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• W4220704098 abstract "Electronic health records (EHRs) are real-time, patient-specific registers that make information available immediately, and securely, to authorised users. EHRs contain a patient's full medical history, including diagnoses, medication, treatment plans, immunisation, family histories, allergies, risks, referrals, consultations, laboratory test results and imaging. They also collect timestamps in audit logs so that they can be used for clinical workflow analysis. EHRs are designed so that information can be shared with other healthcare providers and organisations, such as laboratories, imaging facilities, consultants, pharmacies and collaborating inpatient and outpatient clinics. In many countries, EHRs are the only legitimate form of patient records. They have the potential to transform healthcare activities, by using evidence-based medical guidelines and efficiently coordinating patient treatment and care. In addition, EHRs provide opportunities to incorporate performance measures into clinical practice and facilitate clinical research. Ideally, EHRs should provide doctors with access to evidence-based guidelines and the tools they need to make decisions about patient care. In addition, they can contain automated instruments and algorithms to guide the advice and interventions offered by healthcare providers. Doctors’ diagnoses and treatment habits can be modified by incorporating a range of interventions into EHRs, including tailored education, alerts, prompts and even restrictions. However, these possibilities have not been sufficiently used to date. There are numerous identified factors that hamper the implementation of EHRs for interventions, research and translation to clinical care. These include increased initial cost (and uncertainty about cost-benefit symmetry), lack of technical infrastructure, staff shortage, lack of incentives, preconception about onerous usability, concerns about technical errors and security, legal issues, lack of consensus within the organisation as well as physician attitude and resistance (e.g. perceived usefulness and fear of losing autonomy).1 During the COVID-19 pandemic, medical journals have published ample studies using real-life data, including data obtained from EHR databases. The interpretation and application of such knowledge are challenging, because conventional skills in statistics and clinical epidemiology are not sufficient to fully understand the opportunities and limitations of EHR-based studies.2 In addition, EHRs have only been used in paediatric research on a rather small scale. Most of the studies have been retrospective and have used the EHR as a source of data, in the same way that they would use traditional non-electronic patient records. Clinical decision support systems, which can be voluntary options for healthcare professionals, have been used to steer antibiotic prescriptions in primary care and enhance the stewardship of the antibiotics that are available.3 In addition, models have been constructed for obligatory EHR-based interventions, such as guiding the use of antibiotic prescriptions, providing counselling, benchmarking, tailored education and even restrictions.4 However, these interventions have not been put in place until now, with the exception of the voluntary use of decision support systems. The next step is to integrate these steering tools into the core of the electronic platforms. There are several proposed key characteristics by which EHR systems could confer maximum potential benefits to patients, clinicians and investigators: (1) explainable (to convey the relative importance of features in determining outputs); (2) dynamic (to capture temporal changes in physiologic signals and clinical events); (3) precise (using high-resolution, multimodal data and apply complex architecture); (4) autonomous (that learn with minimal supervision and execute without human input); (5) fair (able to evaluate and mitigate implicit bias and social inequity); and (6) reproducible (that are validated externally and prospectively and shared with academic communities).5 EHRs have proved useful for comparing continuous versus non-continuous tailored monitoring of oxygen saturation with pulse oximetry for infants with bronchiolitis.6 They have also been used to assess the likelihood of children being prescribed antibiotics by members of a network for primary care paediatricians.7 Other applications have included spatial and profile analyses of the risk of antibiotic resistance when patients have had frequently diagnosed bacterial infections8 and encouraging adolescents to attend hospital-based reproductive health visits.9 These studies all concluded that EHRs offered reliable information and provided effective platforms for these purposes. However, none of these studies included interventions that were prospectively developed with the help of EHRs. The authors of one Finnish study constructed, and tested, an intervention programme to reduce prescriptions for cough and cold medication. The cohort comprised children who were treated by a nationwide healthcare service company that used a centralised EHR that enabled it to monitor the clinical practices of specific doctors in real time.10 The step-by-step intervention consisted of disseminating educational materials to doctors and families, educational staff meetings, continuously monitoring prescriptions and targeting feedback. Outreach visits were held in non-compliant units. Finally, those physicians who continued to prescribe these medicines, despite the EHR-based activities, were contacted directly. There were more than one million paediatric visits during the four-year intervention period covered by the study. Physicians in 41% of the 322 units completely stopped prescribing cough and cold medicines for children and the total number of prescriptions fell by 89%. During the fourth year of the intervention, medication containing cough suppressants was only prescribed for 0.2% of children under two years of age with respiratory infections. The overall annual cost of these medicines decreased by 90%, in line with the decreasing number of prescriptions. The total cost of the four-year intervention for the company was about the same as the amount the parents spent on cough and cold medication during the last year. The study showed that a nationwide systematic intervention to reduce such prescriptions was feasible and only required modest financial investments and an online EHR system with coded data.10 So far, national public and private databases have mainly been used for data collection for retrospective studies, rather than prospective clinical interventions. For example, the national electronic prescription database used in Finland could also be used for online monitoring of age-specific and medication-specific initiatives. It could also be used when interventions to steer prescribing are considered essential, such as broad-spectrum antibiotics and drugs that aim to relieve symptoms but carry a risk of side effects. In principle, the system could also be used to monitor and steer over-the-counter medicines sales and target educational material that promotes guidelines. EHR algorithms can help physicians to select the correct diagnostic code to initiate treatment, indicate the need for admissions or consultations, identify at-risk patients and plan follow-ups.2 Warning systems can be created, based on the patient's diagnosis, risk information, prescribed medication and laboratory values. A patient's recovery could be monitored more efficiently by using automated messages on self-management and reminders. Implementation of these activities should be guided and strengthened by research. Systems are already in place to monitor adults with chronic diseases, such as diabetes, arrhythmias and asthma, based on automatically saved laboratory or physiological data. However, this huge area of health care is outside the scope of this editorial. EHRs can produce automatically generated reports. These can be used by health managers for quality assessment purposes and by healthcare service providers to improve processes and optimise resources. They can also be used by doctors, to monitor their own practices, and those of peers, in relation to guidelines. It is relatively easy to generate and disseminate reports, but it is more challenging, and in fact essential, to carry out research to confirm their effectiveness, monitor their use and evaluate their impact. EHRs are already making a contribution to the way we practice medicine, but it is clear that we need to make much greater use of the potential that these systems offer. The authors have no conflicts of interest to declare. Péter Csonka Matti Korppi" @default.
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• W4220704098 date "2022-03-24" @default.
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• W4220704098 title "Electronic health record databases provide a platform for intervention studies" @default.
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• W4220704098 doi "https://doi.org/10.1111/apa.16329" @default.
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