Does acute kidney injury alerting improve patient outcomes?

BACKGROUND: Electronic alerts (e-alerts) for Acute Kidney Injury (AKI) have been implemented into a variety of different Electronic Health Records (EHR) systems worldwide in order to improve recognition and encourage early appropriate management of AKI. We were interested in the impact on patient safety, specialist referral and clinical management. METHODS: All patients admitted to our institution with AKI were included in the study. We studied AKI progression, dialysis dependency, length of hospital stay, emergency readmission, ICU readmission, and death, before and after the introduction of electronic alerts. The impact on prescription of high risk drugs, fluid administration, and referral to renal services was also analysed. RESULTS: After the introduction of the e-alert, progression to higher AKI stage, emergency readmission to hospital and death during admission were significantly reduced. More prescriptions were stopped for drugs that adversely affect renal function in AKI and there was a significant increase in the ICU admissions and in the number of patients having dialysis, especially in earlier stages. Longer term mortality, renal referrals, and fluid alteration did not change significantly after the AKI e-alert introduction. CONCLUSIONS: AKI e-alerts can improve clinical outcomes in hospitalised patients.

De-identified Bayesian personal identity matching for privacy-preserving record linkage despite errors: development and validation.

BACKGROUND: Epidemiological research may require linkage of information from multiple organizations. This can bring two problems: (1) the information governance desirability of linkage without sharing direct identifiers, and (2) a requirement to link databases without a common person-unique identifier. METHODS: We develop a Bayesian matching technique to solve both. We provide an open-source software implementation capable of de-identified probabilistic matching despite discrepancies, via fuzzy representations and complete mismatches, plus de-identified deterministic matching if required. We validate the technique by testing linkage between multiple medical records systems in a UK National Health Service Trust, examining the effects of decision thresholds on linkage accuracy. We report demographic factors associated with correct linkage. RESULTS: The system supports dates of birth (DOBs), forenames, surnames, three-state gender, and UK postcodes. Fuzzy representations are supported for all except gender, and there is support for additional transformations, such as accent misrepresentation, variation for multi-part surnames, and name re-ordering. Calculated log odds predicted a proband's presence in the sample database with an area under the receiver operating curve of 0.997-0.999 for non-self database comparisons. Log odds were converted to a decision via a consideration threshold θ and a leader advantage threshold δ. Defaults were chosen to penalize misidentification 20-fold versus linkage failure. By default, complete DOB mismatches were disallowed for computational efficiency. At these settings, for non-self database comparisons, the mean probability of a proband being correctly declared to be in the sample was 0.965 (range 0.931-0.994), and the misidentification rate was 0.00249 (range 0.00123-0.00429). Correct linkage was positively associated with male gender, Black or mixed ethnicity, and the presence of diagnostic codes for severe mental illnesses or other mental disorders, and negatively associated with birth year, unknown ethnicity, residential area deprivation, and presence of a pseudopostcode (e.g. indicating homelessness). Accuracy rates would be improved further if person-unique identifiers were also used, as supported by the software. Our two largest databases were linked in 44 min via an interpreted programming language. CONCLUSIONS: Fully de-identified matching with high accuracy is feasible without a person-unique identifier and appropriate software is freely available.

Prevalence of Health Problems and Health-Care Use in Partners of People with Dementia: Longitudinal Analysis with Routinely Recorded Health and Administrative Data.

INTRODUCTION: This study aims to provide insight into the prevalence of health problems and the frequency of general practitioner (GP) contacts in cohabiting partners of persons with dementia, during the year prior to the dementia diagnosis and up to 3 years after the diagnosis. METHODS: Partners of persons with dementia and a matched control group of partners of persons without dementia were identified in the routinely recorded electronic health records of 451 Dutch general practices in 2008-2015. These data were used to examine the prevalence of the partners' health problems. Differences between these partners and comparison partners in the prevalence of 16 groups of health problems (diagnostic chapters) and in the frequency of GP contacts were examined using generalized estimating equation models. RESULTS: 1,711 partners of persons with dementia and 6,201 comparison partners were included in the analyses. Social problems, more specifically problems related to the illness and/or the loss of the partner, were significantly more prevalent in partners than in comparison partners across the years (p < 0.01), as were musculoskeletal problems (p < 0.01). Respiratory and psychological problems increased over time in partners and remained stable in comparison partners. Across the years, partners contacted their GP more often than comparison partners (p < 0.01). DISCUSSION/CONCLUSION: Having a cohabiting partner with dementia has consequences for caregiver's physical and psychosocial health. The specific health problems found in this study and the increase in GP contacts might be relevant indicators of overburdening in partners of persons with dementia.

LoVE in a time of CoVID: Clinician and patient experience using telemedicine for chronic epilepsy management.

As part of our ongoing interest in patient- and family-centered care in epilepsy, we began, before the onset of the CoVID-19 pandemic, to evaluate the concerns and preferences of those delivering and receiving care via telemedicine. CoVID-19 arrived and acted as an unexpected experiment in nature, catalyzing telemedicine's widespread implementation across many disciplines of medicine. The arrival of CoVID-19 in Ireland gave us the opportunity to record these perceptions pre- and post-CoVID. Data were extracted from the National Epilepsy Electronic Patient Record (EEPR). Power BI Analytics collated data from two epilepsy centers in Dublin. Analysis of data on reasons for using the telephone support line was conducted. A subset of patients and clinicians who attended virtual encounters over both periods were asked for their perception of telemedicine care through a mixed methods survey. Between 23rd December 2019 and 23rd March 2020 (pre-CoVID era), a total of 1180 patients were seen in 1653 clinical encounters. As part of a telemedicine pilot study, 50 of these encounters were scheduled virtual telephone appointments. Twenty eight surveys were completed by clinicians and 18 by patients during that period. From 24th March 2020 to 24th June 2020, 1164 patients were seen in 1693 encounters of which 729 (63%) patients were seen in 748 scheduled virtual encounters. 118 clinician impressions were captured through an online survey and 75 patients or carers completed a telephone survey during the post-CoVID era. There was no backlog of appointments or loss of care continuity forced by the pandemic. Clinicians expressed strong levels of satisfaction, but some doubted the suitability of new patients to the service or candidates for surgery receiving care via telemedicine. Patients reported positive experiences surrounding telephone appointments comparing them favorably to face-to-face encounters. The availability of a shared EEPR demonstrated no loss of care contact for patients with epilepsy. The survey showed that telemedicine is seen as an effective and satisfactory method of delivering chronic outpatient care.

Second primary cancers: a retrospective analysis of real world data using the enhanced medical research engine ConSoRe in a French comprehensive cancer center.

BACKGROUND: Second primary cancers (SPC) account for 18% of all cancers. We used the enhanced medical/health data mining tool ConSoRe to search aggregated data, analyze electronic patient records (EPR), and better characterize patients with SPC. METHODS: This retrospective cohort study used ConSoRe to identify EPRs from patients with SPC referred to the regional cancer center Leon Bérard from 1993 to 2017, and examined characteristics of patients with SPC, frequencies of first primary cancer (FPC) localization in the global population of patients with SPC, and time to SPC. Data set was extracted on January 1, 2018. RESULTS: Among 296,530 EPRs, we identified 157,187 patients with FPC, including 13,002 (8%) patients with SPC. Between 2000 and 2010, the rate of SPC was 34%, and 52% of SPC were identified in the last years (2010-2017). In men, main cancers were head and neck cancer, lymphoma, and prostate carcinoma accounting for 15.6%, 12.8%, and 10.5% of FPC, while the three most common SPC were head and neck cancer (13.2%), lung cancer (11.8%) and lymphoma (9.2%). In women, breast cancers, lymphoma, and skin cancers accounted for 48.8%, 8%, and 5.1% of first cancers, and for 31.1%, 7% and 6% of SPC. CONCLUSION: The data mining tool ConSoRe contributes to access to real world data, and to better characterize patients with SPC. Expanding such approach to any comprehensive center will allow a global overview of the follow-up of patients with cancer, and help to improve long-term management and adapt surveillance.

Hidden labour: the skilful work of clinical audit data collection and its implications for secondary use of data via integrated health IT.

BACKGROUND: Secondary use of data via integrated health information technology is fundamental to many healthcare policies and processes worldwide. However, repurposing data can be problematic and little research has been undertaken into the everyday practicalities of inter-system data sharing that helps explain why this is so, especially within (as opposed to between) organisations. In response, this article reports one of the most detailed empirical examinations undertaken to date of the work involved in repurposing healthcare data for National Clinical Audits. METHODS: Fifty-four semi-structured, qualitative interviews were carried out with staff in five English National Health Service hospitals about their audit work, including 20 staff involved substantively with audit data collection. In addition, ethnographic observations took place on wards, in 'back offices' and meetings (102 h). Findings were analysed thematically and synthesised in narratives. RESULTS: Although data were available within hospital applications for secondary use in some audit fields, which could, in theory, have been auto-populated, in practice staff regularly negotiated multiple, unintegrated systems to generate audit records. This work was complex and skilful, and involved cross-checking and double data entry, often using paper forms, to assure data quality and inform quality improvements. CONCLUSIONS: If technology is to facilitate the secondary use of healthcare data, the skilled but largely hidden labour of those who collect and recontextualise those data must be recognised. Their detailed understandings of what it takes to produce high quality data in specific contexts should inform the further development of integrated systems within organisations.

The anatomy of electronic patient record ethics: a framework to guide design, development, implementation, and use.

BACKGROUND: This manuscript presents a framework to guide the identification and assessment of ethical opportunities and challenges associated with electronic patient records (EPR). The framework is intended to support designers, software engineers, health service managers, and end-users to realise a responsible, robust and reliable EPR-enabled healthcare system that delivers safe, quality assured, value conscious care. METHODS: Development of the EPR applied ethics framework was preceded by a scoping review which mapped the literature related to the ethics of EPR technology. The underlying assumption behind the framework presented in this manuscript is that ethical values can inform all stages of the EPR-lifecycle from design, through development, implementation, and practical application. RESULTS: The framework is divided into two parts: context and core functions. The first part 'context' entails clarifying: the purpose(s) within which the EPR exists or will exist; the interested parties and their relationships; and the regulatory, codes of professional conduct and organisational policy frame of reference. Understanding the context is required before addressing the second part of the framework which focuses on EPR 'core functions' of data collection, data access, and digitally-enabled healthcare. CONCLUSIONS: The primary objective of the EPR Applied Ethics Framework is to help identify and create value and benefits rather than to merely prevent risks. It should therefore be used to steer an EPR project to success rather than be seen as a set of inhibitory rules. The framework is adaptable to a wide range of EPR categories and can cater for new and evolving EPR-enabled healthcare priorities. It is therefore an iterative tool that should be revisited as new EPR-related state-of-affairs, capabilities or activities emerge.

Examination and diagnosis of electronic patient records and their associated ethics: a scoping literature review.

BACKGROUND: Electronic patient record (EPR) technology is a key enabler for improvements to healthcare service and management. To ensure these improvements and the means to achieve them are socially and ethically desirable, careful consideration of the ethical implications of EPRs is indicated. The purpose of this scoping review was to map the literature related to the ethics of EPR technology. The literature review was conducted to catalogue the prevalent ethical terms, to describe the associated ethical challenges and opportunities, and to identify the actors involved. By doing so, it aimed to support the future development of ethics guidance in the EPR domain. METHODS: To identify journal articles debating the ethics of EPRs, Scopus, Web of Science, and PubMed academic databases were queried and yielded 123 eligible articles. The following inclusion criteria were applied: articles need to be in the English language; present normative arguments and not solely empirical research; include an abstract for software analysis; and discuss EPR technology. RESULTS: The medical specialty, type of information captured and stored in EPRs, their use and functionality varied widely across the included articles. Ethical terms extracted were categorised into clusters 'privacy', 'autonomy', 'risk/benefit', 'human relationships', and 'responsibility'. The literature shows that EPR-related ethical concerns can have both positive and negative implications, and that a wide variety of actors with rights and/or responsibilities regarding the safe and ethical adoption of the technology are involved. CONCLUSIONS: While there is considerable consensus in the literature regarding EPR-related ethical principles, some of the associated challenges and opportunities remain underdiscussed. For example, much of the debate is presented in a manner more in keeping with a traditional model of healthcare and fails to take account of the multidimensional ensemble of factors at play in the EPR era and the consequent need to redefine/modify ethical norms to align with a digitally-enabled health service. Similarly, the academic discussion focuses predominantly on bioethical values. However, approaches from digital ethics may also be helpful to identify and deliberate about current and emerging EPR-related ethical concerns.

Staff perspectives on the usability of electronic patient records for planning and delivering dementia care in nursing homes: a multiple case study.

BACKGROUND: The electronic patient record (EPR) has been introduced into nursing homes in order to facilitate documentation practices such as assessment and care planning, which play an integral role in the provision of dementia care. However, little is known about how the EPR facilitates or hinders these practices from the end-user's perspective. Therefore, the objective of this qualitative study was to explore the usability issues associated with the EPR for assessment and care planning for people with dementia in nursing homes from a staff perspective. METHODS: An exploratory, qualitative research design with a multiple case study approach was used. Contextual Inquiry was carried out with a variety of staff members (n = 21) who used the EPR in three nursing homes situated in Belgium, Czech Republic and Spain. Thematic analysis was used to code interview data, with codes then sorted into a priori components of the Health Information Technology Evaluation Framework: device, software functionality, organisational support. Two additional themes, structure and content, were also added. RESULTS: Staff provided numerous examples of the ways in which EPR systems are facilitating and hindering assessment and care planning under each component, particularly for people with dementia, who may have more complex needs in comparison to other residents. The way in which EPR systems were not customisable was a common theme across all three homes. A comparison of organisational policies and practices revealed the importance of training, system support, and access, which may be linked with the successful adoption of the EPR system in nursing homes. CONCLUSIONS: EPR systems introduced into the nursing home environment should be customisable and reflect best practice guidelines for dementia care, which may lead to improved outcomes and quality of life for people with dementia living in nursing homes. All levels of nursing home staff should be consulted during the development, implementation and evaluation of EPR systems as part of an iterative, user-centred design process.

[Cross-enterprise interoperability : Challenges and principles for technical implementation]. / Einrichtungsübergreifende Interoperabilität : Herausforderungen und Grundlagen für die technische Umsetzung.

Demographic change, the migration of medical professionals and economic constraints are leading to an increasing specialisation and concentration of resources in the healthcare sector. The digital mapping of cross-enterprise process chains between different medical care levels in turn requires digital networking and syntactical and semantical interoperability in information exchange. Cross-enterprise electronic patient records based on the Cross-Enterprise Document Sharing (XDS.b) integration profile defined by the Integrating the Healthcare Enterprise (IHE) initiative are the basis of the digital exchange of medical information between patients and service providers. Syntactical interoperability is ensured by the object definitions in the XDS Affinity domain and the Clinical Document Architecture (CDA) document format. Semantical interoperability is achieved by the use of standardized terminology and code systems. Terminology servers make it easy to deploy standard ontologies and translate proprietary code systems. New interoperability standards, e.g. based on Fast Healthcare Interoperability Resources (FHIR), are being developed to facilitate the exchange of structured medical information objects on mobile platforms in the future.

Introducing standardised care plans as a new recording tool in municipal health care.

AIMS AND OBJECTIVES: To explore how nurses use standardised care plans as a new recording tool in municipal health care, and to identify their thoughts and opinions. BACKGROUND: In spite of being an important information source for nurses, care plans have repeatedly been found unsatisfactory. Structuring and coding information through standardised care plans is expected to raise the quality of recorded information, improve overviews, support evidence-based practice and facilitate data aggregation. Previous research on this topic has mostly focused on the hospital setting. There is a lack of knowledge on how standardised care plans are used as a recording tool in the municipal healthcare setting. DESIGN: An exploratory design with a qualitative approach using three qualitative methods of data collection. The study complied with the Consolidated Criteria for Reporting Qualitative Research. METHODS: Empirical data were collected in three Norwegian municipalities through participant observation and individual interviews with 17 registered nurses. In addition, we collected nursing records from 20 electronic patient records. RESULTS: Use of standardised care plans was influenced by the nurses' consideration of their benefits. Partial implementation created an opportunity for nonuse. There was no consensus regarding how much information to include, and the standardised care plans could become both short and generic, and long and comprehensive. The themes "balancing between the old and the new care planning system," "considering the usefulness of standardised care plans as a source of information" and "balancing between overview and detail" reflect these findings. CONCLUSIONS: Nurses' use of standardised care plans was influenced by the plans' partial implementation, their views on usefulness and their personal views on the detail required in a care plan. RELEVANCE TO CLINICAL PRACTICE: The structuring of nursing records is a fast-growing trend in health care. This study gives valuable information for those attempting to implement such structures in municipal health care.

Nurses' information practice in municipal health care-A web-like landscape.

AIM: To uncover the characteristics of nurses' information practice in municipal health care and to address how, when and why various pieces of information are produced, shared and managed. BACKGROUND: Nursing documentation in the electronic patient record has repeatedly been found unsatisfactory. Little is known about how the information practice of nurses in municipal health care actually is borne out. In order to understand why nursing documentation continues to fail at living up to the expected requirements, a better understanding of nurses' information practice is needed. DESIGN: A qualitative observational field study. The study complied with the Consolidated Criteria for Reporting Qualitative Research. METHODS: Empirical data were collected in three Norwegian municipalities through participant observations and individual interviews with 17 registered nurses on regular day shifts. The data were analysed through thematic content analysis. RESULTS: Nurses' information practice in municipal health care can be described as complex. The complexity is reflected in four themes that emerged from the data: (1) web of information sources, (2) knowing the patient and information redundancy, (3) asynchronous information practice and (4) compensatory workarounds. CONCLUSIONS: The complex and asynchronous nature of nurses' information practice affected both how and when information was produced, recorded and shared. When available systems lacked functions the nurses wanted, they created compensatory workarounds. Although electronic patient record was an important part of their information practice, nurses in long-term care often knew their patients well, which meant that a lot of information about the patients was in their heads, and that searching for information in the electronic patient record sometimes seemed redundant. RELEVANCE TO CLINICAL PRACTICE: This study provides contextual knowledge that might be valuable (a) in the further development of information systems tailored to meet nurses' information needs and (b) when studying patient safety in relation to nurses' information practice.

Pilot implementation of co-designed software for co-production in mental health care planning: a qualitative evaluation of staff perspectives.

Background: Mental health policies advocate service user participation in care planning. However, service users often feel they're not fully involved and direct access to users' own electronic care plans in the community can be an obstacle. To address this, an electronic care pathway tool (CPT) was co-designed by service users, staff and software developers, to facilitate co-production of care and crisis plans. Aims: To investigate the feasibility and acceptability of the pilot implementation of the CPT in professionals' practice to co-produce care plans and enable efficient working. Method: Qualitative interviews with fifteen mental health practitioners, and five service development/management staff. Normalisation process theory, which outlines the social processes involved in implementing technology, and co-production theory, informed interviews and data analysis. Results: Multiple factors influenced CPT usage, including people's views of technology, practitioners' relationships with service users, service users' mental health needs, and their capacity for reflective thinking. The CPT's visual and interactive features could enable co-production of care plans. The CPT supported practitioners' efficiency, but its features did not easily streamline with electronic patient records. Conclusions: CPT interactive touchpoints supported service users' therapeutic reflection and facilitated care planning involvement. Information technology system interoperability was an obstacle.

Development of an integrated electronic platform for patient self-report and management of adverse events during cancer treatment.

BACKGROUND: Significant adverse events (AE) during cancer therapy disrupt treatment and escalate to emergency admissions. Approaches to improve the timeliness and accuracy of AE reporting may improve safety and reduce health service costs. Reporting AE via patient reported outcomes (PROs), can improve clinician-patient communication and making data available to clinicians in 'real-time' using electronic PROs (ePROs) could potentially transform clinical practice by providing easily accessible records to guide treatment decisions. This manuscript describes the development of eRAPID (electronic patient self-Reporting of Adverse-events: Patient Information and aDvice) is a National Institute for Health Research-funded programme, a system for patients to self-report and manage AE online during and after cancer treatment. MATERIALS AND METHODS: A multidisciplinary team of IT experts, staff and patients developed using agile principles a secure web application interface (QStore) between an existing online questionnaire builder (QTool) displaying real-time ePRO data to clinicians in the electronic patient record at Leeds Teaching Hospitals NHS Trust. Hierarchical algorithms were developed corresponding to Common Terminology Criteria for Adverse Events grading using the QTool question dependency function. Patient advocates (N = 9), patients (N = 13), and staff (N = 19) usability tested the system reporting combinations of AE. RESULTS: The eRAPID system allows patients to report AE from home on PC, tablet or any web enabled device securely during treatment. The system generates immediate self-management advice for low or moderate AE and for severe AE advice to contact the hospital immediately. Clinicians can view patient AE data in the electronic patient record and receive email notifications when patients report severe AE. CONCLUSIONS: Evaluation of the system in a randomised controlled trial in breast, gynaecological and colorectal cancer patients undergoing systemic therapy is currently underway. To adapt eRAPID for different treatment groups, pilot studies are being undertaken with patients receiving pelvic radiotherapy and upper gastrointestinal surgery. ISRCTN88520246.

Electronic patient self-Reporting of Adverse-events: Patient Information and aDvice (eRAPID): a randomised controlled trial in systemic cancer treatment.

BACKGROUND: eRAPID (electronic patient self-Reporting of Adverse-events: Patient Information and aDvice) is an internet based system for patients to self-report symptoms and side effects (adverse events or AE) of cancer treatments. eRAPID allows AE reporting from home and patient reported data is accessible via Electronic Patient Records (EPR) for use in routine care. The system can generate alerts to clinical teams for severe AE and provides patient advice on managing mild AEs. The overall aims of eRAPID are to improve the safe delivery of cancer treatments, enhance patient care and standardise AE documentation. METHODS: The trial is a prospective randomised two-arm parallel group design study with repeated measures and mixed methods. Participants (adult patients with breast cancer on neo-adjuvant or adjuvant chemotherapy, colorectal and gynaecological cancer receiving chemotherapy) are randomised to receive the eRAPID intervention or usual care over 18 weeks of treatment. Participants in the intervention arm receive training in using the eRAPID system to provide routine weekly adverse event reports from home. Hospital staff can access eRAPID reports via the EPR and use the information during consultations or phone calls with patients. Prior to commencing the full trial an internal pilot phase was conducted (N = 87 participants) to assess recruitment procedures, consent and attrition rates, the integrity of the intervention information technology and establish procedures for collecting outcome data. The overall target sample for the trial is N = 504. The primary outcome of the trial is quality of life (FACT-G) with secondary outcomes including health economics (costs to patients and the NHS), process of care (e.g. contacts with the hospital, number of admissions, clinic appointments and changes to treatment/medications) and patient self-efficacy. Outcome data is collected at baseline, 6, 12, 18 weeks and 12 months. The intervention is also being evaluated via end of study interviews with patient participants and clinical staff. DISCUSSION: The pilot phase was completed in February 2016 and recruitment and attrition rates met criteria for continuing to the full trial. Recruitment recommenced in May 2016 and is planned to continue until December 2017. Overall findings will determine the value of the eRAPID intervention for supporting the care of patients receiving systemic cancer treatment. TRIAL REGISTRATION: Current Controlled Trials ISRCTN88520246 . Registered 11 September 2014.

Infectious Disease Surveillance in the Big Data Era: Towards Faster and Locally Relevant Systems.

While big data have proven immensely useful in fields such as marketing and earth sciences, public health is still relying on more traditional surveillance systems and awaiting the fruits of a big data revolution. A new generation of big data surveillance systems is needed to achieve rapid, flexible, and local tracking of infectious diseases, especially for emerging pathogens. In this opinion piece, we reflect on the long and distinguished history of disease surveillance and discuss recent developments related to use of big data. We start with a brief review of traditional systems relying on clinical and laboratory reports. We then examine how large-volume medical claims data can, with great spatiotemporal resolution, help elucidate local disease patterns. Finally, we review efforts to develop surveillance systems based on digital and social data streams, including the recent rise and fall of Google Flu Trends. We conclude by advocating for increased use of hybrid systems combining information from traditional surveillance and big data sources, which seems the most promising option moving forward. Throughout the article, we use influenza as an exemplar of an emerging and reemerging infection which has traditionally been considered a model system for surveillance and modeling.

Reduction in antibiotic prescribing for respiratory tract infections in Swedish primary care- a retrospective study of electronic patient records.

BACKGROUND: Swedish studies on antibiotic use in primary care have been based on one-week registrations of infections. In order to study adherence to guidelines, analyses based on large databases that provide information on diagnosis linked prescriptions, are needed. This study describes trends in management of infections in Swedish primary care particularly with regards to antibiotic prescribing and adherence to national guidelines. METHODS: A descriptive study of Sweden's largest database regarding diagnosis linked antibiotic prescription data, the Primary care Record of Infections in Sweden (PRIS), for the years 2008, 2010 and 2013. RESULTS: Although the consultation rate for all infections remained around 30% each year, antibiotic prescribing rates decreased significantly over the years from 53.7% in 2008, to 45.5% in 2010, to 38.6% in 2013 (p = .032). The antibiotic prescribing rate for respiratory tract infections (RTIs) decreased from 40.5% in 2008 to 24.9% in 2013 while those for urinary tract infections and skin and soft tissue infections were unchanged. For most RTI diagnoses there was a decrease in prescription rate from 2008 to 2013, particularly for the age group 0-6 years. Phenoxymethylpenicillin (PcV) was the antibiotic most often prescribed, followed by tetracycline. Tonsillitis and acute otitis media were the two RTI diagnoses with the highest number of prescriptions per 1000 patient years (PY). For these diagnoses an increase in adherence to national guidelines was seen, with regards to treatment frequency, choice of antibiotics and use of rapid antigen detection test. The frequency in antibiotic prescribing varied greatly between different Primary Healthcare Centres (PHCCs). CONCLUSION: Falling numbers of consultations and decreased antibiotic prescription rates for RTIs have reduced the antibiotic use in Swedish primary care substantially. Overprescribing of antibiotics could still be suspected due to large variability in prescribing frequency, especially for acute bronchitis and sinusitis. Continuous evaluation of diagnosis linked prescribing data and feedback to doctors is essential in order to achieve a more prudent antibiotic use.

A method for extracting electronic patient record data from practice management software systems used in veterinary practice.

BACKGROUND: Data extracted from electronic patient records (EPRs) within practice management software systems are increasingly used in veterinary research. The use of real patient data gives the potential to generate research that can readily be applied to clinical practice. The use of veterinary EPRs for research in the United Kingdom is hindered by the number of different Practice Management System (PMS) providers used by practices, as obtaining and combining data from different systems electronically can be problematic. The use of extensible mark up language (XML) to extract clinical data for research would potentially resolve the compatibility issues between systems. The aim of this study was to establish and validate a method for the extraction of small animal patient records from a veterinary PMS that could potentially be used across multiple systems. An XML schema was designed to extract clinical information from EPRs. The schema was tested and validated in a test system, and was then tested in a real small animal practice where data was extracted for 16 weeks. A 10 % sample of the extracted records was then compared to paper copies provided by the practice. RESULTS: All 21 fields encoded by the XML schema, from all of the records in the test system, were extracted with 100 % accuracy. Over the 18 week data collection period 4946 records, from 1279 patients, were extracted from the small animal practice. The 10 % printed records checked and compared with the XML extracted records demonstrated all required data was present. No unrequired, sensitive information e.g. costs or services/products or personal client information was extracted. CONCLUSIONS: This is the first time a method for data extraction from EPRs in veterinary practice using an XML schema has been reported in the United Kingdom. This is an efficient and accurate way of extracting data which could be applied to all PMSs nationally and internationally.

Documentation of shared decision-making in diagnostic testing for dementia in Dutch general practice: A retrospective study in electronic patient records.

OBJECTIVE: To explore (1) documentation of shared decision-making (SDM) in diagnostic testing for dementia in electronic patient records (EPR) in general practice and (2) study whether documentation of SDM is related to specific patient characteristics. METHODS: In this retrospective observational study, EPRs of 228 patients in three Dutch general practices were explored for the documentation of SDM elements using Elwyn's model (team talk, option talk, decision talk). Patient characteristics (gender, age, comorbidities, chronic polypharmacy, the number of consultations on memory complaints) and decision outcome (wait-and-see, GP diagnostics, referral) were also extracted. RESULTS: In EPRs of most patients (62.6 %), at least one SDM element was documented. Most often this concerned team talk (61.6 %). Considerably less often option talk (4.3 %) and decision talk (12.8 %) were documented. SDM elements were more frequently documented in patients with lower comorbidity scores and patients with a relatively high number of consultations. Decision talk was more frequently documented in referred patients. CONCLUSION: Patients' and significant others' needs, goals, and wishes on diagnostic testing for dementia are often documented in EPRs. PRACTICE IMPLICATIONS: Limited documentation of option and decision talk stresses the need for future SDM interventions to facilitate timely dementia diagnosis.

Embracing Digital Transformation: A Three-Cycle Audit on Improving Intraoperative Tourniquet Documentation Following BOAST (British Orthopaedic Association Standards for Trauma) Guidelines.

Introduction Tourniquets are vital devices in orthopaedic surgery that aid in creating a bloodless field. While they reduce operative time and outcomes, improper use can lead to severe complications. The British Orthopaedic Association Standards for Trauma (BOAST) offers guidelines for safe intraoperative tourniquet usage, emphasising proper application and accurate documentation. With the push for a paperless National Health Service (NHS), orthopaedic units across the UK are transitioning to electronic patient records (EPR). In this audit, we aim to evaluate the impact of electronic patient records (EPR) implementation on tourniquet documentation and subsequent interventions to enhance guideline adherence. Methods This closed-loop audit evaluated 159 emergency trauma cases at a single UK-based district general hospital across three different cycles. The first cycle (n=50) was collected before the trust-wide adoption of an EPR system (EPIC HIVE). Upon collecting the second cycle (n=59), local intraoperative tourniquet usage results compared to BOAST were presented at a departmental audit meeting. A specialised smart phrase template was subsequently shared with the department and the results were re-audited in the third cycle (n=50). Statistical analyses were performed to compare the cycles. Results Following the introduction of the EPR, compliance with documentation standards (fully and partially adhered to) initially declined from 38.0% to 17.0%. Post-intervention, compliance increased to 62.0% (p=0.0005). Individual aspects of documentation revealed notable improvements, including increases in skin assessment pre- and post-tourniquet application (0% to 56% and 0% to 60%, respectively, p<0.0001), isolation method (0% to 60%, p<0.0001), exsanguination method (2% to 24%, p=0.0003), tourniquet pressure (39% to 76%, p=0.0001) and tourniquet time (59% to 94%, p=0.0001). Lower limb tourniquet pressures significantly decreased between audit cycles (mean: 287.06 vs mean: 265.91, p=0.007) while upper limb pressures remained relatively stable (mean: 236.67 vs mean: 236.56, p=0.993). No tourniquet-related complications were reported across all audit cycles. Conclusion While the introduction of new EPR systems may initially present challenges in upholding accurate operative records, the incorporation of specialised electronic templates and active staff engagement has shown to be instrumental in improving tourniquet safety and enhancing care standards.