answers on their own? With full histories available at the touch of a button, will tired interns and residents cut corners, neglecting to ask their own questions? EMRs must be a tool for improving patient care rather than a crutch or a hindrance to the primary work of caring for patients. This month, MSJAMA examines the legal, ethical, and technical challenges of EMRs. With a new generation of physicians accustomed to working with computer technology, we may see some of the promise of the past 3 decades of research in this field come to fruition in the coming years.