'Optimising PharmacoTherapy In the multimorbid elderly in primary CAre' (OPTICA) to improve medication appropriateness: study protocol of a cluster randomised controlled trial.

INTRODUCTION: Multimorbidity and polypharmacy are major risk factors for potentially inappropriate prescribing (eg, overprescribing and underprescribing), and systematic medication reviews are complex and time consuming. In this trial, the investigators aim to determine if a systematic software-based medication review improves medication appropriateness more than standard care in older, multimorbid patients with polypharmacy. METHODS AND ANALYSIS: Optimising PharmacoTherapy In the multimorbid elderly in primary CAre is a cluster randomised controlled trial that will include outpatients from the Swiss primary care setting, aged ≥65 years with ≥three chronic medical conditions and concurrent use of ≥five chronic medications. Patients treated by the same general practitioner (GP) constitute a cluster, and clusters are randomised 1:1 to either a standard care sham intervention, in which the GP discusses with the patient if the medication list is complete, or a systematic medication review intervention based on the use of the 'Systematic Tool to Reduce Inappropriate Prescribing'-Assistant (STRIPA). STRIPA is a web-based clinical decision support system that helps customise medication reviews. It is based on the validated 'Screening Tool of Older Person's Prescriptions' (STOPP) and 'Screening Tool to Alert doctors to Right Treatment' (START) criteria to detect potentially inappropriate prescribing. The trial's follow-up period is 12 months. Outcomes will be assessed at baseline, 6 and 12 months. The primary endpoint is medication appropriateness, as measured jointly by the change in the Medication Appropriateness Index (MAI) and Assessment of Underutilisation (AOU). Secondary endpoints include the degree of polypharmacy, overprescribing and underprescribing, the number of falls and fractures, quality of life, the amount of formal and informal care received by patients, survival, patients' quality adjusted life years, patients' medical costs, cost-effectiveness of the intervention, percentage of recommendations accepted by GPs, percentage of recommendation rejected by GPs and patients' willingness to have medications deprescribed. ETHICS AND DISSEMINATION: The ethics committee of the canton of Bern in Switzerland approved the trial protocol. The results of this trial will be published in a peer-reviewed journal. MAIN FUNDING: Swiss National Science Foundation, National Research Programme (NRP 74) 'Smarter Healthcare'. TRIAL REGISTRATION NUMBERS: Clinicaltrials.gov (NCT03724539), KOFAM (Swiss national portal) (SNCTP000003060), Universal Trial Number (U1111-1226-8013).

[Electronic medical record in Swiss primary care - discrepancy between expectations and reality]. / Elektronische Krankengeschichte in der Schweizer Grundversorgung - Diskrepanz zwischen Anspruch und Wirklichkeit.

The most recent data on the use of electronic medical records (EMR) in Swiss practices are from 2007. Since then, software products have evolved. The aim of our article is to update the knowledge about the current status of EMR implementation in Swiss practices and to gain information about Swiss primary healthcare providers' views of software tools providing clinical decision support.

Les données les plus récentes concernant l'utilisation de dossiers médicaux électroniques dans les cabinets suisses datent de 2007. Or les programmes informatiques ont largement évolué depuis. Le but de cet article est de mettre ces données à jour ainsi que d'obtenir des informations concernant le statut actuel de l'implémentation de dossiers médicaux électroniques et de connaître le point de vue des médecins de premier recours suisses quant aux fonctions supplémentaires facilitant la prise en charge des patients (support de décision clinique par exemple).

Age- and gender-related prevalence of multimorbidity in primary care: the Swiss FIRE project.

BACKGROUND: General practitioners often care for patients with several concurrent chronic medical conditions (multimorbidity). Recent data suggest that multimorbidity might be observed more often than isolated diseases in primary care. We explored the age- and gender-related prevalence of multimorbidity and compared these estimates to the prevalence estimates of other common specific diseases found in Swiss primary care. METHODS: We analyzed data from the Swiss FIRE (Family Medicine ICPC Research using Electronic Medical Record) project database, representing a total of 509,656 primary care encounters in 98,152 adult patients between January 1, 2009 and July 31, 2011. For each encounter, medical problems were encoded using the second version of the International Classification of primary Care (ICPC-2). We defined chronic health conditions using 147 pre-specified ICPC-2 codes and defined multimorbidity as 1) two or more chronic health conditions from different ICPC-2 rubrics, 2) two or more chronic health conditions from different ICPC-2 chapters, and 3) two or more medical specialties involved in patient care. We compared the prevalence estimates of multimorbidity defined by the three methodologies with the prevalence estimates of common diseases encountered in primary care. RESULTS: Overall, the prevalence estimates of multimorbidity were similar for the three different definitions (15% [95%CI 11-18%], 13% [95%CI 10-16%], and 14% [95%CI 11-17%], respectively), and were higher than the prevalence estimates of any specific chronic health condition (hypertension, uncomplicated 9% [95%CI 7-11%], back syndrome with and without radiating pain 6% [95%CI 5-7%], non-insulin dependent diabetes mellitus 3% [95%CI 3-4%]), and degenerative joint disease 3% [95%CI 2%-4%]). The prevalence estimates of multimorbidity rose more than 20-fold with age, from 2% (95%CI 1-2%) in those aged 20-29 years, to 38% (95%CI 31-44%) in those aged 80 or more years. The prevalence estimates of multimorbidity were similar for men and women (15% vs. 14%, p=0.288). CONCLUSIONS: In primary care, prevalence estimates of multimorbidity are higher than those of isolated diseases. Among the elderly, more than one out of three patients suffer from multimorbidity. Management of multimorbidity is a principal concern in this vulnerable patient population.

Improving the quality of morbidity indicators in electronic health records in Swiss primary care.

QUESTIONS UNDER STUDY: The FIRE Project established a standardised data collection to facilitate research and quality improvement projects in Swiss primary care. The project is based on the concept of merging clinical and administrative data. Since chronic conditions and multimorbidity are major challenges in primary care, in this study we investigated the agreement between different approaches to identify patients with chronic and multimorbid conditions in electronic medical records (EMRs). METHODS: A total of 60 primary care physicians were included and data were collected between October 2008 and June 2011. In total, data from 509594 consultations derived from 98152 patients were analysed. Chronic and multimorbid conditions were identified either by ICPC-2 codes or by the type of prescribed medication. We compared these different approaches regarding the completeness of the data to describe chronic conditions and multimorbidity of patients in primary care practices. RESULTS: The data showed a high correlation between the two morbidity schemes and both indicators apparently provide reliable measures of morbidity within practices. There was considerable variability of patients with chronic conditions across practices, irrespective of whether ICPC-2-diagnoses or prescribed drugs were used to code clinical encounters. Obvious discrepancies between diagnoses and therapies across major disease categories existed. CONCLUSIONS: This study describes the current situation of EMRs in terms of the ability to measure the burden of chronic conditions in primary care practices. The results illustrate a need of action for this specific topic and the results of this study will be incorporated into the functional specification of EMRs of a planned eHealth project in Swiss primary care.

The FIRE project: a milestone for research in primary care in Switzerland.

QUESTIONS UNDER STUDY/PRINCIPLES: Research is scarce where most patients are found. One of the main reasons is the difficulty in extracting data from traditionally conducted paper-based medical records. Thus, until now most existing patient records have originated from invoicing-tools. Endeavours to truly reflect a doctor's consultation have been rare. FIRE (Family Medicine ICPC-Research using Electronic Medical Records) is an ambitious project to establish a proper knowledge base in primary care by using the ongoing implementation of EPR (electronic patient records). FIRE will enable many questions on epidemiology and performance within the PC (primary care) setting to be answered. METHODS: GPs (general practitioners) throughout Switzerland working with EPR were eligible for participation. Workshops were held to train and standardise ICPC-coding (International Classification of Primary Care), a classification system especially designed for the PC-setting. The recorded data included administrative information on the GP and patient, vital signs, ICPC codes, laboratory analysis and medication. Data exporter software was developed for extracting anonymised data automatically from the EPR onto a database for further statistical analysis. RESULTS: From 1.1.2009 until the beginning of April 2010 24 GPs were successfully recruited providing standardised information on 127,922 consultations in 29,398 patients and 159,956 medical problems according to the ICPC-2 classification. CONCLUSION: The project proves the feasibility of standardised ongoing collection of research data embedded in routine clinical practice. FIRE provides a unique database for research in PC and highlights the potential of broad implementation of EPR in a PC-setting. Studies resulting from the ongoing project have the potential to assess the quality of care provided by GP's.

Utilisation of information technologies in ambulatory care in Switzerland.

BACKGROUND: The importance of electronic medical records for the healthcare system is well documented. IT enables easy storage, communication and decision support and can provide important tools in the care of chronically ill patients in the form of a reminder system. METHODS: A questionnaire was developed and send out to 1200 physicians extracted from the official data base. After four weeks the non-responders received a written reminder. Data collection started in December 2007 and was completed in February 2008. RESULTS: 719 questionnaires were received back, representing a response rate of 59.9%. The data revealed a significant underuse of electronic medical records (EMRs) and IT compared to other European countries. Smaller practices, older physicians and especially primary care physicians tended to use less EMR. Only 10.2% of all physicians declared an interest in considering investment in IT in the next three years, 66.9% expressly denied wishing to do so. The most important barriers were the costs, the unclear benefit and a feared worsening of the doctor-patient-communication during consultation. CONCLUSION: IT and especially EMRs are underused in daily ambulatory care in Switzerland. To increase the use of EMRs, several approaches could be helpful. First of all, the benefit of EMRs in daily routine care have to be increased as, for example, by decision support systems, tools to avoid pharmaceutical interactions and reminder systems to enable a proactive treatment of chronically ill patients. Furthermore, adequate approaches to offer appropriate reimbursement for the financial investments have to considered such as an additional payment for electronically generated, evidence based quality indicators.

Guidelines for computer security in general practice.

BACKGROUND: As general practice becomes increasingly computerised, data security becomes increasingly important for both patient health and the efficient operation of the practice. OBJECTIVE: To develop guidelines for computer security in general practice based on a literature review, an analysis of available information on current practice and a series of key stakeholder interviews. While the guideline was produced in the context of Australian general practice, we have developed a template that is also relevant for other countries. METHOD: Current data on computer security measures was sought from Australian divisions of general practice. Semi-structured interviews were conducted with general practitioners (GPs), the medical software industry, senior managers within government responsible for health IT (information technology) initiatives, technical IT experts, divisions of general practice and a member of a health information consumer group. The respondents were asked to assess both the likelihood and the consequences of potential risks in computer security being breached. RESULTS: The study suggested that the most important computer security issues in general practice were: the need for a nominated IT security coordinator; having written IT policies, including a practice disaster recovery plan; controlling access to different levels of electronic data; doing and testing backups; protecting against viruses and other malicious codes; installing firewalls; undertaking routine maintenance of hardware and software; and securing electronic communication, for example via encryption. This information led to the production of computer security guidelines, including a one-page summary checklist, which were subsequently distributed to all GPs in Australia. CONCLUSIONS: This paper maps out a process for developing computer security guidelines for general practice. The specific content will vary in different countries according to their levels of adoption of IT, and cultural, technical and other health service factors. Making these guidelines relevant to local contexts should help maximise their uptake.