Electronic health records and clinician burnout: A story of three eras.

OBJECTIVE: The study sought to provide physicians, informaticians, and institutional policymakers with an introductory tutorial about the history of medical documentation, sources of clinician burnout, and opportunities to improve electronic health records (EHRs). We now have unprecedented opportunities in health care, with the promise of new cures, improved equity, greater sensitivity to social and behavioral determinants of health, and data-driven precision medicine all on the horizon. EHRs have succeeded in making many aspects of care safer and more reliable. Unfortunately, current limitations in EHR usability and problems with clinician burnout distract from these successes. A complex interplay of technology, policy, and healthcare delivery has contributed to our current frustrations with EHRs. Fortunately, there are opportunities to improve the EHR and health system. A stronger emphasis on improving the clinician's experience through close collaboration by informaticians, clinicians, and vendors can combine with specific policy changes to address the causes of burnout. TARGET AUDIENCE: This tutorial is intended for clinicians, informaticians, policymakers, and regulators, who are essential participants in discussions focused on improving clinician burnout. Learners in biomedicine, regardless of clinical discipline, also may benefit from this primer and review. SCOPE: We include (1) an overview of medical documentation from a historical perspective; (2) a summary of the forces converging over the past 20 years to develop and disseminate the modern EHR; and (3) future opportunities to improve EHR structure, function, user base, and time required to collect and extract information.

The Evolution of Publication Hotspots in Electronic Health Records from 1957 to 2016 and Differences Among Six Countries.

This study aims to reveal the evolution of publication hotspots in the field of electronic health records (EHRs) and differences among countries. We applied keyword frequency analysis, keyword co-occurrence analysis, principal component analysis, multidimensional scaling analysis, and visualization technology to compare the high-frequency Medical Subject Heading (MeSH) terms in six countries during the periods 1957-2008 and 2009-2016. After 2009, the number of MeSH terms reflecting information exchange and information mining increased, and various types of evaluations based on EHRs and cohort studies significantly increased. The top 20 MeSH terms between 2009 and 2016 constitute five relatively larger knowledge groups. Thus, we conclude that publication hotspots in EHR field have shifted from issues related to the adoption of EHRs to the utilization of EHRs, and the knowledge structure has become systematic. The publication's focus was different in the six countries, which may relate to their national characteristics.

PEP-Prontuário Eletrônico do Paciente / Electronic Patient Medical Records

As principais vantagens apontadas, pela literatura, para os prontuários eletrônicos são melhor acesso, maior segurança e novos recursos, de modo que sua implantação possa se justificar pela melhoria na qualidade da assistência à saúde do paciente, pelo melhor gerenciamento dos recursos e pela melhoria de processos administrativos e financeiros. E as desvantagens envolvem o custo de implantação, tempo necessário para se avaliar os resultados, sujeição a falhas operacionais (COSTA, 2001)

The main advantages pointed out by the literature for electronic medical records are better access, greater security and new resources, so that their implementation can be justified by the improvement in the quality of patient health care, better management of resources and improvement of administrative and financial processes. And the disadvantages involve the cost of implementation, time required to evaluate the results, subjection to operational failures (COSTA, 2001)

Anesthesia Information Management Systems.

Anesthesia information management systems (AIMS) have evolved from simple, automated intraoperative record keepers in a select few institutions to widely adopted, sophisticated hardware and software solutions that are integrated into a hospital's electronic health record system and used to manage and document a patient's entire perioperative experience. AIMS implementations have resulted in numerous billing, research, and clinical benefits, yet there remain challenges and areas of potential improvement to AIMS utilization. This article provides an overview of the history of AIMS, the components and features of AIMS, and the benefits and challenges associated with implementing and using AIMS. As AIMS continue to proliferate and data are increasingly shared across multi-institutional collaborations, visual analytics and advanced analytics techniques such as machine learning may be applied to AIMS data to reap even more benefits.

[The Historical Collection of the Institut universitaire en santé mentale de Montreal: from the Quill to the Electronic Record, 140 Years of Mental Health Records]. / La collection patrimoniale de l'Institut universitaire en santé mentale de Montréal : un trésor à préserver.

Few institutions have kept the vast majority of their records. It is the enviable position of l'IUSMM. The article describes the collection, the challenges of preserving and sharing with limited budget within a legal context protecting confidentiality.

Electronic multidimensional health assessment questionnaire (eMDHAQ): past, present and future of a proposed single data management system for clinical care, research, quality improvement, and monitoring of long-term outcomes.

An MDHAQ/RAPID3 (multidimensional health assessment questionnaire/routine assessment of patient index data) was developed from the HAQ over 25 years, based on observations made from completion by every patient (with all diagnoses) at every routine rheumatology visit since 1980. Modification of the HAQ was viewed as similar to improving a laboratory test, with a primary focus on clinical value for diagnosis, prognosis, and/or management, as well as feasibility for minimal effect on clinical workflow. Rigorous attention, was also directed to validity, reliability, other methodologic and technological considerations, but after clinical value and feasibility were established. A longer "intake" MDHAQ was introduced for new patients to record a complete past medical history - illnesses, hospitalisations, surgeries, allergies, family history, social history and medications. MDHAQ scales not found on the HAQ record complex activities, sleep quality, anxiety, depression, self-report joint count, fatigue, symptom checklist, morning stiffness, exercise status, recent medical history, social history and demographic data within 2 pages on one sheet of paper. An electronic eMDHAQ/RAPID3 provides a similar platform to pool data from multiple sites. A patient may be offered a patient-administered, password-protected, secure, web site, to store the medical history completed on the eMDHAQ. This eMDHAQ would allow a patient to complete a single general medical history questionnaire rather than different intake questionnaires in different medical settings. The eMDHAQ would be available for updates and correction by the patient for future visits, regardless of electronic medical record (EMR). The eMDHAQ is designed to interface with an EMR using HL7 (health level seven) and SMART (Substitutable Medical Apps, Reusable Technology) on FHIR (Fast Healthcare Interoperability Resources), although implementation requires collaboration with the EMR vendor. Advanced features include reports for the physician formatted as a medical record note of past medical history for entry into any EMR without typing or dictation, and a periodic "tickler" function to monitor long-term outcomes with minimal effort of the physician and staff. Nonetheless, clinical use of an eMDHAQ should be guided primarily not by the latest technology, but by value and feasibility in clinical care, the same principles that guided development of the pencil-and-paper MDHAQ/RAPID3.

Resultados de la aplicación de una escala de alerta clínica precoz en pediatría como plan de mejora de calidad asistencial / Results of applying a paediatric early warning score system as a healthcare quality improvement plan

Objetivo. Introducir una escala de alerta clínica precoz en nuestra práctica habitual, evaluar su utilidad para prevenir el deterioro evitable en niños hospitalizados y capacitar al personal para comunicar la información y responder de forma efectiva. Material y métodos. Valoración de la aplicación de una escala de alerta clínica precoz incluida en la historia clínica electrónica, en pacientes hospitalizados de 0 a 15años (febrero 2014-septiembre 2014). La puntuación máxima era 6. Se requería evaluación del personal de enfermería cuando era >2 o conjunta médico-enfermera cuando era >3. Indicadores de seguimiento: porcentaje de pacientes con escala; porcentaje de registros completos; porcentaje de escalas >3; porcentaje de registros >3 con aviso al médico; porcentaje de cambios de tratamiento derivados del aviso y pacientes trasladados a la unidad de cuidados intensivos pediátricos (UCIP) o fallecimientos no detectados por la escala. Resultados. La escala se aplicó al 100% de pacientes ingresados (931), realizándose 7.917 tomas, con el 78,8% de registros completos. El 1,9% de las tomas fueron >3 y en el 70,5% se cumplió el aviso al médico. En el 14% de registros >3 se registró intensificación del tratamiento o solicitud de pruebas complementarias. Un paciente precisó traslado a UCIP (puntuación 2) y no hubo fallecimientos. La preocupación de los familiares/personal quedó registrada en el 80% de tomas. Conclusiones. Las escalas de alerta clínica precoz infantil permiten homogeneizar la monitorización, unificar formularios y mejorar los registros. La escasa aparición de complicaciones graves que requieran ingreso en UCIP y fallecimientos obligan a buscar otras variables de resultado para su evaluación (AU)

Objectives. The aims of this study were to introduce a paediatric early warning score (PEWS) into our daily clinical practice, as well as to evaluate its ability to detect clinical deterioration in children admitted, and to train nursing staff to communicate the information and response effectively. Material and methods. An analysis was performed on the implementation of PEWS in the electronic health records of children (0-15 years) in our paediatric ward from February 2014 to September 2014. The maximum score was 6. Nursing staff reviewed scores >2, and if >3 medical and nursing staff reviewed it. Monitoring indicators: % of admissions with scoring; % of complete data capture; % of scores >3; % of scores >3 reviewed by medical staff, % of changes in treatment due to the warning system, and number of patients who needed Paediatric Intensive Care Unit (PICU) admission, or died without an increased warning score. Results. The data were collected from all patients (931) admitted. The scale was measured 7,917 times, with 78.8% of them with complete data capture. Very few (1.9%) showed scores >3, and 14% of them with changes in clinical management (intensifying treatment or new diagnostic tests). One patient (scored 2) required PICU admission. There were no deaths. Parents or nursing staff concern was registered in 80% of cases. Conclusions. PEWS are useful to provide a standardised assessment of clinical status in the inpatient setting, using a unique scale and implementing data capture. Because of the lack of severe complications requiring PICU admission and deaths, we will have to use other data to evaluate these scales (AU)

The Renewed Promise of Medical Informatics.

The promise of the field of Medical Informatics has been great and its impact has been significant. In 1999, the Yearbook editors of the International Medical Informatics Association (IMIA) - also the authors of the present paper - sought to assess this impact by selecting a number of seminal papers in the field, and asking experts to comment on these articles. In particular, it was requested whether and how the expectations, represented by these papers, had been fulfilled since their publication several decades earlier. Each expert was also invited to comment on what might be expected in the future. In the present paper, these areas are briefly reviewed again. Where did these early papers have an impact and where were they not as successful as originally expected? It should be noted that the extraordinary developments in computer technology observed in the last two decades could not have been foreseen by these early researchers. In closing, some of the possibilities and limitations of research in medical informatics are outlined in the context of a framework that considers six levels of computer applications in medicine and health care. For each level, some predictions are made for the future, concluded with thoughts on fruitful areas for ongoing research in the field.

Electronic Health Records: Then, Now, and in the Future.

OBJECTIVES: Describe the state of Electronic Health Records (EHRs) in 1992 and their evolution by 2015 and where EHRs are expected to be in 25 years. Further to discuss the expectations for EHRs in 1992 and explore which of them were realized and what events accelerated or disrupted/derailed how EHRs evolved. METHODS: Literature search based on "Electronic Health Record", "Medical Record", and "Medical Chart" using Medline, Google, Wikipedia Medical, and Cochrane Libraries resulted in an initial review of 2,356 abstracts and other information in papers and books. Additional papers and books were identified through the review of references cited in the initial review. RESULTS: By 1992, hardware had become more affordable, powerful, and compact and the use of personal computers, local area networks, and the Internet provided faster and easier access to medical information. EHRs were initially developed and used at academic medical facilities but since most have been replaced by large vendor EHRs. While EHR use has increased and clinicians are being prepared to practice in an EHR-mediated world, technical issues have been overshadowed by procedural, professional, social, political, and especially ethical issues as well as the need for compliance with standards and information security. There have been enormous advancements that have taken place, but many of the early expectations for EHRs have not been realized and current EHRs still do not meet the needs of today's rapidly changing healthcare environment. CONCLUSION: The current use of EHRs initiated by new technology would have been hard to foresee. Current and new EHR technology will help to provide international standards for interoperable applications that use health, social, economic, behavioral, and environmental data to communicate, interpret, and act intelligently upon complex healthcare information to foster precision medicine and a learning health system.

From papyrus to the electronic tablet: a brief history of the clinical medical record with lessons for the digital age.

A major transition is underway in documentation of patient-related data in clinical settings with rapidly accelerating adoption of the electronic health record and electronic medical record. This article examines the history of the development of medical records in the West in order to suggest lessons applicable to the current transition. The first documented major transition in the evolution of the clinical medical record occurred in antiquity, with the development of written case history reports for didactic purposes. Benefiting from Classical and Hellenistic models earlier than physicians in the West, medieval Islamic physicians continued the development of case histories for didactic use. A forerunner of modern medical records first appeared in Paris and Berlin by the early 19th century. Development of the clinical record in America was pioneered in the 19th century in major teaching hospitals. However, a clinical medical record useful for direct patient care in hospital and ambulatory settings was not developed until the 20th century. Several lessons are drawn from the 4000-year history of the medical record that may help physicians improve patient care in the digital age.

History of the birth certificate: from inception to the future of electronic data.

Enumerations of people were carried out long before the birth of Jesus. Data related to births were recorded in church registers in England as early as the 1500s. However, not until the 1902 Act of Congress was the Bureau of Census established as a permanent agency to develop birth registration areas and a standard registration system. Although all states had birth records by 1919, the use of the standardized version was not uniformly adopted until the 1930's. In the 1989 US Standard Birth Certificate revision, the format was finally uniformly adopted to include checkboxes to improve data quality and completeness. The evolution of the 12 federal birth certificate revisions is reflected in the growth of the number of items from 33 in 1900 to more than 60 items in the 2003 birth certificate. As birth registration has moved from paper to electronic, the birth certificate's potential utility has broadened, yet issues with updating the electronic format and maintaining quality data continue to evolve. Understanding the birth certificate within its historical context allows for better insight as to how it has been and will continue to be used as an important public-health document shaping medical and public policies.

Can health care information technology save babies?

Electronic medical records (EMRs) facilitate fast and accurate access to patient records, which could improve diagnosis and patient monitoring. Using a 12-year county-level panel, we find that a 10 percent increase in births that occur in hospitals with EMRs reduces neonatal mortality by 16 deaths per 100,000 live births. This is driven by a reduction of deaths from conditions requiring careful monitoring. We also find a strong decrease in mortality when we instrument for EMR adoption using variation in state medical privacy laws. Rough cost-effectiveness calculations suggest that EMRs are associated with a cost of $531,000 per baby's life saved.

Presentation of the 2009 Morris F Collen Award to Betsy L Humphreys, with remarks from the recipient.

The American College of Medical Informatics is an honorary society established to recognize those who have made sustained contributions to the field. Its highest award, for lifetime achievement and contributions to the discipline of medical informatics, is the Morris F Collen Award. Dr Collen's own efforts as a pioneer in the field stand out as the embodiment of creativity, intellectual rigor, perseverance, and personal integrity. The Collen Award, given once a year, honors an individual whose attainments have, throughout a whole career, substantially advanced the science and art of biomedical informatics. In 2009, the college was proud to present the Collen Award to Betsy Humphreys, MLS, deputy director of the National Library of Medicine. Ms Humphreys has dedicated her career to enabling more effective integration and exchange of electronic information. Her work has involved new knowledge sources and innovative strategies for advancing health data standards to accomplish these goals. Ms Humphreys becomes the first librarian to receive the Collen Award. Dr Collen, on the occasion of his 96th birthday, personally presented the award to Ms Humphreys.

La historia clínica electrónica. Revisión y análisis de la actualidad. Diraya: la historia de salud electrónica de Andalucía / Electronic medical records. A review and analysis of the current situation. Diraya: Electronic Medical Records in Andalusia, Spain

El desarrollo de los sistemas de información en la atención sanitaria está modificando ciertos aspectos de la práctica clínica y producirán cambios en un futuro cercano que requerirán la participación y el consenso de todos los profesionales implicados en la asistencia a los pacientes. No cabe duda de que la historia clínica es el eje de la información clínica del paciente y el soporte para la comunicación entre los diferentes profesionales que lo atienden. Es importante que la recogida de la información terminológica en la historia clínica electrónica se defina previamente para poder procesarla y explotarla con posterioridad. Las herramientas para el procesamiento de la información terminológica en la historia clínica electrónica se basan en lenguajes documentales que permitan clasificar y codificar las enfermedades. La tendencia para el futuro será la compilación de los diferentes lenguajes documentales que permitan al profesional no sólo navegar a través de la historia clínica, sino también acceder a bases de datos bibliográficos y herramientas de ayuda para la toma de decisiones. El papel de la historia clínica electrónica en la calidad de la atención sanitaria ha sido motivo de numerosas publicaciones, con resultados variables por problemas metodológicos. Los efectos beneficiosos más importantes están en relación con la mayor adhesión a las guías de práctica clínica y la disminución de errores en la medicación (AU)

The growing use of information technology in healthcare is altering certain aspects of clinical practice and will, in the near future, lead to changes that will require the active participation and consent of all professionals involved in patient care. There is no doubt that the medical record lies at the heart of all clinical information on the patient and, in addition, provides the basis for communication between different professionals involved in the patient’s care. It is important that any terminological information included in electronic medical records is defined beforehand so that it can be subsequently processed and made use of. The tools for processing terminological information in electronic medical records are based on classification languages that facilitate disease classification and coding. In the future, the trend will be towards the compilation of different classification languages so that professionals will be able not only to browse medical records but also to access literature databases and tools that can aid decision-making. The influence of electronic medical records on the quality of healthcare provision has been the focus of a number of publications, which have produced variable results due to methodological problems. The most important benefits are better adherence to clinical practice guidelines and a reduction in the number of prescription errors (AU)