Global quality indicators for primary care Electronic Patient Records.

Electronic Patient Records can be interfaced with medical decision support systems and quality of care assessment tools. An easy way of measuring the quality of EPR data is therefore essential. This study identified a number of global quality indicators (tracers) that could be easily calculated and validated them by correlating them with the Sensitivity and Positive Predictive Value (PPV) of data extracted from the EPR. Sensitivity and PPV of automatically extracted data were calculated using a gold standard constructed using answers to questions GPs were asked at the end of each contact with a patient. These properties were measured for extracted diagnoses, drug prescriptions, and certain parameters. Tracers were defined as drug-disease pairs (e.g. insulin-diabetes) with the assumption that if the patient is taking the drug, then the patient is suffering from the disease. Four tracers were identified that could be used for the ResoPrim primary care research database, which includes data from 43 practices, 10,307 patients, and 13,372 contacts. Moderately positive correlations were found between the 4 tracers and between the tracers and the sensitivity of automatically extracted diagnoses. For some purposes, these results may support the potential use of tracers for monitoring the quality of information systems such as EPRs.

COVID-19 Clusters in Belgian Nursing Homes: Impact of Facility Characteristics and Vaccination on Cluster Occurrence, Duration and Severity.

COVID-19 severely affected nursing home residents from March 2020 onwards in Belgium. This study aimed to model the impact of vaccination and facility characteristics on cluster occurrence, duration and severity in this setting. Possible clusters were identified between June 2020 and January 2022, based on the Belgian COVID-19 surveillance in nursing homes. Median attack rates (AR) among residents and staff, case hospitalization rates (CHR) and case fatality rates (CFR) were calculated. A negative binomial model was used to identify the association between nursing home characteristics and the number of cases, hospital admissions and deaths and the duration of the cluster. A total of 2239 clusters were detected in more than 80% of nursing homes. Most of these (62%) occurred before the start of COVID-19 vaccination (end of December 2020). After vaccination, the number of clusters, the AR among residents and staff, the CHR and the CFR dropped. Previous cluster(s) and vaccination decreased the number of cases, hospital admissions and deaths among residents. Previous cluster experience and having started vaccination were protective factors. We recommend continued implementation of targeted interventions such as vaccination, large-scale screening and immediate implementation of additional infection prevention and control measures.

Quality assessment of automatically extracted data from GPs' EPR.

There are many secondary benefits to collecting routine primary care data, but we first need to understand some of the properties of this data. In this paper we describe the method used to assess the PPV and sensitivity of data extracted from Belgian GPs' EPR (diagnoses, drug prescriptions, referrals, and certain parameters), using data collected through an electronic questionnaire as a gold standard. We describe the results of the ResoPrim phase 2 project, which involved 4 software systems and 43 practices (10,307 patients). This method of assessment could also be applied to other research networks.

Nation-wide primary healthcare research network: a privacy protection assessment.

Efficiency and privacy protection are essential when setting up nationwide research networks. This paper investigates the extent to which basic services developed to support the provision of care can be re-used, whilst preserving an acceptable privacy protection level, within a large Belgian primary care research network. The generic sustainable confidentiality management model used to assess the privacy protection level of the selected network architecture is described. A short analysis of the current architecture is provided. Our generic model could also be used in other countries.

COVID-19 cases, hospitalizations and deaths in Belgian nursing homes: results of a surveillance conducted between April and December 2020.

BACKGROUND: In Belgium, the first COVID-19 death was reported on 10 March 2020. Nursing home (NH) residents are particularly vulnerable for COVID-19, making it essential to follow-up the spread of COVID-19 in this setting. This manuscript describes the methodology of surveillance and epidemiology of COVID-19 cases, hospitalizations and deaths in Belgian NHs. METHODS: A COVID-19 surveillance in all Belgian NHs (n = 1542) was set up by the regional health authorities and Sciensano. Aggregated data on possible/confirmed COVID-19 cases and hospitalizations and case-based data on deaths were reported by NHs at least once a week. The study period covered April-December 2020. Weekly incidence/prevalence data were calculated per 1000 residents or staff members. RESULTS: This surveillance has been launched within 14 days after the first COVID-19 death in Belgium. Automatic data cleaning was installed using different validation rules. More than 99% of NHs participated at least once, with a median weekly participation rate of 95%. The cumulative incidence of possible/confirmed COVID-19 cases among residents was 206/1000 in the first wave and 367/1000 in the second wave. Most NHs (82%) reported cases in both waves and 74% registered ≥10 possible/confirmed cases among residents at one point in time. In 51% of NHs, at least 10% of staff was absent due to COVID-19 at one point. Between 11 March 2020 and 3 January 2021, 11,329 COVID-19 deaths among NH residents were reported, comprising 57% of all COVID-19 deaths in Belgium in that period. CONCLUSIONS: This surveillance was crucial in mapping COVID-19 in this vulnerable setting and guiding public health interventions, despite limitations of aggregated data and necessary changes in protocol over time. Belgian NHs were severely hit by COVID-19 with many fatal cases. The measure of not allowing visitors, implemented in the beginning of the pandemic, could not avoid the spread of SARS-CoV-2 in the NHs during the first wave. The virus was probably often introduced by staff. Once the virus was introduced, it was difficult to prevent healthcare-associated outbreaks. Although, in contrast to the first wave, personal protective equipment was available in the second wave, again a high number of cases were reported.

Primary healthcare research network: the Belgian ResoPrim recommendations.

Dedicated primary care research networks aim to gather and analyse data collected from general practioners' (GPs) electronic health records (EHRs). ResoPrim (2003-2008) was a Belgian multidisciplinary research project which was set up to provide recommendations for facilitating the organisation and management of these primary care research networks, assessing and improving opportunities for researchers working with available data from EHRs, and stimulating the involvement of GPs in such networks. This paper provides a short description of Resoprim's global methodology (which included 2 pilot phases involving 64 GPs and 6 different software systems), followed by the project's final recommendations.

Access to paediatric palliative care in children and adolescents with complex chronic conditions: a retrospective hospital-based study in Brussels, Belgium.

BACKGROUND: Paediatric complex chronic conditions (CCCs) are life-limiting conditions requiring paediatric palliative care, which, in Belgium, is provided through paediatric liaison teams (PLTs). Like the number of children and adolescents with these conditions in Belgium, their referral to PLTs is unknown. OBJECTIVES: The aim of the study was to identify, over a 5-year period (2010-2014), the number of children and adolescents (0-19 years) living with a CCC, and also their referral to PLTs. METHODS: International Classification of Disease codes (ICD-9) corresponding to a CCC, as described by Feudtner et al, and national registration numbers were extracted from the databases of all hospitals (n=8) and PLTs (n=2) based in the Brussels region. Aggregated data and pseudonymised national registration number were transmitted to the research team by a Trusted Third Party (eHealth). Ages and diagnostic categories were calculated using descriptive statistics. RESULTS: Over 5 years (2010-2014) in the Brussels region, a total of 22 721 children/adolescents aged 0-19 years were diagnosed with a CCC. Of this number, 22 533 were identified through hospital registries and 572 through PLT registries. By comparing the registries, we found that of the 22 533 children/adolescents admitted to hospital, only 384 (1.7%) were also referred to a PLT. CONCLUSION: In Belgium, there may be too few referrals of children and adolescents with CCC to PLTs that ensure continuity of care.

From a conceptual problem-oriented electronic patient record model to running systems: a nationwide assessment.

BACKGROUND: The development of problem-oriented conceptual models for electronic patient record (EPR) systems can improve data communication between health professionals. But little has been done so far to investigate to what extent it is possible to implement such models in operational EPR systems. OBJECTIVE: In this paper, we measure the conformance between a conceptual model and the various ways it is implemented within general practitioners' (GPs') electronic patient records. METHODS: We started from a simple problem-oriented conceptual model and we defined an original discriminating method to assess its implementation. This method is scenario-based (dummy patient), functional, and relative (comparison between software systems). Each implementation is assessed by two evaluators and the final result is a "success/failure" score. The assessment was performed within the scope of the official Belgian accreditation procedure for GPs' electronic patient records, which is voluntary, publicly funded, and based on a dynamic quality improvement paradigm. Almost all Belgian GPs' software systems (17) were assessed. The robustness of our results was assessed through a sensitivity analysis. RESULTS: We found that 65% (11/17) of the software systems currently used succeeded in implementing the problem-oriented conceptual model with a high confidence level (error rate<10%). The results were widely accepted by the software developers. CONCLUSIONS: A problem-oriented conceptual model can be successfully implemented in many operational EPR systems. The quality of the implementation can be assessed. Our results could be used at the international level to improve semantic interoperability between patient information systems, for instance in relation to broader conceptual models such as the European CONTsys pre-norm.

Electronic Patient Record data as proxy of GPs' thoughts.

Data currently available in primary care Electronic Patient Records (EPR) can potentially be used to study quality of care. In this paper we investigate to which extend these data can reflect GPs' "thoughts" that are an important issue when considering GPs' practice and quality improvement cycle. Within the Resoprim project, we mainly used the consolidated data of three software systems, 26 practices, 1,554 hypertensive patients and 1,977 contacts. Extracted data from the EPR were: some diagnoses, some drugs, referral events, marital status, some parameters (smoking status, height, weight, blood pressure). As "gold standard" of GPs' thoughts we used an electronic questionnaire at the end of each contact. Measures of missing and incoherent values were used to assess our "gold standard". Sensitivity, positive predictive values, correctness and global completeness were used to measure the quality of the automatic extracted data (our proxy). For the "gold standard", the global percentage of missing values is 1.88% and of incoherent values is 3.92%. For most of the practices, the PPV or the correctness of automatic extracted drugs and automatic extracted parameters is high (>95%). The PPV of automatic extracted diagnoses is variable (42.1% to 94.9%). The sensitivity of automatic extracted diagnoses and drugs is lower than 67%. For most of the practices the sensitivity of automatic extracted parameters (excl. smoking status) is higher than 95%. The global completeness of height and weight is lower than 76%. Referrals are badly recorded or extracted. Currently in Belgium, without additional investigations, databases built on data extracted from EPRs can hardly be considered as good proxies of what is thought or known by the GPs. To use them as proxies, we should at least develop tools such as electronic questionnaires to calibrate them. As priority, we suggest an improvement of the extraction procedure design, of the current software interfaces and of the quality control of the extraction modules in order to improve respectively the extracted drugs sensitivity, the global completeness of extracted parameters and the PPV of extracted diagnoses. Training GPs could also be helpful.

Health data exchange, health data sharing and decentralised clinical data collections--recommendations from a Belgian expert group.

The Belgian Federal Health Authorities are willing to redefine their eHealth vision and to reformulate their strategy in consensus with healthcare professionals and other domain experts. The National Health Insurance Institute ordered end 2007 a study to a group of experts, representing the majority of the eHealth stakeholders. The aim of the study was to define the strategy to be followed regarding health data exchange, data sharing, decentralised clinical data collections and Electronic Health Records. The experts issued, June 2008, a description of the current standing regarding nationally available (or to be made available) services as well as a set of priorities (structural and technological ones) for the coming years. This paper presents the experts' recommendations and some translated excerpts of their report.

Purposes of health identification cards and role of a secure access platform (Be-Health) in Belgium.

Although other alternatives may exist, identification cards have been chosen as an acceptable and adequate tool to be used to identify patients and health professionals. It is planned to use these for digital signature and for access to electronic health records: for searching various databases as well as for health information exchange. Local applications might exist independently, but the Belgian federal state has now developed Be-Health, a platform for health professionals, social security personnel and the general public, designed to facilitate a secure common uniform access to certain health data.

Are problem-oriented medial records (POMR) suitable for use in GPs' daily practice?

Problem-oriented functions have been implemented in almost all Belgian GPs' software systems since 2003. We therefore investigated whether some of them - especially the explicit linking procedure between treatments or referrals and the relevant problems - can be used by GPs in their current daily practice. In 2005, within the Belgian ResoPrim project, we organized data collection, mainly around the theme of "hypertension and cardiovascular risk factors", by 26 volunteer GPs' practices using three different software systems. Data were collected prospectively over six weeks in early 2005, and retrospectively for 2004. In this paper we report only on the part of the study that aimed to assess the linking procedure. For all patients and hypertensive patients alike, the key indicators used were the percentage of (problem-) linked drugs among the drugs extracted, the percentage of anti-hypertensive (problem-) linked drugs among anti-hypertensive drugs extracted, and the percentage of (problem-) linked referrals among the number of referrals extracted. For all patients, the data collected relate to 10,914 contacts (7,831 patients) in 2005, and to 74,878 contacts (16,813 patients) in 2004. Large variations were observed per software system and GP, and also over time. The percentage of linked drugs rose from 2% (2004, two GPs) to 36% (2005, fourteen GPs). For linked referrals the percentage was 65% in 2004 vs. 75% in 2005. Our study shows that some functions related to the problem-oriented patient record were spontaneously used by GPs in daily practice. This use increased during collaboration with the primary care research network. This increase was not restricted to the theme of data collection (i.e. not restricted to hypertensive patients, to anti-hypertensive drugs or to links with cardiovascular problems).

Research networks: can we use data from GPs' electronic health records?

As widely discussed in the literature, there are many potential scientific usages of data extracted from the primary care Electronic Health Records (EHR), such as quality of care, epidemiological or socio-economical studies. Yet, can we use the current available data in the EHR for such purposes? In this paper, our objective is to report on the preliminary findings of the Belgian ResoPrim project (2003-2005) to answer the question. We set up a semi-anonymous network involving 26 current practices (28 volunteer GPs), 3 different EHR software systems and two Trusted Third Parties. Based on a literature overview we identified 27 research questions to be answered using 50 indicators. The study design includes retrospective (2002-2004) and prospective (6 weeks) data collection processes around the theme of "Hypertension and cardiovascular risk factors". For some data sets, the data extraction was a full automatic procedure, for some others, the data extraction was related to an input from the GPs allowing some comparisons between both procedures. At this stage, we performed an extended descriptive analysis of our data. Retrospectively we collected data related to 42,217 patients and 203,128 contacts. Prospectively we collected data for 9,236 patients and 15,234 contacts. Our main findings are briefly presented and discussed in this paper. The most promising fields seem to be the Health Research Information Systems assessment and the quality of care studies. It is quite too soon to reach the expected theoretical benefits for epidemiologic and socio-economic studies, yet some progresses could be made in relation with the denominator issue. Based on our preliminary findings and hypotheses, further analyses are foreseen during the second phase of the project (2006-2007).

Does the Belgian diabetes type 2 care trajectory improve quality of care for diabetes patients?

BACKGROUND: The Belgian care trajectory (CT) for diabetes mellitus type 2 (T2DM), implemented in September 2009, aims at providing integrated, evidence-based, multidisciplinary patient- centred care, based on the chronic care model. The research project ACHIL (Ambulatory Care Health Information Laboratory) studied the adherence of CT patients, in the early phases of CT programme implementation, with CT obligations, their uptake of incentives for self-management, whether the CT programme was targeting the appropriate group of patients, how care processes for these patients evolved over time and whether CT start led to better quality in the processes and outcomes of care. METHODS: This observational study took place in the period 2006-2011 and covered T2DM patients who started a CT between 01/09/2009 and 31/12/2011. Four data sources were used: outcome data, from electronic patient records (EPRs) on all CT patients, provided by general practitioners (GPs); reimbursement process data on all CT patients and clinically comparable patients; and data from a sample of CT patients and clinically comparable patients from an EPR-based regional GP network and a paper-based national GP network, respectively. Through multilevel analysis of cross-sectional and longitudinal data, the effect of CT inclusion on processes and outcome was estimated, controlling for potential confounders. RESULTS: By the end of 2011, data on 18,250 CT patients had been collected. Approximately 50 % of these CT patients had received reimbursement for a glucometer and nearly 60 % had had at least one encounter with a diabetes educator. The CT programme recruited T2DM patients who had been difficult to control in the past. In the years prior to CT start, there had been a gradual improvement in the follow up of these patients. Moreover, compared to non-CT patients, the proportion of CT patients adhering to the recommended frequency for monitoring of parameters, such as HbA1c, increased significantly around CT start. Some data sources, albeit not all, suggested there had been an improvement in certain outcomes, such as HbA1c, after CT inclusion. CONCLUSIONS: According to this study, CT enrolment is associated with better quality of care processes compared to non-CT patients. This improvement was found in several of the data sources used in this study. However, results on outcome parameters remain inconclusive.

Integration of electronic patient record context with message context.

A methodology to construct specific messages with clear objectives inside clinical processes, while simultaneously including contextual information, remains a problem today. This paper addresses the issue of combining specific message context (process driven) with the context of a patient record (patient centered). In Belgium, simplified conceptual models for Electronic Patient Record (EPR) architecture and for message architecture, based on previous comprehensive and international work, have been produced, validated and mapped into an integrated message format. The resulting model described in this paper highlights the main conceptual links between both basic models: at the action level and at the Transaction level. Using XML, some parts of the model have already been implemented in various national projects. Key lessons learned may be imported at the international level.

Quality of care assessment using GPs' electronic patient records: do we need data from home visits?

The paper tackles the topic of collecting data from home visits using the electronic patient record (EPR) of general practitioners (GPs), in a context with a high proportion of home visits in primary care. Since data from home visits, representing about 40% of GPs' consultations in Belgium, are rather scarcely recorded in the EPR, we wanted to study the impact of not taking into account home visits for quality assessment in primary care. Five quality indicators, which measured the accordance of the delivered care with guidelines on the management of osteoarthritis, were compared between a pooled database (consultations and home visits) and a restricted database (after removal of home visits). Our findings suggest that removing home visits from a database collected from primary care may provide a slight modification of the estimate of the quality of care, whereas conclusions on quality improvement remain relatively stable. Quality of care assessment with the EPR of GPs seems not to be dramatically hampered by the poor recording rate of home visits in the EPR.

What determines inclusion in the early phase of the type 2 diabetes care trajectory in Belgium?

BACKGROUND: In 2009, the Belgian National Institute of Health and Disability Insurance established a care trajectory (CT) for a subgroup of type 2 diabetes mellitus patients (T2DM) based on Wagner's chronic care model. The goal of this CT is to optimise the quality of care using an integrated multidisciplinary approach. This study aims to identify patient-related factors associated with inclusion in a CT and to determine the most frequent reasons for non-inclusion. METHODS: In 2010, the Belgian Sentinel Network of General Practices conducted a prevalence study of type 2 diabetes. The surveillance study carried out by this nationwide, representative network collected unique information about eligibility for the CT, inclusion in the CT and reasons for non-inclusion. Based on the official inclusion and exclusion criteria, we first identified a group of eligible patients. Within this group, we then calculated the proportion of patients included in a CT as well as the prevalence of reasons for non-inclusion as reported by GPs. Furthermore, bivariate associations between patient-level parameters and inclusion were analysed. Finally, any patient-level parameters found to be statistically significant were included in a multivariate logistic regression model. RESULTS: The 2010 study recorded 4600 Belgian type 2 diabetes patients. According to the official criteria, 589 patients were eligible for inclusion in a CT T2DM. By the end of August 2011, 95 patients had been included in a CT T2DM. Our findings reveal that the younger the eligible patient was, the more likely he or she was to be included in a CT. Patients living in Flanders were more likely to be included in the CT than were patients living in Wallonia. Motivated patients with specific plans to change their diets were also more likely to be included in a CT. The two most frequently reported reasons for non-inclusion were participation in another diabetes care programme and the timing of this surveillance study (inclusion will take place in the near future). CONCLUSIONS: Eligible diabetes patients who were admitted to a CT T2DM during the early phases of CT implementation were mainly found to be those who are able to make progress in their disease trajectories. In the future, more attention could be paid to also include more high-risk patients.

Belgian primary care EPR: assessment of nationwide routine data extraction.

Starting in 2009, the first ever Belgian nationwide data collection network using routine data extracted from primary care EPR (upload method) has been built from scratch. The network also uses a manual web-based data collection method. This paper compares these two methods by analysing missing and most recent values for certain parameters. We collected data from 4954 practices, pertaining to 29,180 patients. Mean values for the most recent parameters were similar regardless of which data collection method was used. Many missing recent values (>46%) were found for all of the parameters when using the upload method. It seems that, in Belgium, uploading routine data from primary care EPR on a large scale is suitable and allows the collection of chronological retrospective data. However, the method still requires major, carefully controlled improvements.

Routinely-collected general practice data from the electronic patient record and general practitioner active electronic questioning method: a comparative study.

The numerous existing primary care-based research networks currently use various data collection methods. In this paper, we compared routine data extracted from general practitioners' (GPs') electronic patient records (EPRs) and GPs' answers to an electronic questionnaire. We investigated for 10,307 Belgian patients 10 healthcare conditions using clinical and biological parameters (cholesterol, blood pressure, and body mass index), diagnoses (hypertension, diabetes, and personal past cardiovascular event(s)), and drug prescriptions (antidiabetic drugs, aspirin, statins, and antihypertensive drugs). We found a relatively fair agreement (Kappa≥0.40) between the two data collection methods for 7 healthcare conditions, but no agreement for the biological parameters. When EPR data was used and compared with the questioning method, the prevalence of diagnoses and drug prescriptions was relatively lower and the prevalence of clinical and biological parameters was relatively higher (all missing data excluded) in the EPR data than in the data collected using the questioning method. Using EPR data, we calculated an acceptable proxy for the prevalence as observed using the questioning method. The comparison of the two data collection methods was a worthwhile approach, in that it could highlight potential ways to improve both care quality and information systems.

Long-term evolution of renal function in patients with type 2 diabetes mellitus: a registry-based retrospective cohort study.

OBJECTIVES: To picture the 10-year evolution of renal function in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) and to describe the risk factors for severe decline. SETTING: Primary registration network with 97 general practitioners working in 55 practices sending routinely collected patient data. PARTICIPANTS: From the database, we selected all patients aged 40 years or older with T2DM and at least two creatinine measurements in two different years with an interval of at least 3 months. Based on the last available value of estimated glomerular filtration rate calculated by the modification of diet in renal disease (MDRD) equation, patients were divided into grades of CKD. Severe decline (decline of >4 mL/min/year) and 'certain drop' (CD, year-to-year decline >10 mL/min) were determined in patients with CKD. Determinants of severe decline and CD were investigated with logistic regression and longitudinal logistic regression analysis, respectively. PRIMARY OUTCOME MEASURE: Kidney function (MDRD). RESULTS: 4041 patients, 1980 women, were included. The mean age was 71 years, mean diabetes duration was 7.7 years; 1514 (38%) suffered from CKD, 231 (15%) presented with severe decline and 18% of the patients with CKD presented with two or more CDs. Younger age, male gender, mean glycated haemoglobin and a higher number of CDs were significantly associated with the presence of severe decline (p<0.05); statins and higher diastolic blood pressure were significantly associated with the absence of severe decline (p<0.001). ACE inhibitors, other antihypertensive drugs and antidiabetic drugs including insulin therapy were specific determinants of CD. CONCLUSIONS: CKD is highly prevalent in patients with T2DM; a minority of patients evolve into severe decline that is associated with younger age, male gender, 'CD' and manageable factors such as blood pressure, blood glucose, associated drugs prescriptions and statin therapy. Further prospective observational and experimental research is needed to clarify the nature of those associations.