A hospital-wide transition from paper to digital problem-oriented clinical notes. A descriptive history and cross-sectional survey of use, usability, and satisfaction.

OBJECTIVES: To evaluate the use, usability, and physician satisfaction of a locally developed problem-oriented clinical notes application that replaced paper-based records in a large Dutch university medical center. METHODS: Using a clinical notes database and an application event log file and a cross-sectional survey of usability, authors retrospectively analyzed system usage for medical specialties, users, and patients over 4 years. A standardized questionnaire measured usability. Authors analyzed the effects of sex, age, professional experience, training hours, and medical specialty on user satisfaction via univariate analysis of variance. Authors also examined the correlation between user satisfaction in relation to users' intensity of use of the application. RESULTS: In total 1,793 physicians used the application to record progress notes for 219,755 patients. The overall satisfaction score was 3.2 on a scale from 1 (highly dissatisfied) to 5 (highly satisfied). A statistically significant difference occurred in satisfaction by medical specialty, but no statistically significant differences in satisfaction took place by sex, age, professional experience, or training hours. Intensity of system use did not correlate with physician satisfaction. CONCLUSIONS: By two years after the start of the implementation, all medical specialties utilized the clinical notes application. User satisfaction was neutral (3.2 on a 1-5 scale). Authors believe that the significant factors facilitating this transition mirrored success factors reported by other groups: a generic, consistent, and transparent design of the application; intensive collaboration; continuous monitoring; and an incremental rollout.

Does language ambiguity in clinical practice justify the introduction of standard terminology? An integrative review.

AIMS AND OBJECTIVES: To research the use of ambiguous language in written information concerning patients' functioning and to identify problems resulting from the use of ambiguous language in clinical practice. BACKGROUND: Many projects that aimed to introduce standard terminology concerning patients' functioning in clinical practice are unsuccessful because standard terminology is rarely used in clinical practice. These projects mainly aim to improve communication by reducing ambiguous language. Considering their lack of success, the validity of the argument that language ambiguity is used in clinical practice is questioned. DESIGN: An integrative literature review. METHODS: A systematic search of the MEDLINE (1950-2012) and CINAHL (1982-2012) databases was undertaken, including empirical and theoretical literature. The selected studies were critically appraised using a data assessment and extraction form. RESULTS: Seventeen of 767 papers were included in the review and synthesis. The use of ambiguous language in written information concerning patients' functioning was demonstrated. Problems resulting from the use of ambiguous language in clinical practice were not identified. However, several potential problems were suggested, including hindered clinical decision-making and limited research opportunities. CONCLUSION: The results of this review demonstrated the use of ambiguous language concerning patients' functioning, but health professionals in clinical practice did not experience this issue as a problem. This finding might explain why many projects aimed at introducing standard terminology concerning functioning in clinical practice to solve problems caused by ambiguous language are often unsuccessful. Language ambiguity alone is not a valid argument to justify the introduction of standard terminology. RELEVANCE TO CLINICAL PRACTICE: The introduction of standard terminology concerning patients' functioning will only be successful when clinical practice requires the aggregation and reuse of data from electronic patient records for different purposes, including multidisciplinary decision-making and research.

Comparing patient characteristics, type of intervention, control, and outcome (PICO) queries with unguided searching: a randomized controlled crossover trial.

BACKGROUND: Translating a question into a query using patient characteristics, type of intervention, control, and outcome (PICO) should help answer therapeutic questions in PubMed searches. The authors performed a randomized crossover trial to determine whether the PICO format was useful for quick searches of PubMed. METHODS: Twenty-two residents and specialists working at the Radboud University Nijmegen Medical Centre were trained in formulating PICO queries and then presented with a randomized set of questions derived from Cochrane reviews. They were asked to use the best query possible in a five-minute search, using standard and PICO queries. Recall and precision were calculated for both standard and PICO queries. RESULTS: Twenty-two physicians created 434 queries using both techniques. Average precision was 4.02% for standard queries and 3.44% for PICO queries (difference nonsignificant, t(21) = -0.56, P = 0.58). Average recall was 12.27% for standard queries and 13.62% for PICO queries (difference nonsignificant, t(21) = -0.76, P = 0.46). CONCLUSIONS: PICO queries do not result in better recall or precision in time-limited searches. Standard queries containing enough detail are sufficient for quick searches.

Decision tables and rule engines in organ allocation systems for optimal transparency and flexibility.

Organ allocation systems have become complex and difficult to comprehend. We introduced decision tables to specify the rules of allocation systems for different organs. A rule engine with decision tables as input was tested for the Kidney Allocation System (ETKAS). We compared this rule engine with the currently used ETKAS by running 11,000 historical match runs and by running the rule engine in parallel with the ETKAS on our allocation system. Decision tables were easy to implement and successful in verifying correctness, completeness, and consistency. The outcomes of the 11,000 historical matches in the rule engine and the ETKAS were exactly the same. Running the rule engine simultaneously in parallel and in real time with the ETKAS also produced no differences. Specifying organ allocation rules in decision tables is already a great step forward in enhancing the clarity of the systems. Yet, using these tables as rule engine input for matches optimizes the flexibility, simplicity and clarity of the whole process, from specification to the performed matches, and in addition this new method allows well controlled simulations.

Spirometry expert support in family practice: a cluster-randomised trial.

AIM: To assess the impact of two modes of spirometry expert support on Family physicians' (FPs') diagnoses and planned management in patients with apparent respiratory disease. METHOD: A cluster-randomised trial was performed with family practices as the unit of randomisation. FPs from 44 family practices recorded their diagnosis and planned management before and after spirometry for 868 patients. Intervention consisted of spirometry interpretation support by either a chest physician or expert software. Both interventions were compared with usual care (i.e. no additional interpretation support). Change in FPs' diagnoses after spirometry served as the primary outcome. Secondary outcomes were referral rate, additional diagnostic tests, and disease management changes. Effects were expressed as percentages and Odds Ratios (OR) with 95% confidence intervals. RESULTS: Diagnoses changed after intervention in all groups: 47.8% (95% CI 41.8 to 53.9) for chest physician support; 45.0% (95% CI 39.5 to 50.6) for software support; and 53.3% (95% CI 47.2 to 59.4) for usual care. Differences in the proportions of changed diagnosis were not statistically significant: chest physician support versus usual care OR 0.79 (95%CI 0.49 to 1.30); software support versus usual care OR 0.72 (95% CI 0.45 - 1.15). There were no differences in secondary outcomes. CONCLUSION: Neither chest physician spirometry support nor expert software spirometry support had a significant impact on FPs' diagnosis of respiratory conditions or management decisions. TRIAL NUMBER: http://www.clinicaltrials.gov/ct/show/NCT00131157?order=1.

Evaluation of PubMed filters used for evidence-based searching: validation using relative recall.

OBJECTIVES: The research sought to determine the value of PubMed filters and combinations of filters in literature selected for systematic reviews on therapy-related clinical questions. METHODS: References to 35,281 included and 48,514 excluded articles were extracted from 2,629 reviews published prior to January 2008 in the Cochrane Database of Systematic Reviews and sent to PubMed with and without filters. Sensitivity, specificity, and precision were calculated from the percentages of unfiltered and filtered references retrieved for each review and averaged over all reviews. RESULTS: Sensitivity of the Sensitive Clinical Queries filter was reasonable (92.7%, 92.1-93.3); specificity (16.1%, 15.1-17.1) and precision were low (49.5%, 48.5-50.5). The Specific Clinical Queries and the Single Term Medline Specific filters performed comparably (sensitivity, 78.2%, 77.2-79.2 vs. 78.0%; 77.0-79.0; specificity, 52.0%, 50.8-53.2 vs. 52.3%, 51.1-53.5; precision, 60.4%, 59.4-61.4 vs. 60.6%, 59.6-61.6). Combining the Abridged Index Medicus (AIM) and Single Term Medline Specific (65.2%, 63.8-66.6), Two Terms Medline Optimized (64.2%, 62.8-65.6), or Specific Clinical Queries filters (65.0%, 63.6-66.4) yielded the highest precision. CONCLUSIONS: Sensitive and Specific Clinical Queries filters used to answer questions about therapy will result in a list of clinical trials but cannot be expected to identify only methodologically sound trials. The Specific Clinical Queries filters are not suitable for questions regarding therapy that cannot be answered with randomized controlled trials. Combining AIM with specific PubMed filters yields the highest precision in the Cochrane dataset.

Striking trends in the incidence of health problems in The Netherlands (2002-05). Findings from a new strategy for surveillance in general practice.

BACKGROUND: This study aimed to detect striking trends based on a new strategy for monitoring public health. METHODS: We used data over 4 years from electronic medical records of a large, nationally representative network of general practices. Episodes were either directly recorded by general practitioners (GPs) or were constructed using a new record linkage method (EPICON). The episodes were used to estimate raw morbidity rates for all codes of the International Classification of Primary Care (ICPC). Multilevel Poisson regression models were used to analyse the trend over time for 15 health problems that showed an obvious change over time. Based on these models, we calculated adjusted incidence rates corrected for clustering, sex and age. RESULTS: During 2002-05, both men and women increasingly consulted the GP because of concern about a drug reaction, a change in faeces/bowel movements and urination problems. Men showed an increase in consultations for prostate problems and venereal diseases. The incidence of chronic internal knee derangement decreased for both sexes. Women consulted their GP less frequently about sterilization and fear of being pregnant. CONCLUSION: The strategy developed proved to be useful to detect trends across a short period of time. Changes in the health care market, such as the increasing availability of over-the-counter drugs and various large advertising campaigns for medications may explain some of the findings. The increasing incidence of health problems in the urogenital area deserves attention as it could reflect increases in the incidence of sexually transmitted diseases (STDs) and urinary tract infections.

Dynamics of Internet usage during the stages of in vitro fertilization.

Hospitals and clinics develop Internet strategies to emancipate and empower their patient population. At Radboud University Nijmegen Medical Centre, we developed an Internet-based personal health record that provides patients with general and personal information about their treatment and that provides facilities for communication with fellow patients and with physicians. Because not much is known about information and communication needs of IVF and ICSI patients in relation to their treatment, we observed the intensity of use of this personal health record during the various stages of IVF treatment. We measured the numbers of page views and the number of contributions to the chat room. Data regarding Website use and treatment schedules were available for 51 couples. These couples generated 25,420 page views and posted 11,403 utterances. Two-way analysis of variance showed that significant individual changes occurred in the intensity of use during the different stages of the treatment. During the stages in which there is no contact between the patient and the clinic, patients make use of the Website's communication functions. This reflects the patients' need for continued communication and support during the last stages of treatment, a service that IVF clinics traditionally cannot or do not provide.

Decreasing incidence of adenotonsillar problems in Dutch general practice: real or artefact?

BACKGROUND: The incidence of hypertrophy and recurrent infections of the tonsils/adenoids appears to be decreasing in the Netherlands. It is uncertain whether this is a 'real' decrease in the incidence of disease or an 'artefact'. AIM: To investigate possible causes of the decreasing incidence of adenotonsillar problems among Dutch children. DESIGN OF STUDY: Observational. SETTING: A nationally representative general practice database. METHOD: Incidence rates were calculated over 2002-2005 among children aged 0-14 years. Multilevel Poisson regression analyses were used to examine the following possible causes of changing incidence rates: change in recording (more substitution codes), change in the demand for care (fewer visits to the GP), and change in the supply of care (fewer antibiotic prescriptions and referrals). Indications for a 'real' change in the incidence of disease were examined by calculating incidence rates of other clinical manifestations of microbial pathogens that may cause adenotonsillar problems. RESULTS: The incidence rate decreased significantly (P = 0.017) from 3.0 to 1.3 per 1000 children per year. Correcting for demand for and supply of care led to a smaller decline in yearly incidence, from 2.9 to 1.7 per 1000 children per year (P = 0.105). No clearly similar trend was found in other clinical manifestations of viruses and bacteria that may cause adenotonsillar problems. CONCLUSION: Part of the declining trend can be explained by a change in the demand for and supply of care, but no apparent causal clue emerged for the residual declining trend in the incidence of disease.

Empowering patients undergoing in vitro fertilization by providing Internet access to medical data.

OBJECTIVE: To study the effect of an Internet-based personal health record on the empowerment of patients undergoing IVF. DESIGN: Randomized clinical trial. SETTING: Patients undergoing IVF and intracytoplasmic sperm injection (ICSI) in an academic research environment. PATIENT(S): We selected patients who were undergoing an IVF or ICSI treatment, have an Internet connection, and speak fluent Dutch. INTERVENTION(S): An Internet-based personal health record that provides patients with general and personal information concerning their given treatment and that also provides facilities for communication with fellow patients and physicians. MAIN OUTCOME MEASURE(S): Patient empowerment (measured as a multidimensional concept consisting of self-efficacy, actual and perceived knowledge, and involvement in the decision process), patient satisfaction, meaning of infertility problems, social support, anxiety, and depression. RESULT(S): A total of 91 female and 89 male participants were suitable for analysis. No significant differences were observed in per person change in patient empowerment. We did not find any significant differences regarding per person change in patient satisfaction, the meaning of infertility problems, social support, anxiety, and depression. CONCLUSION(S): Usage of the personal health record did not have any effects on patient empowerment, but, at the same time, the study did not find that the personal health record had any significant adverse effects either.

Which data source in clinical performance assessment? A pilot study comparing self-recording with patient records and observation.

OBJECTIVE: A pilot study aimed to determine the extent to which each of three data sources could provide complete and reliable data for valid assessment of clinical performance. DESIGN: Clinical decisions taken in 168 consultations by seven family physicians were reviewed against guidelines for 15 clinical conditions. In total, 206 criteria were reviewed using three sources: medical records, observation in surgery, and structured self-recording by the physicians. SETTING AND PARTICIPANTS: Seven family practices in the Netherlands. MAIN MEASURE: Scores (%) of data recorded/total were obtained for each method. Kappa scores for the agreement between the three data sources were also obtained. RESULTS: Medical record examination provided 40%, observation 72%, and physician self-recording 95% of the data required for the review against guidelines. Nine per cent of the clinical decisions could be reviewed when using medical records, 46% when using observation data, and 69% when using data from prospective self-recording. In particular, decisions in the area of patient education and diagnostic examinations could not be reviewed validly using medical records only. Kappa agreements between the data available from the three sources as well as between the review results appeared to be 0.79. CONCLUSIONS: Medical records alone only supply sufficient information for the review of a very limited set of clinical decisions. Physician self-recording has significantly more potential for valid review of a broad range of clinical decisions. Furthermore, self-recording seems a reliable data collection method that deserves further research.