Mortality and continuity of care - Definitions matter! A cohort study in diabetics.

OBJECTIVE: To demonstrate that when investigating the relevance of continuity of care for patient outcomes, different definitions can lead to contradicting results. METHODS: We used claims data from the regional public health insurer of Lower Austria covering the period from 2008 to 2011. The study sample included subjects with repeated dispensings of anti-diabetic drugs. The continuity of care index was calculated firstly based on a patient's contacts with general practitioners (primary COCI) and secondly based on contacts at all medical disciplines (total COCI). The association of the two continuity of care measures with mortality was assessed in separate univariable and multivariable Cox regression models. RESULTS: Our study sample consisted of 51,717 patients with a median observation time of 3.65 years. The data showed that a high total COCI was associated with increased mortality, while there was no association between primary COCI and mortality. CONCLUSIONS: Measures of continuity of care are highly sensitive to the type of medical disciplines taken into account. The continuity of care index calculated from contacts at all medical disciplines might measure diversity rather than continuity of care.

A nationwide computerized patient medication history: evaluation of the Austrian pilot project "e-Medikation".

PURPOSE: To manage medication treatment and to assure medication safety, health care professionals need a complete overview of all drugs that have been prescribed or are taken by a patient. In 2009, Austria launched the pilot project "e-Medikation" in three pilot regions. E-Medikation gives access to a patient's nationwide medication list and includes medication safety checks. The objective of this paper is to report on the evaluation results and lessons learnt. METHODS: A formative evaluation study performed between July and December 2011 comprised a standardized survey of participating physicians, pharmacists, and patients, as well as an analysis of the e-Medikation log files. RESULTS: During the evaluation period, 18,310 prescriptions and 13,797 dispensings were documented, and 22,359 medication safety checks were performed. Overall, 61 physicians, 68 pharmacists, and 553 patients responded to a written survey. The results showed high acceptance of the idea of e-Medikation among pharmacists and patients and mixed acceptance among physicians. The satisfaction with the quality of the software used in the pilot project was low. CONCLUSIONS: The overall aim to increase medication safety seems achievable through e-Medikation, but several limitations of the pilot project need to be solved before a national rollout. Based on the evaluation results and after redesign of e-Medikation, Austria is now planning a nationwide introduction of e-Medikation starting in 2015.

The Austrian e-Medikation pilot evaluation: lessons learned from a national medication list.

The objective of this paper is to present results and recommendations from the Austrian e-Medikation pilot project. e-Medikation comprises a national medication list of all prescribed and dispensed medications as well as central medication checks. Evaluation was based on log-file analysis and survey of all participants (physicians, pharmacists, patients). During the evaluation period, 97 physicians, 58 pharmacies and more than 5.000 patients, participated. All user groups found that e-Medikation has the potential to improve patient safety, but that software quality and system architecture is not yet suitable for routine use. The evaluation resulted in 34 recommendations for further development and roll out of e-Medikation in Austria. Most of these recommendations have already been included in the recently passed law concerning the upcoming Austrian electronic health record system called "ELGA".

Fragmentation of diabetes treatment in Austria - an indicator for the need for shared electronic health record systems.

Shared electronic health record (EHR) systems aim to support continuity of care within the joint treatment of a patient by a community of cooperating care providers. By analyzing the fragmentation of care of Austrian diabetes patients, we aim to find evidence whether there is actually a need for shared EHR systems in this context. Our results show that almost three quarters of the observed diabetes patients visit two or more different care providers during their diabetes-related visits. Overall, our findings strongly support the demand for shared EHR systems for the treatment of diabetes patients.

Critical areas of national electronic health record programs-is our focus correct?

OBJECTIVE: National electronic health record programs are frequently associated with a number of problems. In view of their long duration and costs, efficient implementation of the programs with due regard given to the conclusions drawn thus far would be a meaningful goal from the economic point of view. In the present report we analyze programs from various countries with regard to the problems documented therein and derive, on a cross-country basis, the most common critical aspects of national electronic health record programs. These aspects should be given special attention in the implementation of future national electronic health record programs. Furthermore, measures which have proven to be useful in coping with the respective problems in individual countries will be suggested for each critical area. METHOD: Five countries were selected in which (a) programs for a national electronic health record system exist since at least 5 years, (b) the planned electronic health record systems encompass various approaches of implementation, and (c) pilot projects have already been conducted. The programs of these countries were analyzed on the basis of project reviews and audits with reference to the problems documented during their implementation. These were abstracted and standardized into cross-country categories which, in turn, were grouped into critical areas. RESULTS: From the analysis of national electronic health record programs from England, Germany, Canada, Denmark and Australia, the following frequently involved critical areas were derived: (a) acceptance and change management, (b) demonstration of benefits and funding, (c) project management, (d) Health-policy-related goals and implementation strategy, (e) basic legal requirements, particularly in the field of data protection. CONCLUSIONS: The analysis shows that similar critical areas exist in the various countries. Strategic, organizational and human challenges are usually more difficult to master than technical aspects. The measures used thus far to deal with the critical areas are selective approaches towards resolving individual problems. For the future it would be desirable to set up a comprehensive method that provides support in the complete process of implementing national electronic health record programs and hereby covers all critical areas identified within this paper.

Analysis of EHRs for research, quality management and health politics.

Lifelong electronic health records can supply valuable information for research, quality management and health politics in addition to supporting treatment of patients. Based on experiences with scientific data analysis in a university hospital environment, requirements on cross-institutional analysis of electronic health records in a healthcare system are discussed. The concept of archetypes can play a key role in this context. Archetypes can be utilized in data analysis for visualization, semantic linkage and finally for standardized data transfer.

Venous thromboembolism--a manifestation of the metabolic syndrome.

BACKGROUND AND OBJECTIVES: The metabolic syndrome, defined by abdominal obesity, elevation of blood pressure, fasting glucose and triglycerides and low levels of high-density lipoprotein cholesterol is associated with atherosclerotic disease. It induces a pro-inflammatory and prothrombotic state. Despite its high prevalence, data on the association with venous thromboembolism (VTE) are scarce. The aim of our study was to elucidate the association of the metabolic syndrome with the risk of VTE. DESIGN AND METHODS: We conducted a case-control study to investigate the presence of the metabolic syndrome defined according to guidelines of the National Cholesterol Education Program, in high-risk patients with objectively confirmed recurrent VTE, who had had at least one unprovoked event of deep venous thrombosis or pulmonary embolism. Age and sex-matched healthy individuals served as controls. RESULTS: A total of 116 patients and 129 controls were enrolled. The prevalence of the metabolic syndrome was statistically significantly higher in patients (40/116, 35%) than in controls (26/129, 20%, p=0.012). The unadjusted odds ratio (OR) of the metabolic syndrome for VTE was 2.1 (95% CI [1.2-3.7], p=0.012) and remained statistically significant after adjustment for established thrombosis risk factors, sex and age (OR=2.2, 95% CI [1.1-4.3], p=0.020). Individuals with the metabolic syndrome (n=66) had significantly higher levels of high-sensitivity C-reactive protein (median, [interquartile range]: 0.312 mg/dL, [0.142-0.751] vs. 0.153 mg/dL, [0.073-0.330], p<0.001), fibrinogen (390 mg/dL, [342-432] vs. 343 mg/dL, [310-394], p<0.001) and factor VIII activity (182%, [157-216] vs. 159%, [133-199], p=0.005) compared to those without (n=179). INTERPRETATION AND CONCLUSIONS: The metabolic syndrome may contribute to the development of VTE and is associated with a two-fold increased risk of VTE.

Introducing the electronic health record in austria.

The Austrian parliament has adopted legislation to introduce the electronic health record under the title ELGA. The present article first discusses several activities of other countries in this context. It then deals with the current situation of healthcare telematics in Austria and the next planned steps to introduce the life-long electronic health record.

[Guidelines for the planning and implementation of telemedical applications]. / Richtlinien zur Planung und Realisierung telemedizinischer Anwendungen.

Before a telemedical application can be implemented in practice, various technical, organisational, and legal questions have to be solved. The answers to these questions are, however, in most cases not very obvious. Telemedicine guidelines which could provide a path to follow currently exist only for selected medical fields and are frequently customized for particular medical and technical scenarios. The use of existing telemedicine guidelines in Austrian health care is further complicated by the fact that most of them are based on foreign legal systems. This paper therefore aims to develop general telemedicine guidelines which are appropriate for all application areas of telemedicine in Austrian health care. From nine existing telemedicine guidelines for individual medical fields, two generally applicable guidelines were derived. The corresponding abstraction process was based on a categorization of telemedical applications, which is oriented on the communication partners involved. The derived, general guidelines address seven typical problem domains in the practical application of a telemedical application. As opposed to the existing guidelines, they (1) are independent of special medical fields and are therefore appropriate for all application areas of telemedicine -- also in medical fields where no specific guidelines have existed before; (2) are adapted to the Austrian legal system; (3) provide additional insight for medical fields where specific guidelines have already existed, as they can benefit from recommendations of other medical fields where equivalent telemedical applications are employed.

Management of data from clinical trials using the ArchiMed system.

Clinical trials constitute a key source of medical research and are therefore conducted on a regular basis at university hospitals. The professional execution of trials requires, among other things, a repertoire of tools that support efficient data management. Tasks that are essential for efficient data management in clinical trials include the following: the design of the trial database, the design of electronic case report forms, recruiting patients, collection of data, and statistical analysis. The present article reports the manner in which these tasks are supported by the ArchiMed system at the University of Vienna and Graz Medical Schools. ArchiMed is customized for clinical end users, allowing them to autonomously manage their clinical trials without having to consult computer experts. An evaluation of the ArchiMed system in 12 trials recently conducted at the University of Vienna Medical School shows that the individual system functions can be usefully applied for data management in clinical trials.