Electronic health record functionality needed to better support primary care

Electronic health records (EHRs) must support primary care clinicians and patients, yet many clinicians remain dissatisfied with their system. This article presents a consensus statement about gaps in current EHR functionality and needed enhancements to support primary care. The Institute of Medicine primary care attributes were used to define needs and meaningful use (MU) objectives to define EHR functionality. Current objectives remain focused on disease rather than the whole person, ignoring factors such as personal risks, behaviors, family structure, and occupational and environmental influences. Primary care needs EHRs to move beyond documentation to interpreting and tracking information over time, as well as patient-partnering activities, support for team-based care, population-management tools that deliver care, and reduced documentation burden. While stage 3 MU''s focus on outcomes is laudable, enhanced functionality is still needed, including EHR modifications, expanded use of patient portals, seamless integration with external applications, and advancement of national infrastructure and policies.     

我国电子健康档案建立与应用进展

电子健康档案的发展是全球数字化的必然趋势,介绍电子健康档案的建立与国家相关政策,阐述电子健康档案在德阳、上海、北京、广州、南昌等地的建设实践,对未来发展进行展望,为其他省市电子健康档案的建设提供有益参考。     

基于Hadoop的电子健康档案云平台设计和实现

阐述基于Hadoop的电子健康档案云平台架构设计,包括服务对象及需求、逻辑架构、软件架构等方面,介绍基于HBase的电子健康档案云平台数据预处理模型,进行实验环境的搭建和配置,通过实验完成Hadoop集群的启动。     

利用EHR/EMR数据的慢性病防控临床研究进展

介绍电子健康档案（EHR）和电子病历（EMR）的概念及其医疗应用,从横向研究、病例对照及前瞻性研究、精准医学研究3方面阐述目前国内外应用EHR/EMR数据进行慢性病防控的临床研究现状,为更好地应用医疗大数据进行医学研究做一些探索。     

Research and applications: ICD-9 tobacco use codes are effective identifiers of smoking status

Objective

To evaluate the validity of, characterize the usage of, and propose potential research applications for International Classification of Diseases, Ninth Revision (ICD-9) tobacco codes in clinical populations.

Materials and methods

Using data on cancer cases and cancer-free controls from Vanderbilt''s biorepository, BioVU, we evaluated the utility of ICD-9 tobacco use codes to identify ever-smokers in general and high smoking prevalence (lung cancer) clinic populations. We assessed potential biases in documentation, and performed temporal analysis relating transitions between smoking codes to smoking cessation attempts. We also examined the suitability of these codes for use in genetic association analyses.

Results

ICD-9 tobacco use codes can identify smokers in a general clinic population (specificity of 1, sensitivity of  0.32), and there is little evidence of documentation bias. Frequency of code transitions between ‘current’ and ‘former’ tobacco use was significantly correlated with initial success at smoking cessation (p<0.0001). Finally, code-based smoking status assignment is a comparable covariate to text-based smoking status for genetic association studies.

Discussion

Our results support the use of ICD-9 tobacco use codes for identifying smokers in a clinical population. Furthermore, with some limitations, these codes are suitable for adjustment of smoking status in genetic studies utilizing electronic health records.

Conclusions

Researchers should not be deterred by the unavailability of full-text records to determine smoking status if they have ICD-9 code histories.     

加拿大电子健康档案建设新进展及其启示

阐述电子健康档案建设意义及加拿大电子健康档案建设最新进展,分析建设经验并提出对我国的启示,包括注重统筹规划设计、加强相关法律法规建设、引入认证机制等方面,以期为我国电子健康档案建设提供借鉴。     

e-Measures: insight into the challenges and opportunities of automating publicly reported quality measures

Using electronic health records (EHR) to automate publicly reported quality measures is receiving increasing attention and is one of the promises of EHR implementation. Kaiser Permanente has fully or partly automated six of 13 the joint commission measure sets. We describe our experience with automation and the resulting time savings: a reduction by approximately 50% of abstractor time required for one measure set alone (surgical care improvement project). However, our experience illustrates the gap between the current and desired states of automated public quality reporting, which has important implications for measure developers, accrediting entities, EHR vendors, public/private payers, and government.     

Agreement of Medicaid claims and electronic health records for assessing preventive care quality among adults

To compare the agreement of electronic health record (EHR) data versus Medicaid claims data in documenting adult preventive care. Insurance claims are commonly used to measure care quality. EHR data could serve this purpose, but little information exists about how this source compares in service documentation. For 13 101 Medicaid-insured adult patients attending 43 Oregon community health centers, we compared documentation of 11 preventive services, based on EHR versus Medicaid claims data. Documentation was comparable for most services. Agreement was highest for influenza vaccination (κ =  0.77; 95% CI 0.75 to 0.79), cholesterol screening (κ = 0.80; 95% CI 0.79 to 0.81), and cervical cancer screening (κ = 0.71; 95% CI 0.70 to 0.73), and lowest on services commonly referred out of primary care clinics and those that usually do not generate claims. EHRs show promise for use in quality reporting. Strategies to maximize data capture in EHRs are needed to optimize the use of EHR data for service documentation.     

电子健康档案概念解析及标准化现状分析

通过介绍并分析国内外电子健康档案(Electronic Health Records,EHR)定义的共同点和不同点,指出EHR所具有的关键特点.对国内外EHR标准化工作现状进行分析研究,提出相应建议,对于我国开展EHR系统建设具有一定参考价值.     

QNOTE: an instrument for measuring the quality of EHR clinical notes

Background and objective

The outpatient clinical note documents the clinician''s information collection, problem assessment, and patient management, yet there is currently no validated instrument to measure the quality of the electronic clinical note. This study evaluated the validity of the QNOTE instrument, which assesses 12 elements in the clinical note, for measuring the quality of clinical notes. It also compared its performance with a global instrument that assesses the clinical note as a whole.

Materials and methods

Retrospective multicenter blinded study of the clinical notes of 100 outpatients with type 2 diabetes mellitus who had been seen in clinic on at least three occasions. The 300 notes were rated by eight general internal medicine and eight family medicine practicing physicians. The QNOTE instrument scored the quality of the note as the sum of a set of 12 note element scores, and its inter-rater agreement was measured by the intraclass correlation coefficient. The Global instrument scored the note in its entirety, and its inter-rater agreement was measured by the Fleiss κ.

Results

The overall QNOTE inter-rater agreement was 0.82 (CI 0.80 to 0.84), and its note quality score was 65 (CI 64 to 66). The Global inter-rater agreement was 0.24 (CI 0.19 to 0.29), and its note quality score was 52 (CI 49 to 55). The QNOTE quality scores were consistent, and the overall QNOTE score was significantly higher than the overall Global score (p=0.04).

Conclusions

We found the QNOTE to be a valid instrument for evaluating the quality of electronic clinical notes, and its performance was superior to that of the Global instrument.     

健康体检电子档案的使用与管理

为克服手工书写版纸质体检结果和总检结论字迹潦草,致使受检者随意扔掉报告,从而导致健康体检报告应用有效性的下降问题。采用健康体检电子档案,可使体检精确率明显提高,漏检、错检率明显下降,实现体检信息的自动传递和提取,更好地为受检者提供健康服务,为健康体检教学与科研创造良好条件。     

电子健康档案数据分析应用总体框架研究

梳理电子健康档案数据分析应用的内涵,在对国内外电子健康档案数据分析应用现状进行总结的基础上，构建包含业务领域、分析主题、分析指标3个层次的电子健康档案数据分析应用总体框架，归纳出数据统计、数据分析、综合报告3种数据展现方式，指出大数据技术、数据仓库是实现电子健康档案数据分析应用的关键技术，最后提出电子健康档案分析利用相关建议。     

英国电子健康档案建设与启示

阐述英国电子健康档案建设历程、系统构成及主要功能,分析存在的问题,包括资金短缺、进度滞后、存在安全隐患等,提出对我国的启示,即强化利用先进技术促进国民健康,加强项目资金规划、管理及国家统一指导,建立完备的法律法规。     

基于4W要素的电子健康档案安全管理及应用探索

阐述电子健康档案内涵,分析其建设过程中存在的各地区发展不平衡、缺乏标准规范等问题,基于4W（Why、Who、When、Way）要素对电子健康档案安全管理及应用提出相应建议。     

社区居民电子健康档案管理系统设计

明确社区居民电子健康档案管理系统总体设计需求,从设计目标、功能模块、概念模型、关键技术等方面阐述系统设计,介绍具体的功能实现,包括健康档案建立与维护、信息检索、专档信息管理、数据统计、系统管理等。     

电子健康档案管理网络平台设计与构建

采用B/S模式进行老干部电子健康档案管理网络平台的设计与开发,介绍系统整体架构、技术构成、功能模块及应用效果。填补干休所信息化建设的空白,有利于为老干部提供个性化医疗服务和健康保障。     

美国战略卫生信息技术高级研究项目推进及其启示

介绍美国战略卫生信息技术高级研究项目背景及目标,梳理其卫生信息技术安全、以患者为中心的认知支持、卫生医疗应用和网络平台架构以及电子健康档案数据二次使用4个子项目的主要研究内容,结合我国卫生信息化实际情况,从国家引导、加强协同配合、建立标准化信息模型和重视信息安全等方面提出建议。     

结构化描述语言电子病历模型反其关键技术实现

目的：开发新一代电子病历模型,实现临床医生结构化描述语言信息快速采集,方便临床信息集成与数据复用.方法：建立电子病历结构化描述语言模型,将临床规范化数据与描述性文本信息融为一体,实现重要医疗事件表达和标识,达到临床信息有效利用和医生快速数据录入.讨论：实现了电子病历的模板表达和医生自由文本数据录入,通过自然语言实时处理技术,保障了电子病历的质量控制.结论：结构化描述语言电子病历模型允许医生自由文本数据录入,支持临床信息复用以及结构化数据处理,能实现临床数据快速采集,具有临床文档质量控制功能,是新一代电子病历发展的重要方向.     

电子健康档案的价值认知与应用推进策略研究

介绍电子健康档案的实践发展和理论研究现状,阐述电子健康档案具有应用于多方面的可能性、改善健康信息的可获得性、提高健康决策的效果、促进医疗卫生机构间协作4个方面的独特价值。分析美国电子健康档案应用推进策略,提出我国推进电子健康档案采纳应用可从社会认知的提升、组织机构的保障、政策文件的引导、法律体系的配套、标准规范的完善5方面着手。     

Area-level factors associated with electronic health record adoption and meaningful use in the Regional Extension Center Program

Objective

To identify area-level correlates of electronic health record (EHR) adoption and meaningful use (MU) among primary care providers (PCPs) enrolled in the Regional Extension Center (REC) Program.

Materials and methods

County-level data on 2013 EHR adoption and MU among REC-enrolled PCPs were obtained from the Office of the National Coordinator for Health Information Technology and linked with other county-level data sources including the Area Resource File, American Community Survey, and Federal Communications Commission''s broadband availability database. Hierarchical models with random intercepts for RECs were employed to assess associations between a broad set of area-level factors and county-level rates of EHR adoption and MU.

Results

Among the 2715 counties examined, the average county-level EHR adoption and MU rates for REC-enrolled PCPs were 87.5% and 54.2%, respectively. Community health center presence and Medicaid enrollment concentration were positively associated with EHR adoption, while metropolitan status and Medicare Advantage enrollment concentration were positively associated with MU. Health professional shortage area status and minority concentration were negatively associated with EHR adoption and MU.

Discussion

Increased financial incentives in areas with greater concentrations of Medicaid and Medicare enrollees may be encouraging EHR adoption and MU among REC-enrolled PCPs. Disparities in EHR adoption and MU in some low-resource and underserved areas remain a concern.

Conclusions

Federal efforts to spur EHR adoption and MU have demonstrated some early success; however, some geographic variations in EHR diffusion indicate that greater attention needs to be paid to ensuring equitable uptake and use of EHRs throughout the US.