Exploitation of Electronic Medical Records Data in Primary Health Care

Resistances and Solutions

Study in Eight Walloon Health Care Centres

Brussels, 22nd MIC Congress, november 25, 2004

Prof. Marc VANMEERBEEKDept. of General Practice, University of LiegeFrench-speaking Federation of Medical Houses

Structured electronic medical record (EMR) for each patient

To follow his storyGiving him the most appropriated careClinical database Local use: quality of care

improvement, a new deal for GP’s Regional use: epidemiology, research,

teaching

Belgian « Medical Houses »

Multidisciplinary teamsPrimary health careSelf management

Development of EMR for 10 yearsDevelopment of quality assessment programs for 9 years

Promotion of EMR since 2001

Reflection ForumPaper in « Santé conjuguée »Personalized teams meetings Clinical sofware PRICARE free of chargeSoftware use training, by profession (31 teams, 73 participants) Target : 60 teams, 407 workers (doctors, nurses, physiotherapists)

3 years after

The use of EMR seems to remain very slight

The quality of some collected data is very insufficient in the sight of what could be done

2 Objectives

To assess of indicators of the present use of the FMH’s EMR

To define, with the participation of users, the content of an action program for Medical Houses, with having in mind the removing of the resistances to the data collection in Primary Care through the use of EMR

Methods

Target

8 Walloons teams who , at their demand, had enjoyed in 2002-2003 actions of promotion of the use of EMR 4 reference teams

Comparison with the measures of Okkes et al. for the doctors.

Okkes IM et al. The role of family practice in different health care systems: a comparison of reasons for encounter, diagnoses, and interventions in primary care populations in the Netherlands, Japan, Poland, and the United States. J Fam Pract. 2002.51(Jan):72-3

Quantitative measuresUse of EMR : indicators

Minimal frequency of use: at least 1 episode/year

Intensivity of use: new episodes/patient/year

Use during consultations: ratio sub-contacts/acts

Qualitative AnalysisNominal groups: per team

Providing each participant with an equal voiceAll participants write the answers they feel are most importantDevelop a master list of issuesRequest that each participant rank the top five issues Tally the results by adding the points for each issueDiscuss the results and generate a final ranked list for action planning

“How can we beat the present blockings to valorise the data our EMR can contain ?”

Results

Use of EMR : clinical data

Nr TeamPopulation at 12/31/03

New episodes in

2003

Patients concerned by those episodes

Proport. patients with min. 1 episode

Episode per

patient

Total contacts

2003

1 2452 8 3 0,12% 2,67 24192

2 1856 73 59 3,49% 1,24 12700

3 3850 427 282 7,63% 1,51 37997

4 1196 1561 574 61,46% 2,72 7042

5 2163 221 174 9,16% 1,27 14061

6 953 1263 462 49,04% 2,73 7310

7 1373 5008 1247 96,37% 4,02 7516

8 3388 474 363 11,99% 1,31 22656

REF1 2983 5146 2236 79,07% 2,30 28191

REF2 778 2264 593 92,08% 3,82 3780

REF3 1935 3657 1404 78,09% 2,60 14163

REF4 1087 3456 959 95,52% 3,60 8426

Okkes 1,3 à 2,5

Sub-contacts / acts

Doctors Physiotherapists Nurses

Nr Team Sub-contacts

Acts Ratio contacts/acts

Sub-contacts

Acts Ratio contacts/acts

Sub-contacts

Acts Ratio contacts

/acts

1 0 15121 0 0 3776 0 0 5295 0

2 123 9959 0,01 0 1226 0 0 1382 0

3 57 24234 0 12 6519 0 0 6813 0

4 0 5394 0 0 1611 0 0 37 0

5 62 8893 0,01 1 2686 0 5 2392 0

6 0 5404 0 0 1085 0 0 797 0

7 11408 5638 2,02 635 1252 0,51 197 626 0,31

8 883 14598 0 3945 4411 0,89 0 3005 0

REF1 10507 17595 0,6 2205 6182 0,36 0 4414 0

REF2 5534 3020 1,83 5 582 0,01 1 178 0,01

REF3 10890 8299 1,31 4313 3251 1,33 731 1515 0,48

REF4 13238 4938 2,68 620 1662 0,37 1534 1826 0,84

Okkes 1,1-1,7

3 years of hard work leads to…

1/8 team: high frequency of use2/8 teams: « rising users »5/8 teams: occasional use or isolated users

Why ?

Results: 5 categories of items

Ethics Training Search for sense Practice Multidisciplinarity

Items split rather differently according to the teams

Nr Team   1 2 3 4 5 6 7 8

Proportion of verbatims

Ethics 0,0%

4,5%

29,2%

12,5%

4,2%

0,0%

5,0%

3,4%

Training 30,8%

9,1%

12,5%

12,5%

12,5%

4,5%

5,0%

17,2%

Search for sense

23,1%

22,7%

33,3%

4,2%

41,7%

45,5%

30,0%

20,7%

Practice 30,8%

40,9%

20,8%

58,3%

29,2%

40,9%

45,0%

51,7%

Multidisciplinarity

15,4%

22,7%

4,2%

12,5%

12,5%

9,1%

15,0%

6,9%

178 verbatims:

Ethics

14 verbatims, 9 votesData securityTherapist / patient relationTherapist / informatics relation

Ethics: priorities

0

1

2

3

4

5

6

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Rank of priority

Occ

urr

ence

s o

f ve

rbat

ims

Ethics

Little or not evoked

No worry about data security

No worry about the relationship with patients (most are not concerned)

Training

21 verbatims, 18 votesFundamental training to informaticsLogical reasoning of computerized records Practical organization

Training: priorities

0

1

2

3

4

5

6

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

rank of priority and tendency curve

Occ

urr

ence

s o

f ve

rbat

ims

Training

Data structuration

Belgian softwares are developping around the « Belgian Bilingual Biclassified Thesaurus (3BT) » and the Process-Thesaurus

Search for sense

49 verbatims, 32 votesLocal data sharing Specific formingNeed of a training personal within the team Increase motivation

Search for sense: priorities

0

1

2

3

4

5

6

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

rank of priority and tendency curve

Occ

urr

ence

s o

f ve

rbat

ims

Search for sense

Strong demand to see outcomes

Quality Improvement habits

No informatics habits

Practice

72 verbatims, 45 votesSoftware improvement Development Easy use

Internal organization Equipment (quality,

availability) Informatic skills Clear choice between

paperless or paper based record

Time spent

Practice: priorities

0

1

2

3

4

5

6

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

rank of priority and tendency curve

Occ

urr

ence

s o

f ve

rbat

ims

Practice

Powerfull software, but uneasy to use

Fear of loosing time because of data processing (during the consultation, in forming)

Nobody imagines saving time

Multidisciplinarity

21 verbatims, 15 votesBetter coordination between professional sectors Everyone feels supported by a collective effort Carrying out of projects

Multidisciplinarity: priorities

0

1

2

3

4

5

6

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

rank of priority and tendency curve

Occ

ure

nce

s o

f ve

rbat

ims

Multidisciplinarity

Self administrative way of working can make the change to informatics difficult Differences between the members: facing the technique, facing motivation, facing available time Data sharing, power sharingNeed of a multidisciplinary software

Possible bias

Little sample, teams that were very motivated by computerization Those teams forms a rather heterogeneous unity as for the solutions they view, the priority stage they gave them Qualitative reflection of the blockings

Discussion

Can solutions be generalized ?

Data collection with an epidemiological aim: short range objective accessible to some teams

Local use of the consultation data in the aim of quality of care improvement should be generalized

The practitioners are willing to improve the quality of care through self evaluation or projects

Quality improvement habits are the result of an effort over 9 years

A distinctive accompaniment in a whole movement Specific tools and training have to be developed and proposed Professional organizations, universities and authorities have a leading part in developing this quality improvement

Action proposals

Motivation improvement: A widely spread information to show the

obtained results and their impact on practice, as the met difficulties

A support structure

Security: Information about security strategies,

procedures and official requirements is all the more essential since the demand is weak

Action proposals

Training Informatic skills Data management ? Meet the users on their workplace Failure can be discussed Public Health information during studying

and continuous formation

Lobbying: The Belgian situation is developing in the

right direction

Action proposals

Practical: Audit of the situation before

computerization

Software improvement: Easy coding of clinical data, data entry tool Typical interfaces for paramedical

professions, structured around the central point of record: the patient’s list of episodes

Users associated to the development

Thank you