Improving emergency care access to patients' past medical history

A key justification for developing shared electronic health records systems (SEHRs) is their potential to improve the quality and outcome of care for unanticipated events such as healthcare emergencies by providing access to patients’ past medical history (PMH). Having some useful background information about an unknown patient entering a hospital emergency department (ED) may be the factor that determines whether that patient lives or dies.

SEHRs, if well designed and appropriately targeted to meet specific and high-value informational needs, should in principle improve the quality, safety and effectiveness of clinical care. At present, however, the evidence for such benefits is weak. Given the scale and cost of SEHR systems, this absence of evidence is both surprising and concerning.

The purpose of this study is to improve emergency care access to patients’ past medical history. Four peer reviewed articles were published. The first was based upon a PRISMA-compliant systematic review assessing the relevance of previously published articles describing instances in which PMH is accessed in different healthcare environments worldwide. Comparisons were made of system architecture, level of uptake and impacts on clinical outcomes and patient safety.

The second article was a narrative synthesis examining the reasons for New Zealand’s HIT leadership as measured by The Commonwealth Fund’s international comparisons of quality of care, clinician satisfaction and levels of advanced healthcare information technology.

Successful SEHR design and implementation typically requires input from several groups of people working together to forge an optimal result. By combining government contributions of core infrastructure, privacy legislation and a clear strategic vision with private enterprise-driven innovation and investment, New Zealand has embraced a ‘middle-out’ approach to developing new systems that address ‘human factors’ and are thus widely used in the provision of healthcare.

A third article describes a cohort observational study in which a PMH access system, was made available to ED clinicians covering 77,181 ED presentations over 4 years and 9 months. Methods included measuring lookup rates of externally held primary care records accessed in emergency care and identified patient characteristics, conditions and potential consequences associated with access.

We found that when primary care records were made available to ED clinicians, in a four-year, ninemonth experimental project, records were accessed more frequently for older patients who were on average 25 years older (z= 9.810, p<.001), for those presenting in higher triage categories (z=-36.47, p>.001), and for patients presenting with specific conditions. Usage grew over a multi-year period, as the system’s value became more widely understood (from 4.9% initially to 8.3% in year five).

The fourth article contained a comparison of anticipated and perceived/actual benefits of SEHR/PMH-access systems to ED and UC clinicians practising in Australia and New Zealand. Methods used included designing a set of technology acceptance questions using the UTAUT2 framework to identify users’ behavioural intentions in relation to introduction of new PMH-access technology.

When surveyed, ED and urgent care (UC) clinicians revealed support for gaining access to useful PMH. ED and UC clinicians know what they want to see in an SEHR/PMH access system. The views of clinicians with access to PMH and those without access indicate clear agreement on the nature and shape of SEHR/PMH access desired. Designing electronic record systems specifically optimised for ED and UC decision support appears to be both needed and capable of delivering significant benefits.

Overall findings included confirmation that the success of a new SEHR heavily depends upon the system’s perceived value. SEHR/PMH access system users typically make judgements as to whether to use an SEHR system, based on the likelihood of finding useful information that they can rely upon. Healthcare providers are more willing to use systems that are easy to use.

Most SEHR/PMH access systems in current use appear to be failing to achieve clinician support for a range of reasons: Patients opting to not participate, technical and integration issues, systems that are difficult to use, or are perceived as unlikely to provide access to information sought or because the information that is available cannot be verified as complete and accurate and therefore is unable to be fully relied upon, are some of those reasons.

Until now, most SEHR/PMH access systems have been based upon databases of patient information. Newer distributed SEHR/PMH access system designs are also being implemented. No approach has yet been established as a benchmark or is being used at any scale.

An alternative to continuing to focus on improving existing SEHR models may be to extend the electronic medical record (EMR) held by the general practice or primary care organisation that the patient uses, to create a shareable Principal Patient Record (PPR). A PPR strategy would especially be suited to health systems in which patients are enrolled with primary-care providers. Most OECD countries have put patient enrolment systems in place or plan to. Much of a patient’s health related information is currently held by his or her main primary care provider, this is especially so, when a patient enrolment system is in place.

Extending a patient’s existing EMR to create a PPR would require relatively little additional software development and its implementation would result in a minimum of disruption. A PPR framework would utilise existing data transfer, messaging and security frameworks. Advanced iterations of a PPR would include electronic links to more detailed data held on external information systems, including those owned by specialists, hospitals, radiology providers and laboratories.

It is time to look afresh at the way in which we are endeavouring to provide SEHR/PMH access to providers of unscheduled medical care.