Essential dataset for ambulatory ear, nose, and throat care in general practice: an aid for quality assessment.
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OBJECTIVE: To describe the documentation of care for the usual range of ear, nose, and throat (ENT) problems seen in primary care as a basis for developing a computerised information system to aid quality assessment. DESIGN: Descriptive study of the pattern of ENT problems and diagnoses and treatment as recorded in individual case notes. SETTING: The primary health care centre in Mjolby, Sweden. PATIENTS: Consultations for ENT problems from a 10% sample randomly selected from all consultations (n = 22,600) in one year. From this sample 375 consultations for ENT problems (16% of all consultations) by 272 patients were identified. MAIN MEASURES: The detailed documentation of each consultation was retrieved from the individual records and compared with the data required for a computer based information system designed to help in quality management. RESULTS: Although the overall picture gained from the data retrieved from the notes suggested that ENT care was probably adequate, the recorded details were limited. The written case notes were insufficient when compared with the details required for a computerised system based on an essential dataset designed to allow assessment of diagnostic accuracy and appropriateness of treatment of ENT problems in primary care. CONCLUSION: There is a gap between the amount and the type of information needed for accurate and useful quality assessment and that which is normally included in case notes. More detailed information is needed if general practitioners' notes are to be used for regular quality assessment of ENT problems but that would mean more time spent on keeping notes. This would be difficult to justify. IMPLICATIONS: The routine information systems used at this primary healthcare centre did not produce sufficient documentation for quality assessment of ENT care. This dilemma might be resolved by specially designed desktop computer software accessed through an essential dataset. (+info)
Improving clinician acceptance and use of computerized documentation of coded diagnosis.
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After the Northwest Division of Kaiser Permanente implemented EpicCare, a comprehensive electronic medical record, clinicians were required to directly document orders and diagnoses on this computerized system, a task they found difficult and time consuming. We analyzed the sources of this problem to improve the process and increase its acceptance by clinicians. One problem was the use of the International Classification of Diseases (ICD-9) as our coding scheme, even though ICD-9 is not a complete nomenclature of diseases and using it as such creates difficulties. In addition, the synonym list we used had some inaccurate associations, contributing to clinician frustration. Furthermore, the initial software program contained no adequate mechanism for adding qualifying comments or preferred terminology. We sought to address all these issues. Strategies included adjusting the available coding choices and descriptions and modifying the medical record software. In addition, the software vendor developed a utility that allows clinicians to replace the ICD-9 description with their own preferred terminology while preserving the ICD-9 code. We present an evaluation of this utility. (+info)
Successful implementation of a comprehensive computer-based patient record system in Kaiser Permanente Northwest: strategy and experience.
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Kaiser Permanente Northwest (KPNW) has implemented a computer-based patient record (CPR) system for outpatients. Clinicians at KPNW use this comprehensive CPR to electronically document patient encounters; code diagnoses and procedures; maintain problem lists; order laboratory tests, radiology tests, and prescriptions; and send patient-specific messages and referrals to other medical providers. More than 700 clinicians, representing more than 20 medical and surgical specialties, and 2600 support staff in 31 geographically separate sites use this system as the information foundation of delivery and documentation of health care for KPNW's membership of 430,000. As of May 1998, more than four million visits and two million telephone calls had been processed and documented into the system. More than 5000 outpatient visits are processed and documented each weekday. From an integrated clinical workstation, clinicians also access e-mail, an extensive results-reporting system, and sites on both the internet and KPNW's intranet. This article describes a strategy for and experience with the implementation of a large-scale, comprehensive CPR in an integrated HMO. This information may be useful for persons attempting to implement CPRs in their own institutions. (+info)
Support of quality and business goals by an ambulatory automated medical record system in Kaiser Permanente of Ohio.
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Kaiser Permanente of Ohio has developed a Medical Automated Record System (MARS) to address the business and clinical needs of the organization. The system is currently used by 220 physicians and 110 allied health personnel. To support the quality initiatives of the organization, the system has been programmed to generate reminders, at the moment of care, on compliance with clinical guidelines. This article details examples of compliance improvements with guidelines for the use of aspirin in coronary artery disease, use of influenza vaccinations in members older than 64 years of age, and stratification of asthmatic patients into severity levels; it also summarizes other quality improvements. MARS provides a data stream for electronic billing, which saves the organization the cost of manual billing. In addition, this system reduces operating costs, in particular the number of staff needed to deliver charts and the cost of printing forms. Cost-benefit analysis demonstrates that the system can produce savings in excess of maintenance costs. (+info)
Evaluating ambulatory resident practice using an Internet-based system.
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To improve faculty participation in providing feedback on resident outpatient practice, we designed and implemented an Internet-based evaluation system. Attending physicians scored residents on 7 questions related to specific practice behaviors, and completed a free-text comment section. Between January and June 1998, 516 evaluations for 107 residents were generated using the Internet-based system, compared with 29 handwritten evaluations for 82 residents between January and June 1997. The number of faculty evaluations was 527 for 121 residents in the second half of 1998. An Internet-based evaluation system can improve faculty compliance with performing evaluations. (+info)
Comparing user acceptance of a computer system in two pediatric offices: a qualitative study.
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The purpose of this qualitative study was to examine user acceptance of a clinical computer system in two pediatric practices in the southeast. Data were gathered through interviews with practice and IS staff, observations in the clinical area, and review of system implementation records. Five months after implementation, Practice A continued to use the system but Practice B had quit using it because it was unacceptable to the users. The results are presented here, in relation to a conceptual framework, which was originally developed to describe the process of successful implementation of research findings into practice. Five main themes were identified relative to the differences in user acceptance at the two practices: 1) Benefits versus expense of system use varied, 2) Organizational cultures differed, 3) IS staff's relationship with practices differed, 4) Post-implementation experiences differed, and 5) Transfer of technology from the academic center to private practice proved challenging in Practice B. The findings indicate a need for the development and validation of tools to measure healthcare organizational climate and readiness for change. (+info)
Studying the human-computer-terminology interface.
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OBJECTIVE: To explore the use of an observational, cognitive-based approach for differentiating between successful, suboptimal, and failed entry of coded data by clinicians in actual practice, and to detect whether causes for unsuccessful attempts to capture true intended meaning were due to terminology content, terminology representation, or user interface problems. DESIGN: Observational study with videotaping and subsequent coding of data entry events in an outpatient clinic at New York Presbyterian Hospital. PARTICIPANTS: Eight attending physicians, 18 resident physicians, and 1 nurse practitioner, using the Medical Entities Dictionary (MED) to record patient problems, medications, and adverse reactions in an outpatient medical record system. MEASUREMENTS: Classification of data entry events as successful, suboptimal, or failed, and estimation of cause; recording of system response time and total event time. RESULTS: Two hundred thirty-eight data entry events were analyzed; 71.0 percent were successful, 6.3 percent suboptimal, and 22.7 percent failed; unsuccessful entries were due to problems with content in 13.0 percent of events, representation problems in 10.1 percent of events, and usability problems in 5.9 percent of events. Response time averaged 0.74 sec, and total event time averaged 40.4 sec. Of an additional 209 tasks related to drug dose and frequency terms, 94 percent were successful, 0.5 percent were suboptimal, and 6 percent failed, for an overall success rate of 82 percent. CONCLUSIONS: Data entry by clinicians using the outpatient system and the MED was generally successful and efficient. The cognitive-based observational approach permitted detection of false-positive (suboptimal) and false-negative (failed due to user interface) data entry. (+info)
Electronic prescribing in ambulatory practice: promises, pitfalls, and potential solutions.
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OBJECTIVE: To examine advantages of and obstacles to electronic prescribing in the ambulatory care environment. DATA SOURCES: MEDLINE and International Pharmaceutical Abstract searches were conducted for the period from January 1980 to September 2000. Key words were electronic prescribing, computerized physician order entry, prior authorization, drug utilization review, and consumer satisfaction. In September 2000, a public search engine (www.google.com) was used to find additional technical information. In addition, pertinent articles were cross-referenced to identify other resources. DATA EXTRACTION: Articles, symposia proceedings, and organizational position statements published in the United States on electronic prescribing and automation in healthcare are cited. DATA SYNTHESIS: Electronic prescribing can eliminate the time gap between point of care and point of service, reduce medication errors, improve quality of care, and increase patient satisfaction. Considerable funding requirements, segmentation of healthcare markets, lack of technology standardization, providers' resistance to change, and regulatory indecisiveness create boundaries to the widespread use of automated prescribing. The potential solutions include establishing a standardizing warehouse or a router and gaining stakeholder support in implementation of the technology. CONCLUSIONS: Electronic prescribing can provide immense benefits to healthcare providers, patients, and managed care. Resolution of several obstacles that limit feasibility of this technology will determine its future. (+info)