Circulating magnesium as a potential risk stratification tool for sudden cardiac death: a systematic review.

BACKGROUND: Sudden cardiac death (SCD) is one of the main causes of cardiovascular mortality and accounts for 15-20% of deaths worldwide. The current stratification strategy using depressed left ventricular ejection fraction is insufficient to stratify the risk of SCD, especially in the general population. In recent years, there has been increasing evidence showing the antiarrhythmic properties of magnesium. In this systematic review, the authors aim to determine circulating magnesium as a potential risk stratification tool for SCD. METHODS: This systematic review was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and was conducted in July 2021 with sources from Google Scholar, PubMed, Science Direct, EBSCO Medline, and ProQuest. RESULTS: A total of six studies were included in this review. Three studies conducted in the general population consistently showed lower risk of SCD in populations with high circulating magnesium. There was no association between circulating magnesium level and risk of SCD in intensive cardiac care unit (ICCU) patients, whilst the results were conflicting in congestive heart failure (CHF) patients. CONCLUSION: High circulating magnesium might have the potential to be utilized as a risk stratification tool for SCD, especially in the general population. However, further study is needed to support this evidence.

Structuring and coding in health care records: a qualitative analysis using diabetes as a case study.

BACKGROUND: Globally, diabetes mellitus presents a substantial and increasing burden to individuals, health care systems and society. Structuring and coding of information in the electronic health record underpin attempts to improve sharing and searching for information. Digital records for those with long-term conditions are expected to bring direct and secondary uses benefits, and potentially to support patient self-management. AIMS AND OBJECTIVES: We sought to investigate if how and why records for adults with diabetes were structured and coded and to explore a range of UK stakeholders' perceptions of current practice in the National Health Service. METHODS: We carried out a qualitative, theoretically informed case study of documenting health care information for diabetes in family practice and hospital settings in England, using semi-structured interviews, observations, systems demonstrations and documentary data. RESULTS: We conducted 22 interviews and four on-site observations. With respect to secondary uses - research, audit, public health and service planning - interviewees clearly articulated the benefits of highly structured and coded diabetes data and it was believed that benefits would expand through linkage to other datasets. Direct, more marginal, clinical benefits in terms of managing and monitoring diabetes and perhaps encouraging patient self-management were also reported. We observed marked differences in levels of record structuring and/or coding between family practices, where it was high, and the hospital. We found little evidence that structured and coded data were being exploited to improve information sharing between care settings. CONCLUSIONS: Using high levels of data structuring and coding in records for diabetes patients has the potential to be exploited more fully, and lessons might be learned from successful developments elsewhere in the UK. A first step would be for hospitals to attain levels of health information technology infrastructure and systems use commensurate with family practices.

Interventions for reducing medication errors in children in hospital.

BACKGROUND: Many hospitalised patients are affected by medication errors (MEs) that may cause discomfort, harm and even death. Children are at especially high risk of harm as the result of MEs because such errors are potentially more hazardous to them than to adults. Until now, interventions to reduce MEs have led to only limited improvements. OBJECTIVES: To determine the effectiveness of interventions aimed at reducing MEs and related harm in hospitalised children. SEARCH METHODS: The Effective Practice and Organisation of Care Group (EPOC) Trials Search Co-ordinator searched the following sources for primary studies: The Cochrane Library, including the Cochrane Central Register of Controlled Trials (CENTRAL), the Economic Evaluation Database (EED) and the Health Technology Assessments (HTA) database; MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Proquest Dissertations & Theses, Web of Science (citation indexes and conference proceedings) and the EPOC Register of Studies. Related reviews were identified by searching the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects (DARE). Review authors searched grey literature sources and trial registries. They handsearched selected journals, contacted researchers in the field and scanned reference lists of relevant reviews. They conducted searches in November 2013 and November 2014. They applied neither language nor date limits. SELECTION CRITERIA: Randomised controlled trials, controlled before-after studies and interrupted time series investigating interventions to improve medication safety in hospitalised children (≤ 18 years). Participants were healthcare professionals authorised to prescribe, dispense or administer medications. Outcome measures included MEs, (potential) patient harm, resource utilisation and unintended consequences of the interventions. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, extracted data and assessed study quality using the EPOC data collection checklist. We evaluated the risk of bias of included studies and used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach to assess the quality of the body of evidence. We described results narratively and presented them using GRADE tables. MAIN RESULTS: We included seven studies describing five different interventions: participation of a clinical pharmacist in a clinical team (n = 2), introduction of a computerised physician order entry system (n = 2), implementation of a barcode medication administration system (n = 1), use of a structured prescribing form (n = 1) and implementation of a check and control checklist in combination with feedback (n = 1).Clinical and methodological heterogeneity between studies precluded meta-analyses. Although some interventions described in this review show a decrease in MEs, the results are not consistent, and none of the studies resulted in a significant reduction in patient harm. Based on the GRADE approach, the overall quality and strengfh of the evidence are low. AUTHORS' CONCLUSIONS: Current evidence on effective interventions to prevent MEs in a paediatric population in hospital is limited. Comparative studies with robust study designs are needed to investigate interventions including components that focus on specific paediatric safety issues.

"How long does it take?" A mixed methods evaluation of computer-related work in GP consultations.

BACKGROUND: Systematic reviews have suggested that time spent on computer-related tasks increases consultation length. However, these reviews pre-date the current ubiquitous use of computers in U.K. general practice. OBJECTIVE: As part of a U.K. national study of the influence of information technology (IT) on the interaction between patients and healthcare professionals during consultations, we explored how IT functions affected time allocation and styles of computer use during general practitioner (GP) consultations. METHODS: We drew on multichannel video recording of consultations and measured consultation phases and the duration of computer-related tasks. We related measures of actual time to GP's interpretation of computer use elicited in qualitative interviews. RESULTS: Our sample included recordings of 112 consultations from 6 GPs in three practices. The computer was used for about one-third of the greater consultation. However, its use was concentrated pre- and post- the patient consultation. The workflow of consultation was exemplified through six computer use cases. Most functionality was accepted and accommodated within the consultation, though disruptive and time-consuming tasks were generally delegated to administrative staff. Recognised styles of computer use (minimal, block and conversational) were apparent, but applied very flexibly by GPs according to the nature of the consultation. CONCLUSIONS: In contrast to earlier reports, contemporary computer use does not appear to have lengthened consultations. GPs adopted different styles of computer use in different consultations, challenging classifications that seek to stereotype GP computer use. Designing systems that support this versatility require an understanding of the fluid application of computer use within consultation structure.

The collection and utilisation of patient ethnicity data in general practices and hospitals in the United Kingdom: a qualitative case study.

BACKGROUND: Although the collection of patient ethnicity data is a requirement of publicly funded healthcare providers in the UK, recording of ethnicity is sub-optimal for reasons that remain poorly understood. AIMS AND OBJECTIVES: We sought to understand enablers and barriers to the collection and utilisation of ethnicity data within electronic health records, how these practices have developed and what benefit this information provides to different stakeholder groups. METHODS: We undertook an in-depth, qualitative case study drawing on interviews and documents obtained from participants working as academics, managers and administrators within the UK. RESULTS: Information regarding patient ethnicity was collected and coded as administrative patient data, and/or in narrative form within clinical records. We identified disparities in the classification of ethnicity, approaches to coding and levels of completeness due to differing local, regional and national policies and processes. Most participants could not identify any clinical value of ethnicity information and many did not know if and when data were shared between services or used to support quality of care and research. CONCLUSIONS: Findings highlighted substantial variations in data classification, and practical challenges in data collection and usage that undermine the integrity of data collected. Future work needs to focus on explaining the uses of these data to frontline clinicians, identifying resources that can support busy professionals to collect standardised data and then, once collected, maximising the utility of these data.

Approaches to recording drug allergies in electronic health records: qualitative study.

BACKGROUND: Drug allergy represent an important subset of adverse drug reactions that is worthy of attention because many of these reactions are potentially preventable with use of computerised decision support systems. This is however dependent on the accurate and comprehensive recording of these reactions in the electronic health record. The objectives of this study were to understand approaches to the recording of drug allergies in electronic health record systems. MATERIALS AND METHODS: We undertook a case study comprising of 21 in-depth interviews with a purposefully selected group of primary and secondary care clinicians, academics, and members of the informatics and drug regulatory communities, observations in four General Practices and an expert group discussion with 15 participants from the Allergy and Respiratory Expert Resource Group of the Royal College of General Practitioners. RESULTS: There was widespread acceptance among healthcare professionals of the need for accurate recording of drug allergies and adverse drug reactions. Most drug reactions were however likely to go unreported to and/or unrecognised by healthcare professionals and, even when recognised and reported, not all reactions were accurately recorded. The process of recording these reactions was not standardised. CONCLUSIONS: There is considerable variation in the way drug allergies are recorded in electronic health records. This limits the potential of computerised decision support systems to help alert clinicians to the risk of further reactions. Inaccurate recording of information may in some instances introduce new problems as patients are denied treatments that they are erroneously believed to be allergic to.

National evaluation of the benefits and risks of greater structuring and coding of the electronic health record: exploratory qualitative investigation.

OBJECTIVE: We aimed to explore stakeholder views, attitudes, needs, and expectations regarding likely benefits and risks resulting from increased structuring and coding of clinical information within electronic health records (EHRs). MATERIALS AND METHODS: Qualitative investigation in primary and secondary care and research settings throughout the UK. Data were derived from interviews, expert discussion groups, observations, and relevant documents. Participants (n=70) included patients, healthcare professionals, health service commissioners, policy makers, managers, administrators, systems developers, researchers, and academics. RESULTS: Four main themes arose from our data: variations in documentation practice; patient care benefits; secondary uses of information; and informing and involving patients. We observed a lack of guidelines, co-ordination, and dissemination of best practice relating to the design and use of information structures. While we identified immediate benefits for direct care and secondary analysis, many healthcare professionals did not see the relevance of structured and/or coded data to clinical practice. The potential for structured information to increase patient understanding of their diagnosis and treatment contrasted with concerns regarding the appropriateness of coded information for patients. CONCLUSIONS: The design and development of EHRs requires the capture of narrative information to reflect patient/clinician communication and computable data for administration and research purposes. Increased structuring and/or coding of EHRs therefore offers both benefits and risks. Documentation standards within clinical guidelines are likely to encourage comprehensive, accurate processing of data. As data structures may impact upon clinician/patient interactions, new models of documentation may be necessary if EHRs are to be read and authored by patients.

Diabetes in the workplace - diabetic's perceptions and experiences of managing their disease at work: a qualitative study.

BACKGROUND: Diabetes represents one of the biggest public health challenges facing the UK. It is also associated with increasing costs to the economy due to working days lost as people with diabetes have a sickness absence rate 2-3 times greater than the general population. Workplaces have the potential to support or hinder self- management of diabetes but little research has been undertaken to examine the relationship between work and diabetes in the UK. This paper seeks to go some way to addressing this gap by exploring the perceptions and experiences of employees with diabetes. METHODS: Forty three people with diabetes were purposively recruited to ascertain ways in which they managed their disease in the workplace. Semi-structured, interviews were undertaken, tape recorded and transcribed. Analysis was conducted using a constant comparative approach. RESULTS: Although respondents had informed managers of their diabetic status they felt that their managers had little concept of the effects of the work environment on their ability to manage their disease. They did not expect support from their managers and were concerned about being stigmatised or treated inappropriately. Work requirements took priority. They had to adapt their disease management to fit their job and reported running their blood glucose levels at higher than optimal levels, thereby putting themselves at higher risk of long term complications. CONCLUSIONS: Little research has examined the way in which employees with diabetes manage their disease in the workplace. This research shows there is a need to increase the awareness of managers of the short and long term economic benefit of supporting employees with diabetes to manage their disease effectively whist at work. Employees may need individually assessed and tailored support on the job in order to manage their disease effectively.

'Too much, too late': mixed methods multi-channel video recording study of computerized decision support systems and GP prescribing.

OBJECTIVE: Computerized decision support systems (CDSS) are commonly deployed to support prescribing, although over-riding of alerts by prescribers remains a concern. We aimed to understand how general practitioners (GPs) interact with prescribing CDSS in order to inform deliberation on how better to support prescribing decisions in primary care. MATERIALS AND METHODS: Quantitative and qualitative analysis of interactions between GPs, patients, and computer systems using multi-channel video recordings of 112 primary care consultations with eight GPs in three UK practices. RESULTS: 132 prescriptions were issued in the course of 73 of the consultations, of which 81 (61%) attracted at least one alert. Of the total of 117 alerts, only three resulted in the GP checking, but not altering, the prescription. CDSS provided information and safety alerts at the point of generating a prescription. This was 'too much, too late' as the majority of the 'work' of prescribing occurred prior to using the computer. By the time an alert appeared, the GP had formulated the problem(s), potentially spent several minutes considering, explaining, negotiating, and reaching agreement with the patient about the proposed treatment, and had possibly given instructions and printed an information leaflet. DISCUSSION: CDSS alerts do not coincide with the prescribing workflow throughout the whole GP consultation. Current systems interrupt to correct decisions that have already been taken, rather than assisting formulation of the management plan. CONCLUSIONS: CDSS are likely to be more acceptable and effective if the prescribing support is provided much earlier in the process of generating a prescription.

Benefits and risks of structuring and/or coding the presenting patient history in the electronic health record: systematic review.

BACKGROUND: Patient histories in electronic health records currently exist mainly in free text format thereby limiting the possibility that decision support technology may contribute to the accuracy and timeliness of clinical diagnoses. Structuring and/or coding make patient histories potentially computable. METHODS: A systematic review was undertaken of the benefits and risks of structuring and/or coding patient history by searching nine international databases for published and unpublished studies over the period 1990-2010. The focus was on the current patient history, defined as information reported by a patient or the patient's caregiver about the patient's present health situation and health status. Findings were synthesised through a theoretically based textural analysis. FINDINGS: Of the 9207 potentially eligible papers identified, 10 studies satisfied the eligibility criteria. There was evidence of a modest number of benefits associated with structuring the current patient history, including obtaining more complete clinical histories, improved accuracy of patient self-documented histories, and better associated decision-making by professionals. However, no studies demonstrated any resulting improvements in patient care or outcomes. When more detailed records were obtained through the use of a structured format no attempt was made to confirm if this additional information was clinically useful. No studies investigated possible risks associated with structuring the patient history. No studies examined coding of the patient history. CONCLUSIONS: There is an insufficient evidence base for sound policy making on the benefits and risks of structuring and/or coding patient history. The authors suggest this field of enquiry warrants further investigation given the interest in use of decision support technology to aid diagnoses.

A review of the empirical evidence of the value of structuring and coding of clinical information within electronic health records for direct patient care.

BACKGROUND: The case has historically been presented that structured and/or coded electronic health records (EHRs) benefit direct patient care, but the evidence base for this is not well documented. METHODS: We searched for evidence of direct patient care value from the use of structured and/or coded information within EHRs. We interrogated nine international databases from 1990 to 2011. Value was defined using the Institute of Medicine's six areas for improvement for healthcare systems: effectiveness, safety, patient-centredness, timeliness, efficiency and equitability. We included studies satisfying the Cochrane Effective Practice and Organisation of Care (EPOC) group criteria. RESULTS: Of 5016 potentially eligible papers, 13 studies satisfied our criteria: 10 focused on effectiveness, with eight demonstrating potential for improved proxy and actual clinical outcomes if a structured and/or coded EHR was combined with alerting or advisory systems in a focused clinical domain. Three studies demonstrated improvement in safety outcomes. No studies were found reporting value in relation to patient-centredness, timeliness, efficiency or equitability. CONCLUSIONS: We conclude that, to date, there has been patchy effort to investigate empirically the value from structuring and coding EHRs for direct patient care. Future investments in structuring and coding of EHRs should be informed by robust evidence as to the clinical scenarios in which patient care benefits may be realised.

Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals.

OBJECTIVES: To evaluate the implementation and adoption of the NHS detailed care records service in "early adopter" hospitals in England. DESIGN: Theoretically informed, longitudinal qualitative evaluation based on case studies. SETTING: 12 "early adopter" NHS acute hospitals and specialist care settings studied over two and a half years. DATA SOURCES: Data were collected through in depth interviews, observations, and relevant documents relating directly to case study sites and to wider national developments that were perceived to impact on the implementation strategy. Data were thematically analysed, initially within and then across cases. The dataset consisted of 431 semistructured interviews with key stakeholders, including hospital staff, developers, and governmental stakeholders; 590 hours of observations of strategic meetings and use of the software in context; 334 sets of notes from observations, researchers' field notes, and notes from national conferences; 809 NHS documents; and 58 regional and national documents. RESULTS: Implementation has proceeded more slowly, with a narrower scope and substantially less clinical functionality than was originally planned. The national strategy had considerable local consequences (summarised under five key themes), and wider national developments impacted heavily on implementation and adoption. More specifically, delays related to unrealistic expectations about the capabilities of systems; the time needed to build, configure, and customise the software; the work needed to ensure that systems were supporting provision of care; and the needs of end users for training and support. Other factors hampering progress included the changing milieu of NHS policy and priorities; repeatedly renegotiated national contracts; different stages of development of diverse NHS care records service systems; and a complex communication process between different stakeholders, along with contractual arrangements that largely excluded NHS providers. There was early evidence that deploying systems resulted in important learning within and between organisations and the development of relevant competencies within NHS hospitals. CONCLUSIONS: Implementation of the NHS Care Records Service in "early adopter" sites proved time consuming and challenging, with as yet limited discernible benefits for clinicians and no clear advantages for patients. Although our results might not be directly transferable to later adopting sites because the functionalities we evaluated were new and untried in the English context, they shed light on the processes involved in implementing major new systems. The move to increased local decision making that we advocated based on our interim analysis has been pursued and welcomed by the NHS, but it is important that policymakers do not lose sight of the overall goal of an integrated interoperable solution.

Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation.

OBJECTIVES: To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide early feedback for the ongoing local and national rollout of the NHS Care Records Service. DESIGN: A mixed methods, longitudinal, multisite, socio-technical case study. SETTING: Five NHS acute hospital and mental health trusts that have been the focus of early implementation efforts and at which interim data collection and analysis are complete. Data sources and analysis Dataset for the evaluation consists of semi-structured interviews, documents and field notes, observations, and quantitative data. Qualitative data were analysed thematically with a socio-technical coding matrix, combined with additional themes that emerged from the data. Main results Hospital electronic health record applications are being developed and implemented far more slowly than was originally envisioned; the top-down, standardised approach has needed to evolve to admit more variation and greater local choice, which hospital trusts want in order to support local activity. Despite considerable delays and frustrations, support for electronic health records remains strong, including from NHS clinicians. Political and financial factors are now perceived to threaten nationwide implementation of electronic health records. Interviewees identified a range of consequences of long term, centrally negotiated contracts to deliver the NHS Care Records Service in secondary care, particularly as NHS trusts themselves are not party to these contracts. These include convoluted communication channels between different stakeholders, unrealistic deployment timelines, delays, and applications that could not quickly respond to changing national and local NHS priorities. Our data suggest support for a "middle-out" approach to implementing hospital electronic health records, combining government direction with increased local autonomy, and for restricting detailed electronic health record sharing to local health communities. CONCLUSIONS: Experiences from the early implementation sites, which have received considerable attention, financial investment and support, indicate that delivering improved healthcare through nationwide electronic health records will be a long, complex, and iterative process requiring flexibility and local adaptability both with respect to the systems and the implementation strategy. The more tailored, responsive approach that is emerging is becoming better aligned with NHS organisations' perceived needs and is, if pursued, likely to deliver clinically useful electronic health record systems.

The benefits and risks of structuring and coding of patient histories in the electronic clinical record: protocol for a systematic review.

BACKGROUND: Data in medical records have in part been recorded in structured and coded forms for some decades. However, the patient history is as yet largely recorded in an uncoded format. There is a need to consider the optimal balance of use of free text and coded data in the patient history. This review protocol summarises our plans to identify, critically appraise and synthesise evidence relating to approaches taken to introduce structure and coding within patient histories in electronic health records, and the empirically demonstrated benefits and risks of structuring and coding of patient histories in health records. OBJECTIVES: To determine how structured and coded data are being introduced for the recording of patient histories, the benefits observed where structuring and coding have been introduced and the risks encountered when structuring and coding are introduced. METHODS: We will search the following databases for evidence of published and unpublished material: CINAHL; EMBASE; Google Scholar; IndMED; LILACS; MEDLINE; NIHR; Paklit and PsycINFO. We will, depending on the study designs employed, use the Cochrane EPOC, Joanna Briggs Institute (JBI) and Newcastle-Ottawa instruments to critically appraise studies. Data synthesis is likely to be undertaken using a narrative approach, although meta-analysis will also be undertaken if appropriate and if the data allow this. RESULTS: This protocol should represent a reproducible approach to reviewing the literature regarding structuring and coding in patient histories. We anticipate that we will be able to report results in early 2011. CONCLUSION: The review should offer increased clarity and direction on the optimal balance between structuring/coding and free text recording of data relating to the patient history.

Adverse drug events in the elderly.

BACKGROUND: Increasing recognition of the burden associated with iatrogenic disease has led to international interest into how best to promote patient safety. Within this field, the subject of adverse drug events (ADEs) has received particular attention, this reflecting the known high frequency with which such events occur, particularly in the elderly. METHODS: We conducted a narrative review summarizing epidemiological data on medication-related adverse events in elderly people, considering various known causes of such events and suggesting practical ways in which prescribing can be made safer for high-risk populations. RESULTS: There is an increasing recognition that a relatively high proportion of ADEs in the elderly may be preventable. Systems issues have been found to play a particularly powerful role in this context, resulting in several promising approaches to address the problem. CONCLUSIONS: Relatively simple system changes have the potential to reduce the burden associated with medication-related adverse events in the elderly.

Identifying and establishing consensus on the most important safety features of GP computer systems: e-Delphi study.

Our objective was to identify and establish consensus on the most important safety features of GP computer systems, with a particular emphasis on medicines management. We used a two-round electronic Delphi survey, completed by a 21-member multidisciplinary expert panel, all from the UK. The main outcome measure was percentage agreement of the panel members on the importance of the presence of a number of different safety features (presented as clinical statements) on GP computer systems. We found 90% or greater agreement on the importance of 32 (58%) statements. These statements, indicating issues considered to be of considerable importance (rated as important or very important), related to: computerised alerts; the need to avoid spurious alerts; making it difficult to override critical alerts; having audit trails of such overrides; support for safe repeat prescribing; effective computer-user interface; importance of call and recall management; and the need to be able to run safety reports. The high level of agreement among the expert panel members indicates clear themes and priorities that need to be addressed in any further improvement of safety features in primary care computing systems.