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The perception of medical professionals and medical students on the usefulness of an emergency medical card and a continuity of care report in enhancing continuity of care
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journal homepage: www.intl.elsevierhealth.com/journals/ijmi
The perception of medical professionals and medical students on the usefulness of an emergency medical card and a continuity of care report in enhancing continuity of care Christopher H.O. Olola a,∗ , Scott Narus a , Jonathan Nebeker c , Mollie Poynton a,d , Joseph Hales a,b , Belle Rowan b , Heather LeSieur b , Cynthia Zumbrennen b , Annemarie A. Edwards b , Robert Crawford b , Spencer Amundsen e , Yasmin Kabir e , Joseph Atkin e , Cynthia Newberry e , Jason Young e , Tariq Hanifi e , Ben Risenmay e , Tyler Sorensen e , R. Scott Evans a,b a
University of Utah, Department of Biomedical Informatics, 20 South 2600 East, Salt Lake City, UT 84112, USA Intermountain Healthcare, Salt Lake City, UT, USA c Veterans Affairs (VA) Hospital, Salt Lake City, UT, USA d College of Nursing, University of Utah, Salt Lake City, UT, USA e University of Utah, School of Medicine, Salt Lake City, UT, USA b
a r t i c l e
i n f o
a b s t r a c t
Article history:
Objectives: To evaluate the medical professionals and medical students perceived usefulness
Received 18 June 2010
of an emergency medical card (EMC) and a continuity of care (CoC) report, in enhancing CoC.
Received in revised form
Methods: The study reviewers included medical professionals from outpatient clinics at Inter-
16 February 2011
mountain Healthcare and fourth-year medical students from the University of Utah. Three
Accepted 16 February 2011
cases we randomly extracted from a database of patients who had added new care information at the time. EMCs and CoC reports were populated for the cases, and information then de-identified. Using patient information in the electronic medical record (EMR), reviewers
Keywords:
evaluated if the EMR information was adequate to support medical decisions made on the
Emergency medical card
patient’s diagnosis, medications, laboratory tests, and disposition. The reviewer assessed
Continuity of care report
if the EMC and CoC report information would influence the medical decisions made. An
Continuity of patient care
online survey was used to assess the reviewers’ perception on the usefulness of the two
Emergency medical services
documents.
Continuity of care record
Results: On average, 94% of the reviewers perceived the EMC to be useful in enhancing medical decision making at the point of care, and 74% found the CoC report to be useful. More specifically, the two documents were found to be useful in decreasing encounter time (100% each), increasing overall knowledge of healthcare providers (100% each), influencing decision on the treatment (94% each), and new laboratory test orders (87% and 90%, respectively).
∗
Corresponding author. Tel.: +1 801 581 4080; fax: +1 801 581 4297. E-mail address: c [email protected] (C.H.O. Olola). 1386-5056/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2011.02.007
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Conclusions: The EMC and CoC report were found to be useful methods for transporting patient healthcare information across the healthcare continuum. The documents were found more specifically to be useful for effective decision making, improving efficiency and quality of care, at the point of care. © 2011 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Healthcare providers require immediate access to reliable patient health information for appropriate medical decision making [1–3]. The dearth of such information may lead to medical errors, adverse events, poor patient safety and outcome, and increased overall cost of care [4–8]. It has been reported that between 44,000 and 98,000 Americans die annually from medical errors and related adverse events, many of which occur as a result of poor quality data [4,9]. Therefore, patient data needs to be managed in a way that makes them of sufficient quality for their intended use [10] and timely available across the healthcare continuum [11]. Availability of the patient’s right information at the right time, at the right place, to the right person, in the right form, is increasingly difficult and challenging. This is because of the slow adoption of the information presentation and data standards, the increasing volume of patient information, lack universal unique patient identifiers, and patients seeking medical care from multiple healthcare providers [10,12]. The availability of patient information at the point of care can be improved by enhancing continuity of care (CoC). A study by Grain [13] showed that patients did not always provide a complete history or description of current health status to multiple healthcare providers they visited. Patients assumed that their health information was transferred among the healthcare providers, which did not always happen. During medical emergencies, patients seldom see the same hospital or community physicians who previously treated them [5,14]. This results in problems associated with discontinuity of care, which increases with multiple healthcare providers seen and increased number of encounters [5]. Patients play a vital role in sharing knowledge of their healthcare history and in the medical decision making process [13,15]. Granting patients access to their medical records through personal health records enhances their communication with healthcare providers, increases knowledge of health status, and helps patients to identify and notify healthcare providers of possible errors in their medical records [3,16,17]. It is, therefore, critical that patients have access to adequate and effective data monitoring and communication mechanisms with their healthcare providers. Sharing of patient information by mail (e.g., via discharge letters) has been a traditional method for many years, but it has proved to be slow, inefficient and erroneous, and can potentially lead to poor quality of patient care [12,18,19]. A better technique is the adoption of an electronic medical record (EMR), which can enable multiple healthcare providers treating the same patient to efficiently share and use the patient’s health information [20–22]. However, it has been reported that only approximately 17–20% of
outpatient settings in the US have comprehensive EMR systems, i.e., computerized physician order entry, computerized laboratory tests ordering and results reporting, and computerized clinical notes [23,24]. It is also the case that most EMRs do not utilize common standards for recording and sharing information. Most communities also lack a health information exchange infrastructure for electronically sharing pertinent patient data. This situation impedes sharing of patient data for CoC. Even in cases where EMR data can be shared between healthcare providers, the data may contain errors or omissions that need to be fixed. Patients are potentially excellent sources of quality control for their records, but direct patient access to information with an ability to provide corrections and/or annotations is rarely available. Therefore, there is an urgent need for techniques that facilitate communication and sharing of quality patient information for decision making while full implementation and adoption of EMR systems continue.
2.
Background
Intermountain Healthcare (“Intermountain”) implemented a Continuity of Care Record (CCR) standard [25] compliant application (“CCR application”) whose design and implementation details were described previously [26]. The application enables patients to view healthcare provider-entered data in the EMR and enter and modify their data from visits to non-Intermountain healthcare providers. Only the patient information that had been integrated in the central clinical data repository (CDR) was available in the EMR for patients to use to create the EMC and continuity of care report. By the time of this study, the social history, family history, immunization, emergency contacts, and personal notes information was not available in the CDR. In addition, the new information that patients either added or obtained from visits to non-Intermountain healthcare providers, were not available in the EMR. The missing information included primary insurance, blood type, organ donor, dentures, pacemakers, current allergies, current health concerns, and current medication. Therefore, the patients entered these pieces of information into the CCR application database. The application users created an emergency medical card (EMC) for use during medical emergencies and a CoC report for their healthcare providers to use in updating EMR information. The CoC report is a full EMR report. It contains both the current and past three months’ patient-entered data and healthcare providerentered data (in two distinct columns) in compliance with the data elements mandated by the CCR standard. The data includes the patient and document identifiers, document pur-
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pose and date, problems, allergies, family and social history, medications, immunization, vital signs, laboratory tests and results, procedures, advance directives, care documentation and care plan, and healthcare providers. The patient-entered new/current data on the CoC report is used by healthcare providers to correct possible errors or to complete missing patient information in the healthcare provider-entered data in the EMR. The EMC, however, contains a portion of the CoC report information. It contains only the most current core patient-entered data using the CCR application and healthcare provider-entered data in the EMR. The EMC data includes the patient identifiers, demographic, insurance/financial, current problems, current medications, active allergies, blood group, advance directives, contact lenses, religious preference, and pacemaker information. The EMC was designed to provide the core patient information to healthcare providers for appropriate medical decision during medical emergencies. This approach allows for a distinction between healthcare provider-reviewed information and patient corrections and annotations, and a means for patients to provide a quality review of their data.
3.
Objectives
The primary objective of the study was to evaluate the medical professionals (medical doctors and physician assistants) and medical students perceived usefulness on an emergency medical card and a CoC report in enhancing continuity of care, at the point of care.
4.
Methods
4.1.
Setting and participants
The study reviewers included healthcare professionals (three MDs and two PAs) from outpatient clinics at Intermountain and fourth-year medical students from the University of Utah, School of Medicine. Clinic Managers at the Intermountain’s outpatient clinics contacted twelve medical professionals and provided them with a summary of the study and requested them to participate in the study. Five (41.2%) healthcare professionals accepted to participate in the study. The study principal investigator (CO) contacted thirteen fourth-year medical students and eight (61.5%) accepted to participate in the study. The overall response rate was 52.0%. The inclusion of the medical students was to enable the investigators to assess if there would be any significant differences between the ratings of the EMC and CoC report by type of reviewer. The fourth-year medical students were chosen because they were believed to be adequately advanced in their medical career to professionally review the study cases. An attempt to recruit senior residents was fruitless – apparently because of their heavy workload. At one month, a follow-up email was sent to non-responders, followed by a second email two weeks later. A package with detailed study evaluation information was then sent to all the responders who accepted to participate in the study.
4.2.
Study cases
Cases of patients who had added new information (i.e., information from visits to healthcare providers outside of the Intermountain network or information on possible errors that patients identified in their records in the EMR) were extracted from the database of all the patients in the project at the time. Three cases were then randomly selected from the resulting database by using a random number generator [Intercooled STATA software, Release 9, StataCorp. 2007; College Station, TX, USA]. We de-identified the information in the three cases by disguising the patient identifying information such as name, date of birth, gender, contacts, healthcare provider details, and insurance/financial information. We then populated, for each case, a CoC report (which also contained EMR information, displayed side-by-side with patient-entered data) and an EMC.
4.3.
Case review process
Each reviewer assessed the three study cases using the patients’ EMR, EMC, and CoC report information (Fig. 1). The review started by the assessment of each case using the patient EMR information. In this assessment, the reviewer evaluated if the EMR information was adequate to support the medical decisions that were made (as stipulated in the EMR) on the patient’s diagnosis, therapy or medications, laboratory tests, and disposition (i.e., admission, discharge home, referral or transfer to other healthcare providers). The reviewer then assessed if the patient corresponding EMC or CoC report information would have any added value to the medical decision previously made using EMR information. For example, was there any additional information in the EMC or CoC report (that was missing in the EMR) which would be useful in influencing the decision making? Finally, each reviewer completed an online survey developed using Opinio software [ObjectPlanet, Inc. 2008. Øvre Slottsgate 5, 0157 Oslo, Norway] to record their perceptions on the usefulness of the EMC and CoC report information, in enhancing CoC. A provision was also made in the survey for the reviewers to comment on the survey measurements and make recommendations for the improvement of the EMC and CoC report.
4.4.
Data analysis
STATA software [Intercooled STATA software, Release 9, StataCorp. 2007; College Station, TX, USA] was used for data analysis. We characterized the usefulness of EMC and CoC report by the reviewer gender, profession, age, and medical professional’s years of job experience. We also tabulated the ratings of the usefulness of the two documents, while categorizing by various CoC measures. We grouped the reviewers’ comments into five themes. The themes included misspelled, mismatched, confusing or complex, little/no, and too much information. We then analyzed the comments, stratifying by theme.
5.
Results
On average, 94% of the reviewers perceived the EMC to be useful in enhancing CoC, and 74% found the CoC report to
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Fig. 1 – A flow diagram of the study case review process.
be useful (Table 1). More male reviewers found the EMC and the CoC report to be useful (100% vs. 88% and 80% vs. 69%, respectively). All the medical students were age 18–30 years and all of them found the EMC to be useful. A majority 83% of the medical students perceived the CoC report to be useful. Similarly, all the medical professionals age 18–30 years, 41–50 years and 51–60 years found the EMC to be useful. Only 50% of the medical professionals age 31–40 years perceived the CoC report to be useful. There was no significant difference in the years of job experience between the medical professionals who perceived the documents to be useful and those who did not.
Overall, a high percentage of the reviewers found the EMC and the CoC report to be legible, and easy to understand and use (92% and 94%, respectively) (Table 2). In addition, the EMC and CoC report were found, generally, to be useful in influencing medical decision making at the point of care (71% and 78%, respectively). More specifically, the EMC and CoC report were perceived to be useful in influencing decision on medications/treatment (94% each), and ordering of new laboratory tests (87% and 90%, respectively). The documents were found also to be a potential resource to shorten encounter time and to increase the healthcare provider’s overall knowledge (100% each).
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Table 1 – Characteristics of the reviewers and perceived usefulness of the EMC and CoC report. Continuity of care measure Sex Female Male Profession MD/PA Medical students Age of Reviewers (years) MD/PA 18–30 31–40 41–50 51–60 Medical students 18–30 31–40 41–50 51–60 Job experience (years) – MD/PA
na
EMC usefulness: n (%) (average 93.5%)
CoC report usefulness: n (%) (average 74.2%)
16 15
14 (87.5) 15 (100.0)
11 (68.8) 12 (80.0)
13 18
11 (84.6) 18 (100.0)
8 (61.5) 15 (83.3)
3 4 3 3
3 (100.0) 2 (50.0) 3 (100.0) 3 (100.0)
3 (100.0) 3 (75.0) 0 (0) 2 (66.7)
18 0 0 0 13
18 (100.0) – – – 11 (11.1 ± 6.3)b 2 (10.0 ± 0.0)c
15 (83.3) – – – 8 (11.3 ± 6.1)b 5 (12.3 ± 6.7)c
EMC: emergency medical card. CoC: continuity of care. MD: medical doctor. PA: physician assistant. –: there were no reviewers in these categories. Number of records reviewed – not all reviewers assessed all the three cases (which would have resulted in a total of 39 records for each CoC measure). Since the review process was anonymous, we could not know who didn’t review all the 3 cases assigned to them. b Mean ± Standard deviation of job experience (where the tool was perceived to be useful). c Mean ± Standard deviation of job experience (where the tool was perceived not to be useful). a
The reviewers provided useful comments or suggestions on how the EMC and CoC report’s templates could be improved to ensure the availability of pertinent patient care information for effective medical decision making, at the point of care (Tables 3 and 4). The reviewers found that patients were likely to misspell medications and to list them under the wrong medical problems. The reviewers also recommended that section headers, medications, and demographics (e.g., address, and phone numbers) in the EMC and the CoC report should be abbreviated and/or condensed. More information on medical problems was recommended to adequately support effective decision making. In addition, one medical doctor seemed to have found the information in both documents to be complex or confusing. On contrary, one doctor found the information in the documents to be adequate for the provision of improved healthcare to patients, at the point of care. More specifically, a number of reviewers perceived the information in the CoC report to be too much (an “overkill”) for medical decision making (Table 4). Therefore, the information should be further condensed to a maximum of one to two pages per patient. Some reviewers suggested that the vital signs, insurance, pending appointments, resolved allergies, and past medical problems should be eliminated. On contrary, some other reviewers suggested that the same information should not be eliminated but rather condensed.
6.
Discussion
Overall, the information in the EMC and CoC report was well perceived by the medical professionals and medical students to be useful in enhancing CoC, at the point of care. More specif-
ically, the information was found to be much more useful in increasing the overall knowledge of healthcare providers, decreasing encounter time, and overall, have significant influence on the medical decision making process e.g., treatment or medication and new laboratory test orders. Interestingly, a majority of reviewers, irrespective of their profession, age, and years of job experience, found the EMC to be more useful than the CoC report. This may mean that healthcare providers are more likely to prefer condensed or summarized patient care information for effective medical decision making. However, healthcare provider perception of the usefulness of the information in the two documents may vary significantly by gender–male healthcare providers are more likely to find the information useful. Overall, there was statistically significant difference in the way the healthcare professionals and medical students perceived the usefulness of the EMC and CoC report. A significant difference would definitely trigger a need for further research to investigate reasons why difference exists. Therefore, these findings suggest that the medical professionals and/or senior medical students (e.g., fourth-year students) could effectively be involved in such evaluation studies, as long as they are appropriately randomized and matched by gender. Although the information in the two documents was of small font size, approximately 95% of the reviewers perceived that healthcare providers are likely to find the information legible, and easy to understand and use. However, despite the high percentage of agreement on the usefulness of the documents, the reviewers suggested further modifications to improve the information presentation. Apparently, there was no unanimous consensus among the reviewers on what information should be condensed or summarized, or eliminated from the EMC and CoC report. For example, some reviewers
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Table 2 – Reviewer-perceived usefulness of the EMC and CoC report, categorized by the continuity of care measurements. Continuity of care measure
EMC na
Usefulness n (%)
CoC report Median rating score na (Q1, Q3)d
Usefulness n (%)
Using the documentb Document was legible 31 29 (93.5) 5 (4, 5) 31 29 (93.5) Document was easy to 31 28 (90.3) 5 (4, 5) 31 29 (93.5) understand and use Document could shorten 31 31 (100.0) 4 (3, 5) 31 31 (100.0) encounter time with patient Document could increase 30 30 (100.0) 4 (4, 5) 31 31 (100.0) healthcare provider’s overall knowledge Rating the influence of the gained knowledge on the decision to change the provided EMR information onc Patient diagnosis 31 21 (67.7) 2 (1, 2) 31 21 (67.7) Patient prescription drugs or 31 29 (93.5) 2 (2, 3) 31 29 (93.5) therapy Recommendation to discharge 30 19 (63.3) 2 (1, 2) 31 23 (74.2) the patient home Recommendation to admit the 31 22 (71.0) 2 (1, 2) 31 23 (74.2) patient Recommendation to repeat the 28 19 (67.9) 2 (1, 3) 28 21 (75.0) laboratory tests Recommendation to order new 31 27 (87.1) 2 (2, 3) 31 28 (90.3) laboratory tests Recommendation to refer the 31 20 (64.5) 2 (1, 2) 31 24 (77.4) patient Recommendation to transfer the 31 17 (54.8) 2 (1, 2) 31 23 (74.2) patient Overall(for medical decision 244 174 (71.3) 245 192 (78.4) making)
Median rating score n (Q1, Q3)d 5 (5, 5) 5 (4, 5) 4 (3, 5) 5 (4, 5)
2 (1, 3)
2 (1, 3) 2 (1, 2) 2 (1.5, 2.5) 2 (2, 3) 2 (2, 3) 2 (1, 2)
EMC: emergency medical card. CoC: continuity of care. EMR: electronic medical record. Records on the reviewers’ perception of the usefulness of the EMC and CoC report in enhancing CoC). b A 5-point Likert scale was used – 1: strongly disagree, 2: disagree, 3: undecided, 4: agree, 5: strongly agree. The strongly agree, agree, useful, undecided responses were grouped into a “useful” response. c A 3-point Likert scale was used – 1: not useful, 2: somewhat useful, 3: very useful. The very useful and somewhat useful responses were grouped into a “useful” response. d Median rating score (25th quartile, 75th quartile) of the perceived usefulness of the EMC and CoC report in each of the CoC measure. a
Table 3 – Healthcare provider comments on the emergency medical card. Theme
Verbatim commentsa
Misspelling
Meds were grossly misspelled.
Mismatch
Med list should be reflected in health concerns. List of health concerns mean nothing for this pt. Health concerns and medications did not match – I guess this is putting the provider at fault for not adding Gout, HTN, and depression. The only important/likely pertinent health concern for this patient was Hx of sepsis, rest had nothing to do with pt’s planned meds, probs, etc.
Confusing or too complex
A bit confusing.
Little or no information
Not enough information about chief complaint to be able to answer this question. There is no information about the patient’s chief complaint to be able to answer this question. No lab tests included.
Too much information
Too many headers, not very streamlined. Too many headers, condense, no need for country. One line per drug in Rx format, get rid of acute drugs like antibiotics (no need for acute meds like antibiotics).
a
The comments are presented as provided by two physician assistants.
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Table 4 – Healthcare provider comments on the continuity of care report. Theme
Verbatim commenta
Confusing or too complex
Too difficult to review at this time. Meds indicate pt has gout, HTN, depression in addition to listed health concerns – is this up to the provider to add to problem list?
Little or no information
Not enough information about the patient’s chief compliant to answer but no added information was received by the patient modified field. No lab tests included. Best to have a range of BPs (e.g., 2–3 BPs at least), not just one random.
Too much information
Too many headers – no need to delineate address, city, state, zip; home phone could be abbreviated to “h”, work to “w”, cell to “c”, no need for country in listing; headers way too verbose, get rid of acute meds like cough syrup and antibiotics on meds list. Is insurance info really necessary/valid? Does every entry need ‘date of last modified’? Get rid of date of last modification in each category – must streamline this so it is only 1–2 pages per patient. Too complicated, meds to be abbreviated and put into medical lingo. If this is for provider reference 1–2 pages max should be there with concise (per patient so easy to use and worthwhile to sort through), abbreviated information. I have many patients that may be on 5–7 meds and that would take up many pages. Condense meds to Rx format, one line per med, not 5 (med list was horrible, would be better as one line Rx listed instead of 5 lines per med, too disjointed). Get rid of unnecessary vital signs; pulse oximetry should be just pulse, no need for resp rate, temp, PEFR (unless has asthma), get rid of pending appts and condense. No need for temp, RR, PEFR or HC. Get rid of pending appts, resolved allergies (too rare) and past health concerns. Past appts could be just reasons, condense date. More info leads to more questions but improved patient care. Abbreviate height to “HT” and weight to “WT”. Condense past appts to reason/date, + - doctor.
a
The comments are presented as provided by three medical doctors and one physician assistant.
found chief complaint or medical problems information in both documents to be too little, while others believed the contrary. In addition, some reviewers found some information in certain portions of the CoC report to be complex or confusing, while others perceived the same information to be explicit and useful in improving care for patients. Although the study sample size was small, the results suggest that further revision to the EMC and CoC report templates may be helpful to yield more relevant core patient information to effectively support decision making at the point of care. Another important problem which the reviewers identified was the misspelling of medications by patients during entry of their care information. Providing a list of medications (“dropdown”) in the data entry system for patients to select from, would help mitigate the problem by standardizing the process. Also filtering to ensure medications medical problem-specific, in the dropdown list, would mitigate the mismatching of drugs and problems during data entry. Despite the few reviewer-identified issues, the healthcare providers can now have access to up to date patient information to use for effective medical decision making, at the point of care. In addition, the EMC information (which was found by reviewers to be more useful than the CoC report information) is based on both the most current patient-entered data and EMR data instead of using mainly patient-entered data as is currently prevalent in the healthcare systems. It is also important to note that the EMC and CoC report information are not specific to any medical problem(s), healthcare institution or medical specialty. Therefore, the findings of this
research can effectively be applied or generalized to any setting.
6.1.
Study limitations
The number of volunteer MDs and PAs from Intermountain was small. The majority of the healthcare providers contacted declined to participate, stating that they were either too busy with their patients, or they were already involved many other projects. No financial incentive was available for participation in this study, which may also have contributed, in part, to the low participation. Therefore, the sample may not have been completely representative of the entire healthcare provider population at Intermountain. This limitation may have had an effect on some study findings. In addition, unfortunately, we did not ask the reviewers why they perceived the new information in the EMC and CoC report (i.e., primary insurance, blood type, organ donor, dentures, pacemakers, current allergies, current health concerns, and current medication) was useful in decision making at the point of care. Nevertheless, we believe that knowing the new information listed above added significant value in the decision making process. Another important issue to note is the exclusion of nonIntermountain healthcare providers from the study. These healthcare providers were excluded because the data access and use agreement policy did not allow the study data to be analyzed outside of the study area (i.e., the study covered entities at Intermountain and the University of Utah). There-
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fore, it was not feasible to compare the perceptions of the Intermountain and non-Intermountain healthcare providers on the usefulness of the documents. Finally, the policies at Intermountain, on the recruitment of study subjects, only permitted the principal investigator to contact the healthcare providers through the clinical managers at the outpatient clinics. The lack of direct contact with the potential participants may also be a cause of the low recruitment of Intermountain healthcare providers. Due to the small sample size, especially in the sub-analyses within of the CoC measurements, interpretation of their results should be done with caution. However, despite these limitations, the three cases were representative of the patient population since they were randomly selected and the EMCs and CoC reports populated from real patient cases, for use in this study.
7.
Conclusions
The EMC and CoC report are useful vehicles for transporting healthcare information across the healthcare continuum to foster the enhancement of continuity of care. More specifically, the documents were found to be useful in supporting efficient and quality patient healthcare, at the point of care. The healthcare providers can now have access to up to date pertinent patient information to use in effective medical decision making, at the point of care. However, due to the small sample size issue, further studies (with larger samples sizes) are needed to validate the findings.
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Summary points “What was already known on this topic” • Majority of the emergency medical cards (EMCs) are predominantly created using patient-entered data, instead of the patient information in the electronic medical record (EMR). • The quality of patient-entered data has been questioned in the past studies. • The dearth of shareable up to date patient care information at the point of care, among healthcare providers, leads to increased adverse events, increased medical errors, poor patient care and outcome, and increased overall cost of care. • Patients seldom provide, to the (multiple) healthcare providers visited, full history of their current health care status. “What this study added to our knowledge” • The EMC and continuity of care report are useful vehicles for transporting up to date patient information across the healthcare continuum, for effective medical decision making and delivery of efficient and quality patient care, at the point of care. • The availability of shareable up to date patient information among healthcare providers, at the point of care, has the potential to significantly reduce the overall coast of care.
Authors’ contributions C. Olola conceived and designed the study, and conducted the acquisition, analysis and interpretation of the data, and drafted the article. R.S. Evans, S. Narus, J. Narus, M. Poynton, J. Hales, and B. Rowan reviewed the study designs. H. LeSieur, C. Zumbrennen, A.A. Edwards, R. Crawford, S. Amandsen, Y. Kabir, J. Atkin, C. Nnewberry, J. Young, T. Hanifi, B. Risenmay and T. Sorensen reviewed all the study cases, completed the survey and reviewed the manuscript. BR also participated in the acquisition of data. All the authors revised the article critically for important intellectual content, and provided final approval of the version for publication. R.S. Evans and B. Rowan supervised this research.
Conflict of interest statement There is no conflict of interest to declare, except that Heather LeSieur, Cynthia Zumbrennen, Annemarie A. Edwards, and Robert Crawford, who participated in the case reviews, are employees of Intermountain Healthcare.
Study approval The study was approved by the Intermountain and University of Utah Institutional Review Boards and conducted from April to July 2009.
Acknowledgments The authors would like to thank the Clinical Managers at Intermountain’s outpatient clinics for their efforts in helping to recruit healthcare providers and for logistical coordination at their facilities. We are truly grateful to all the healthcare providers for invaluable sacrifice in sparing time out of their tight professional schedules to review the study cases. Large teams of database, network and security, information systems and administrative personnel at Intermountain were very crucial in setting up access to the enterprise data warehouse/clinical data repository and network connectivity. We, therefore, salute the following individuals/groups in this regard: Lee Pierce, Chuck Lyon, John Hess, Jose Milla, Len Bowes, the ISSA team, and the Perimeter team. Acknowledgement would not be complete without registering our gratitude to the My Health web portal team (Traci Hastings, Matthew Smith, Babara Gutke) for their invaluable contribution in the coordination of the management and configuration of connections to EMC databases.
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[2] W.J. Crerand, J. Lamb, V. Rulon, B. Karal, J. Mardekian, Building data quality into clinical trials, J. AHIMA 73 (10) (2002) 44–46, 48–53. [3] Institute of Medicine (IOM) – Committee on quality of health care in America, Crossing the Quality Chasm: A New Health System for the 21st Century, National Academy Press, Washington DC, 2001. [4] L.T. Kohn, J.M. Corrigan, M.S. Donaldson, in: Committee on Quality of Health Care in America IOM (Ed.), To Err is Human: Building a Safer Health System. Shaping the Future for Health, National Academy of Sciences, Washington DC, 2000. [5] D.W. Bates, A.A. Gawande, Improving safety with information technology, N. Engl. J. Med. 348 (2003) 2526–2534. [6] P.A. Nutting, M.A. Goodwin, S.A. Flocke, S.J. Zyzanski, K.C. Stange, Continuity of primary care: to whom does it matter and when? Ann. Fam. Med. 1 (3) (2003) 149–155. [7] T.S. Lesar, L. Briceland, D.S. Stein, Factors related to errors in medication prescribing, JAMA 277 (4) (1997) 312–317. [8] D.W. Bates, Preventing medication errors: a summary, Am. J. Health. Syst. Pharm. 64 (14 (Suppl. 9)) (2007) S3–S9, quiz S24-S26. Erratum in: Am. J. Health Syst. Pharm. 64 (16) (2007) 1678. [9] C. Moore, J. Wisnivesky, S. Williams, T. McGinn, Medical errors related to discontinuity of care from an inpatient to an outpatient setting, J. Gen. Intern. Med. 18 (8) (2003) 646–651. [10] R. Haux, P. Knaup, F. Leiner, On educating about medical data management – the other side of the electronic health record, Methods Inf. Med. 46 (1) (2007) 74–79. [11] S.M. Shortell, Continuity of medical care: conceptualization and measurement, Med. Care 14 (5) (1976) 377–391. [12] P.W. Moorman, P.J. Branger, W.J. van der Kam, J. van der Lei, Electronic messaging between primary and secondary care: a four-year case report, J. Am. Med. Inform. Assoc. 8 (4) (2001) 372–378. [13] H. Grain, Changes in doctor–patient relationships for realizing the personal health paradigm, Stud. Health Technol. Inform. 137 (2008) 373–378. [14] C. van Walraven, M. Mamdani, J. Fang, P.C. Austin, Continuity of care and patient outcomes after hospital discharge, J. Gen. Intern. Med. 19 (6) (2004) 624–631.
[15] M. Fieschi, J.C. Dufour, P. Staccini, J. Gouvernet, O. Bouhaddou, Medical decision support systems: old dilemmas and new paradigms? Methods Inf. Med. 42 (3) (2003) 190–198. [16] S.E. Ross, C.T. Lin, The effects of promoting patient access to medical records: a review, J. Am. Med. Inform. Assoc. 10 (2003) 129–138. [17] A. Golodetz, J. Ruess, L.M. Raymond, The right to know: giving the patient his medical record, Arch. Phys. Med. Rehabil. 57 (2) (1976) 78–81. [18] R.J. Mageean, Study of “discharge communications” from hospital, Br. Med. J. (Clin. Res. Ed.) 293 (6557) (1986) 1283–1284. [19] W.J. van der Kam, P.W. Moorman, M.J. Koppejan-Mulder, Effects of electronic communication in general practice, Int. J. Med. Inform. 60 (1) (2000) 59–70. [20] D. Litaker, C. Ritter, S. Ober, D. Aron, Continuity of care and cardiovascular risk factor management: does care by a single clinician add to informational continuity provided by electronic medical records? Am. J. Manage. Care 11 (11) (2005) 689–696. [21] K.A. Kuhn, D.A. Giuse, From hospital information systems to health information systems. Problems, challenges, perspectives, Methods Inf. Med. 40 (4) (2001) 275–287. [22] C. Machan, E. Ammenwerth, T. Schabetsberger, Evaluation of the electronic transmission of medical findings from hospitals to practitioners by triangulation, Methods Inf. Med. 45 (2) (2006) 225–233. [23] Healthcare Information and Management Systems Society (HIMSS) and HIMSS AnalyticsTM , Annual Report of the U.S. Hospital IT Market., HIMSS, 2006 (accessed 11.06.10) www.himss.org/DorenfestInstitute/docs/HIMSS 06AR KEYLINE k2.pdf. [24] E.S. Hing, C.W. Burt, D.A. Woodwell, Electronic medical record use by office-based physicians and their practices: United States, 2006, Adv. Data 393 (2007) 1–7. [25] American Standard for Testing and Materials (ASTM): E2369-05 Standard Specification for Continuity of Care Record (CCR). ASTM International, West Conshohocken, PA, 17 July, 2006. [26] C.H.O. Olola, B. Rowan, S. Narus, M. Smith, T. Hastings, M. Poynton, J. Nebeker, J. Hales, R.S. Evans, Implementation of emergency medical card and continuity of care report for continuity of care, Methods Inf. Med. 48 (6) (2009) 519–530.
journal homepage: www.intl.elsevierhealth.com/journals/ijmi
The perception of medical professionals and medical students on the usefulness of an emergency medical card and a continuity of care report in enhancing continuity of care Christopher H.O. Olola a,∗ , Scott Narus a , Jonathan Nebeker c , Mollie Poynton a,d , Joseph Hales a,b , Belle Rowan b , Heather LeSieur b , Cynthia Zumbrennen b , Annemarie A. Edwards b , Robert Crawford b , Spencer Amundsen e , Yasmin Kabir e , Joseph Atkin e , Cynthia Newberry e , Jason Young e , Tariq Hanifi e , Ben Risenmay e , Tyler Sorensen e , R. Scott Evans a,b a
University of Utah, Department of Biomedical Informatics, 20 South 2600 East, Salt Lake City, UT 84112, USA Intermountain Healthcare, Salt Lake City, UT, USA c Veterans Affairs (VA) Hospital, Salt Lake City, UT, USA d College of Nursing, University of Utah, Salt Lake City, UT, USA e University of Utah, School of Medicine, Salt Lake City, UT, USA b
a r t i c l e
i n f o
a b s t r a c t
Article history:
Objectives: To evaluate the medical professionals and medical students perceived usefulness
Received 18 June 2010
of an emergency medical card (EMC) and a continuity of care (CoC) report, in enhancing CoC.
Received in revised form
Methods: The study reviewers included medical professionals from outpatient clinics at Inter-
16 February 2011
mountain Healthcare and fourth-year medical students from the University of Utah. Three
Accepted 16 February 2011
cases we randomly extracted from a database of patients who had added new care information at the time. EMCs and CoC reports were populated for the cases, and information then de-identified. Using patient information in the electronic medical record (EMR), reviewers
Keywords:
evaluated if the EMR information was adequate to support medical decisions made on the
Emergency medical card
patient’s diagnosis, medications, laboratory tests, and disposition. The reviewer assessed
Continuity of care report
if the EMC and CoC report information would influence the medical decisions made. An
Continuity of patient care
online survey was used to assess the reviewers’ perception on the usefulness of the two
Emergency medical services
documents.
Continuity of care record
Results: On average, 94% of the reviewers perceived the EMC to be useful in enhancing medical decision making at the point of care, and 74% found the CoC report to be useful. More specifically, the two documents were found to be useful in decreasing encounter time (100% each), increasing overall knowledge of healthcare providers (100% each), influencing decision on the treatment (94% each), and new laboratory test orders (87% and 90%, respectively).
∗
Corresponding author. Tel.: +1 801 581 4080; fax: +1 801 581 4297. E-mail address: c [email protected] (C.H.O. Olola). 1386-5056/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2011.02.007
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Conclusions: The EMC and CoC report were found to be useful methods for transporting patient healthcare information across the healthcare continuum. The documents were found more specifically to be useful for effective decision making, improving efficiency and quality of care, at the point of care. © 2011 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Healthcare providers require immediate access to reliable patient health information for appropriate medical decision making [1–3]. The dearth of such information may lead to medical errors, adverse events, poor patient safety and outcome, and increased overall cost of care [4–8]. It has been reported that between 44,000 and 98,000 Americans die annually from medical errors and related adverse events, many of which occur as a result of poor quality data [4,9]. Therefore, patient data needs to be managed in a way that makes them of sufficient quality for their intended use [10] and timely available across the healthcare continuum [11]. Availability of the patient’s right information at the right time, at the right place, to the right person, in the right form, is increasingly difficult and challenging. This is because of the slow adoption of the information presentation and data standards, the increasing volume of patient information, lack universal unique patient identifiers, and patients seeking medical care from multiple healthcare providers [10,12]. The availability of patient information at the point of care can be improved by enhancing continuity of care (CoC). A study by Grain [13] showed that patients did not always provide a complete history or description of current health status to multiple healthcare providers they visited. Patients assumed that their health information was transferred among the healthcare providers, which did not always happen. During medical emergencies, patients seldom see the same hospital or community physicians who previously treated them [5,14]. This results in problems associated with discontinuity of care, which increases with multiple healthcare providers seen and increased number of encounters [5]. Patients play a vital role in sharing knowledge of their healthcare history and in the medical decision making process [13,15]. Granting patients access to their medical records through personal health records enhances their communication with healthcare providers, increases knowledge of health status, and helps patients to identify and notify healthcare providers of possible errors in their medical records [3,16,17]. It is, therefore, critical that patients have access to adequate and effective data monitoring and communication mechanisms with their healthcare providers. Sharing of patient information by mail (e.g., via discharge letters) has been a traditional method for many years, but it has proved to be slow, inefficient and erroneous, and can potentially lead to poor quality of patient care [12,18,19]. A better technique is the adoption of an electronic medical record (EMR), which can enable multiple healthcare providers treating the same patient to efficiently share and use the patient’s health information [20–22]. However, it has been reported that only approximately 17–20% of
outpatient settings in the US have comprehensive EMR systems, i.e., computerized physician order entry, computerized laboratory tests ordering and results reporting, and computerized clinical notes [23,24]. It is also the case that most EMRs do not utilize common standards for recording and sharing information. Most communities also lack a health information exchange infrastructure for electronically sharing pertinent patient data. This situation impedes sharing of patient data for CoC. Even in cases where EMR data can be shared between healthcare providers, the data may contain errors or omissions that need to be fixed. Patients are potentially excellent sources of quality control for their records, but direct patient access to information with an ability to provide corrections and/or annotations is rarely available. Therefore, there is an urgent need for techniques that facilitate communication and sharing of quality patient information for decision making while full implementation and adoption of EMR systems continue.
2.
Background
Intermountain Healthcare (“Intermountain”) implemented a Continuity of Care Record (CCR) standard [25] compliant application (“CCR application”) whose design and implementation details were described previously [26]. The application enables patients to view healthcare provider-entered data in the EMR and enter and modify their data from visits to non-Intermountain healthcare providers. Only the patient information that had been integrated in the central clinical data repository (CDR) was available in the EMR for patients to use to create the EMC and continuity of care report. By the time of this study, the social history, family history, immunization, emergency contacts, and personal notes information was not available in the CDR. In addition, the new information that patients either added or obtained from visits to non-Intermountain healthcare providers, were not available in the EMR. The missing information included primary insurance, blood type, organ donor, dentures, pacemakers, current allergies, current health concerns, and current medication. Therefore, the patients entered these pieces of information into the CCR application database. The application users created an emergency medical card (EMC) for use during medical emergencies and a CoC report for their healthcare providers to use in updating EMR information. The CoC report is a full EMR report. It contains both the current and past three months’ patient-entered data and healthcare providerentered data (in two distinct columns) in compliance with the data elements mandated by the CCR standard. The data includes the patient and document identifiers, document pur-
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pose and date, problems, allergies, family and social history, medications, immunization, vital signs, laboratory tests and results, procedures, advance directives, care documentation and care plan, and healthcare providers. The patient-entered new/current data on the CoC report is used by healthcare providers to correct possible errors or to complete missing patient information in the healthcare provider-entered data in the EMR. The EMC, however, contains a portion of the CoC report information. It contains only the most current core patient-entered data using the CCR application and healthcare provider-entered data in the EMR. The EMC data includes the patient identifiers, demographic, insurance/financial, current problems, current medications, active allergies, blood group, advance directives, contact lenses, religious preference, and pacemaker information. The EMC was designed to provide the core patient information to healthcare providers for appropriate medical decision during medical emergencies. This approach allows for a distinction between healthcare provider-reviewed information and patient corrections and annotations, and a means for patients to provide a quality review of their data.
3.
Objectives
The primary objective of the study was to evaluate the medical professionals (medical doctors and physician assistants) and medical students perceived usefulness on an emergency medical card and a CoC report in enhancing continuity of care, at the point of care.
4.
Methods
4.1.
Setting and participants
The study reviewers included healthcare professionals (three MDs and two PAs) from outpatient clinics at Intermountain and fourth-year medical students from the University of Utah, School of Medicine. Clinic Managers at the Intermountain’s outpatient clinics contacted twelve medical professionals and provided them with a summary of the study and requested them to participate in the study. Five (41.2%) healthcare professionals accepted to participate in the study. The study principal investigator (CO) contacted thirteen fourth-year medical students and eight (61.5%) accepted to participate in the study. The overall response rate was 52.0%. The inclusion of the medical students was to enable the investigators to assess if there would be any significant differences between the ratings of the EMC and CoC report by type of reviewer. The fourth-year medical students were chosen because they were believed to be adequately advanced in their medical career to professionally review the study cases. An attempt to recruit senior residents was fruitless – apparently because of their heavy workload. At one month, a follow-up email was sent to non-responders, followed by a second email two weeks later. A package with detailed study evaluation information was then sent to all the responders who accepted to participate in the study.
4.2.
Study cases
Cases of patients who had added new information (i.e., information from visits to healthcare providers outside of the Intermountain network or information on possible errors that patients identified in their records in the EMR) were extracted from the database of all the patients in the project at the time. Three cases were then randomly selected from the resulting database by using a random number generator [Intercooled STATA software, Release 9, StataCorp. 2007; College Station, TX, USA]. We de-identified the information in the three cases by disguising the patient identifying information such as name, date of birth, gender, contacts, healthcare provider details, and insurance/financial information. We then populated, for each case, a CoC report (which also contained EMR information, displayed side-by-side with patient-entered data) and an EMC.
4.3.
Case review process
Each reviewer assessed the three study cases using the patients’ EMR, EMC, and CoC report information (Fig. 1). The review started by the assessment of each case using the patient EMR information. In this assessment, the reviewer evaluated if the EMR information was adequate to support the medical decisions that were made (as stipulated in the EMR) on the patient’s diagnosis, therapy or medications, laboratory tests, and disposition (i.e., admission, discharge home, referral or transfer to other healthcare providers). The reviewer then assessed if the patient corresponding EMC or CoC report information would have any added value to the medical decision previously made using EMR information. For example, was there any additional information in the EMC or CoC report (that was missing in the EMR) which would be useful in influencing the decision making? Finally, each reviewer completed an online survey developed using Opinio software [ObjectPlanet, Inc. 2008. Øvre Slottsgate 5, 0157 Oslo, Norway] to record their perceptions on the usefulness of the EMC and CoC report information, in enhancing CoC. A provision was also made in the survey for the reviewers to comment on the survey measurements and make recommendations for the improvement of the EMC and CoC report.
4.4.
Data analysis
STATA software [Intercooled STATA software, Release 9, StataCorp. 2007; College Station, TX, USA] was used for data analysis. We characterized the usefulness of EMC and CoC report by the reviewer gender, profession, age, and medical professional’s years of job experience. We also tabulated the ratings of the usefulness of the two documents, while categorizing by various CoC measures. We grouped the reviewers’ comments into five themes. The themes included misspelled, mismatched, confusing or complex, little/no, and too much information. We then analyzed the comments, stratifying by theme.
5.
Results
On average, 94% of the reviewers perceived the EMC to be useful in enhancing CoC, and 74% found the CoC report to
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Fig. 1 – A flow diagram of the study case review process.
be useful (Table 1). More male reviewers found the EMC and the CoC report to be useful (100% vs. 88% and 80% vs. 69%, respectively). All the medical students were age 18–30 years and all of them found the EMC to be useful. A majority 83% of the medical students perceived the CoC report to be useful. Similarly, all the medical professionals age 18–30 years, 41–50 years and 51–60 years found the EMC to be useful. Only 50% of the medical professionals age 31–40 years perceived the CoC report to be useful. There was no significant difference in the years of job experience between the medical professionals who perceived the documents to be useful and those who did not.
Overall, a high percentage of the reviewers found the EMC and the CoC report to be legible, and easy to understand and use (92% and 94%, respectively) (Table 2). In addition, the EMC and CoC report were found, generally, to be useful in influencing medical decision making at the point of care (71% and 78%, respectively). More specifically, the EMC and CoC report were perceived to be useful in influencing decision on medications/treatment (94% each), and ordering of new laboratory tests (87% and 90%, respectively). The documents were found also to be a potential resource to shorten encounter time and to increase the healthcare provider’s overall knowledge (100% each).
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Table 1 – Characteristics of the reviewers and perceived usefulness of the EMC and CoC report. Continuity of care measure Sex Female Male Profession MD/PA Medical students Age of Reviewers (years) MD/PA 18–30 31–40 41–50 51–60 Medical students 18–30 31–40 41–50 51–60 Job experience (years) – MD/PA
na
EMC usefulness: n (%) (average 93.5%)
CoC report usefulness: n (%) (average 74.2%)
16 15
14 (87.5) 15 (100.0)
11 (68.8) 12 (80.0)
13 18
11 (84.6) 18 (100.0)
8 (61.5) 15 (83.3)
3 4 3 3
3 (100.0) 2 (50.0) 3 (100.0) 3 (100.0)
3 (100.0) 3 (75.0) 0 (0) 2 (66.7)
18 0 0 0 13
18 (100.0) – – – 11 (11.1 ± 6.3)b 2 (10.0 ± 0.0)c
15 (83.3) – – – 8 (11.3 ± 6.1)b 5 (12.3 ± 6.7)c
EMC: emergency medical card. CoC: continuity of care. MD: medical doctor. PA: physician assistant. –: there were no reviewers in these categories. Number of records reviewed – not all reviewers assessed all the three cases (which would have resulted in a total of 39 records for each CoC measure). Since the review process was anonymous, we could not know who didn’t review all the 3 cases assigned to them. b Mean ± Standard deviation of job experience (where the tool was perceived to be useful). c Mean ± Standard deviation of job experience (where the tool was perceived not to be useful). a
The reviewers provided useful comments or suggestions on how the EMC and CoC report’s templates could be improved to ensure the availability of pertinent patient care information for effective medical decision making, at the point of care (Tables 3 and 4). The reviewers found that patients were likely to misspell medications and to list them under the wrong medical problems. The reviewers also recommended that section headers, medications, and demographics (e.g., address, and phone numbers) in the EMC and the CoC report should be abbreviated and/or condensed. More information on medical problems was recommended to adequately support effective decision making. In addition, one medical doctor seemed to have found the information in both documents to be complex or confusing. On contrary, one doctor found the information in the documents to be adequate for the provision of improved healthcare to patients, at the point of care. More specifically, a number of reviewers perceived the information in the CoC report to be too much (an “overkill”) for medical decision making (Table 4). Therefore, the information should be further condensed to a maximum of one to two pages per patient. Some reviewers suggested that the vital signs, insurance, pending appointments, resolved allergies, and past medical problems should be eliminated. On contrary, some other reviewers suggested that the same information should not be eliminated but rather condensed.
6.
Discussion
Overall, the information in the EMC and CoC report was well perceived by the medical professionals and medical students to be useful in enhancing CoC, at the point of care. More specif-
ically, the information was found to be much more useful in increasing the overall knowledge of healthcare providers, decreasing encounter time, and overall, have significant influence on the medical decision making process e.g., treatment or medication and new laboratory test orders. Interestingly, a majority of reviewers, irrespective of their profession, age, and years of job experience, found the EMC to be more useful than the CoC report. This may mean that healthcare providers are more likely to prefer condensed or summarized patient care information for effective medical decision making. However, healthcare provider perception of the usefulness of the information in the two documents may vary significantly by gender–male healthcare providers are more likely to find the information useful. Overall, there was statistically significant difference in the way the healthcare professionals and medical students perceived the usefulness of the EMC and CoC report. A significant difference would definitely trigger a need for further research to investigate reasons why difference exists. Therefore, these findings suggest that the medical professionals and/or senior medical students (e.g., fourth-year students) could effectively be involved in such evaluation studies, as long as they are appropriately randomized and matched by gender. Although the information in the two documents was of small font size, approximately 95% of the reviewers perceived that healthcare providers are likely to find the information legible, and easy to understand and use. However, despite the high percentage of agreement on the usefulness of the documents, the reviewers suggested further modifications to improve the information presentation. Apparently, there was no unanimous consensus among the reviewers on what information should be condensed or summarized, or eliminated from the EMC and CoC report. For example, some reviewers
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Table 2 – Reviewer-perceived usefulness of the EMC and CoC report, categorized by the continuity of care measurements. Continuity of care measure
EMC na
Usefulness n (%)
CoC report Median rating score na (Q1, Q3)d
Usefulness n (%)
Using the documentb Document was legible 31 29 (93.5) 5 (4, 5) 31 29 (93.5) Document was easy to 31 28 (90.3) 5 (4, 5) 31 29 (93.5) understand and use Document could shorten 31 31 (100.0) 4 (3, 5) 31 31 (100.0) encounter time with patient Document could increase 30 30 (100.0) 4 (4, 5) 31 31 (100.0) healthcare provider’s overall knowledge Rating the influence of the gained knowledge on the decision to change the provided EMR information onc Patient diagnosis 31 21 (67.7) 2 (1, 2) 31 21 (67.7) Patient prescription drugs or 31 29 (93.5) 2 (2, 3) 31 29 (93.5) therapy Recommendation to discharge 30 19 (63.3) 2 (1, 2) 31 23 (74.2) the patient home Recommendation to admit the 31 22 (71.0) 2 (1, 2) 31 23 (74.2) patient Recommendation to repeat the 28 19 (67.9) 2 (1, 3) 28 21 (75.0) laboratory tests Recommendation to order new 31 27 (87.1) 2 (2, 3) 31 28 (90.3) laboratory tests Recommendation to refer the 31 20 (64.5) 2 (1, 2) 31 24 (77.4) patient Recommendation to transfer the 31 17 (54.8) 2 (1, 2) 31 23 (74.2) patient Overall(for medical decision 244 174 (71.3) 245 192 (78.4) making)
Median rating score n (Q1, Q3)d 5 (5, 5) 5 (4, 5) 4 (3, 5) 5 (4, 5)
2 (1, 3)
2 (1, 3) 2 (1, 2) 2 (1.5, 2.5) 2 (2, 3) 2 (2, 3) 2 (1, 2)
EMC: emergency medical card. CoC: continuity of care. EMR: electronic medical record. Records on the reviewers’ perception of the usefulness of the EMC and CoC report in enhancing CoC). b A 5-point Likert scale was used – 1: strongly disagree, 2: disagree, 3: undecided, 4: agree, 5: strongly agree. The strongly agree, agree, useful, undecided responses were grouped into a “useful” response. c A 3-point Likert scale was used – 1: not useful, 2: somewhat useful, 3: very useful. The very useful and somewhat useful responses were grouped into a “useful” response. d Median rating score (25th quartile, 75th quartile) of the perceived usefulness of the EMC and CoC report in each of the CoC measure. a
Table 3 – Healthcare provider comments on the emergency medical card. Theme
Verbatim commentsa
Misspelling
Meds were grossly misspelled.
Mismatch
Med list should be reflected in health concerns. List of health concerns mean nothing for this pt. Health concerns and medications did not match – I guess this is putting the provider at fault for not adding Gout, HTN, and depression. The only important/likely pertinent health concern for this patient was Hx of sepsis, rest had nothing to do with pt’s planned meds, probs, etc.
Confusing or too complex
A bit confusing.
Little or no information
Not enough information about chief complaint to be able to answer this question. There is no information about the patient’s chief complaint to be able to answer this question. No lab tests included.
Too much information
Too many headers, not very streamlined. Too many headers, condense, no need for country. One line per drug in Rx format, get rid of acute drugs like antibiotics (no need for acute meds like antibiotics).
a
The comments are presented as provided by two physician assistants.
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Table 4 – Healthcare provider comments on the continuity of care report. Theme
Verbatim commenta
Confusing or too complex
Too difficult to review at this time. Meds indicate pt has gout, HTN, depression in addition to listed health concerns – is this up to the provider to add to problem list?
Little or no information
Not enough information about the patient’s chief compliant to answer but no added information was received by the patient modified field. No lab tests included. Best to have a range of BPs (e.g., 2–3 BPs at least), not just one random.
Too much information
Too many headers – no need to delineate address, city, state, zip; home phone could be abbreviated to “h”, work to “w”, cell to “c”, no need for country in listing; headers way too verbose, get rid of acute meds like cough syrup and antibiotics on meds list. Is insurance info really necessary/valid? Does every entry need ‘date of last modified’? Get rid of date of last modification in each category – must streamline this so it is only 1–2 pages per patient. Too complicated, meds to be abbreviated and put into medical lingo. If this is for provider reference 1–2 pages max should be there with concise (per patient so easy to use and worthwhile to sort through), abbreviated information. I have many patients that may be on 5–7 meds and that would take up many pages. Condense meds to Rx format, one line per med, not 5 (med list was horrible, would be better as one line Rx listed instead of 5 lines per med, too disjointed). Get rid of unnecessary vital signs; pulse oximetry should be just pulse, no need for resp rate, temp, PEFR (unless has asthma), get rid of pending appts and condense. No need for temp, RR, PEFR or HC. Get rid of pending appts, resolved allergies (too rare) and past health concerns. Past appts could be just reasons, condense date. More info leads to more questions but improved patient care. Abbreviate height to “HT” and weight to “WT”. Condense past appts to reason/date, + - doctor.
a
The comments are presented as provided by three medical doctors and one physician assistant.
found chief complaint or medical problems information in both documents to be too little, while others believed the contrary. In addition, some reviewers found some information in certain portions of the CoC report to be complex or confusing, while others perceived the same information to be explicit and useful in improving care for patients. Although the study sample size was small, the results suggest that further revision to the EMC and CoC report templates may be helpful to yield more relevant core patient information to effectively support decision making at the point of care. Another important problem which the reviewers identified was the misspelling of medications by patients during entry of their care information. Providing a list of medications (“dropdown”) in the data entry system for patients to select from, would help mitigate the problem by standardizing the process. Also filtering to ensure medications medical problem-specific, in the dropdown list, would mitigate the mismatching of drugs and problems during data entry. Despite the few reviewer-identified issues, the healthcare providers can now have access to up to date patient information to use for effective medical decision making, at the point of care. In addition, the EMC information (which was found by reviewers to be more useful than the CoC report information) is based on both the most current patient-entered data and EMR data instead of using mainly patient-entered data as is currently prevalent in the healthcare systems. It is also important to note that the EMC and CoC report information are not specific to any medical problem(s), healthcare institution or medical specialty. Therefore, the findings of this
research can effectively be applied or generalized to any setting.
6.1.
Study limitations
The number of volunteer MDs and PAs from Intermountain was small. The majority of the healthcare providers contacted declined to participate, stating that they were either too busy with their patients, or they were already involved many other projects. No financial incentive was available for participation in this study, which may also have contributed, in part, to the low participation. Therefore, the sample may not have been completely representative of the entire healthcare provider population at Intermountain. This limitation may have had an effect on some study findings. In addition, unfortunately, we did not ask the reviewers why they perceived the new information in the EMC and CoC report (i.e., primary insurance, blood type, organ donor, dentures, pacemakers, current allergies, current health concerns, and current medication) was useful in decision making at the point of care. Nevertheless, we believe that knowing the new information listed above added significant value in the decision making process. Another important issue to note is the exclusion of nonIntermountain healthcare providers from the study. These healthcare providers were excluded because the data access and use agreement policy did not allow the study data to be analyzed outside of the study area (i.e., the study covered entities at Intermountain and the University of Utah). There-
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fore, it was not feasible to compare the perceptions of the Intermountain and non-Intermountain healthcare providers on the usefulness of the documents. Finally, the policies at Intermountain, on the recruitment of study subjects, only permitted the principal investigator to contact the healthcare providers through the clinical managers at the outpatient clinics. The lack of direct contact with the potential participants may also be a cause of the low recruitment of Intermountain healthcare providers. Due to the small sample size, especially in the sub-analyses within of the CoC measurements, interpretation of their results should be done with caution. However, despite these limitations, the three cases were representative of the patient population since they were randomly selected and the EMCs and CoC reports populated from real patient cases, for use in this study.
7.
Conclusions
The EMC and CoC report are useful vehicles for transporting healthcare information across the healthcare continuum to foster the enhancement of continuity of care. More specifically, the documents were found to be useful in supporting efficient and quality patient healthcare, at the point of care. The healthcare providers can now have access to up to date pertinent patient information to use in effective medical decision making, at the point of care. However, due to the small sample size issue, further studies (with larger samples sizes) are needed to validate the findings.
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Summary points “What was already known on this topic” • Majority of the emergency medical cards (EMCs) are predominantly created using patient-entered data, instead of the patient information in the electronic medical record (EMR). • The quality of patient-entered data has been questioned in the past studies. • The dearth of shareable up to date patient care information at the point of care, among healthcare providers, leads to increased adverse events, increased medical errors, poor patient care and outcome, and increased overall cost of care. • Patients seldom provide, to the (multiple) healthcare providers visited, full history of their current health care status. “What this study added to our knowledge” • The EMC and continuity of care report are useful vehicles for transporting up to date patient information across the healthcare continuum, for effective medical decision making and delivery of efficient and quality patient care, at the point of care. • The availability of shareable up to date patient information among healthcare providers, at the point of care, has the potential to significantly reduce the overall coast of care.
Authors’ contributions C. Olola conceived and designed the study, and conducted the acquisition, analysis and interpretation of the data, and drafted the article. R.S. Evans, S. Narus, J. Narus, M. Poynton, J. Hales, and B. Rowan reviewed the study designs. H. LeSieur, C. Zumbrennen, A.A. Edwards, R. Crawford, S. Amandsen, Y. Kabir, J. Atkin, C. Nnewberry, J. Young, T. Hanifi, B. Risenmay and T. Sorensen reviewed all the study cases, completed the survey and reviewed the manuscript. BR also participated in the acquisition of data. All the authors revised the article critically for important intellectual content, and provided final approval of the version for publication. R.S. Evans and B. Rowan supervised this research.
Conflict of interest statement There is no conflict of interest to declare, except that Heather LeSieur, Cynthia Zumbrennen, Annemarie A. Edwards, and Robert Crawford, who participated in the case reviews, are employees of Intermountain Healthcare.
Study approval The study was approved by the Intermountain and University of Utah Institutional Review Boards and conducted from April to July 2009.
Acknowledgments The authors would like to thank the Clinical Managers at Intermountain’s outpatient clinics for their efforts in helping to recruit healthcare providers and for logistical coordination at their facilities. We are truly grateful to all the healthcare providers for invaluable sacrifice in sparing time out of their tight professional schedules to review the study cases. Large teams of database, network and security, information systems and administrative personnel at Intermountain were very crucial in setting up access to the enterprise data warehouse/clinical data repository and network connectivity. We, therefore, salute the following individuals/groups in this regard: Lee Pierce, Chuck Lyon, John Hess, Jose Milla, Len Bowes, the ISSA team, and the Perimeter team. Acknowledgement would not be complete without registering our gratitude to the My Health web portal team (Traci Hastings, Matthew Smith, Babara Gutke) for their invaluable contribution in the coordination of the management and configuration of connections to EMC databases.
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