1. “Evaluation of a Virtual Electronic Patient Record use by medical doctors working at a hospital” Adviser: Ricardo João Cruz Correia Class 20

2. Introduction

3. Medical record Medical Record: set of documents containing clinical and administrative data which are taken from a patient after seeking medical assistance [1]. [1] Serviço de Bioestatítica e Informática Médica da FMUP. Aula sobre Registos Clínicos Electrónicos do Curso de Informática Médica. Available in http://im.med.up.pt. Accessed in March 2006.http://im.med.up.pt [2] Richard S. Dick, Elaine B. Steen, and Don E. Detmer, The Computer-based patient record: An Essential Technology for Health Care, National Academy Press, 1997. [3] Torchio M, Molino F, Sestero D, Seidemari C, Molino G. An electronic medical diary for computer assisted patient management. Minerva Med. 2003 Jun; 94 (3): 167-79. it has been the primary vehicle for recording patient care information [2].Clinical data is handwritten and all the clinical information is attached to it. [1]. Paper medical record: it has been the primary vehicle for recording patient care information [2]. Clinical data is handwritten and all the clinical information is attached to it. [1]. Electronic medical record: it’s a computerized database containing individual information of each patient.[3]. They are replacing paper medical records [2].

4. Hospital of S. João (HSJ) Scenario: Several information systems (e.g.:SONHO, SAM, applications for support services, various departmental information systems …) which weren’t designed to share information [1]. [1] Lenz R and Kuhn KA. Integration of heterogeneous and autonomous systems in hospitals. Business Briefing: Data management & Storage Technology, 2002. [2] R. Cruz-Correia, P. Vieira-Marques, P. Costa, A. Ferreira, E. Oliveira-Palhares, F. Araújo and A. Costa-Pereira, Integration of hospital data using agent Technologies- A case study. AI Communications. 2005. 18: 191-200. Problems: Repeated or inconsistent data [2]. Information gathering, integration and storage as well as its sharing aren’t automatic, leading to high administrative costs both in time and staff [2].

5. To create a system which integrates the information provided by all the other systems. ICU Hospital of São João Solution

6. ICU (Informação Clínica do Utente) It is a Virtual Electronic Patient Record created by The Biostatistics and Medical Informatics Department of the Faculty of Medicine of the University of Oporto. It is available to users since March 2004. It delivers to health professionals the maximum clinical information of a patient, integrated in a single folder [1,2]. [1] Serviço de Bioestatítica e Informática Médica da FMUP. Manual do utilizador do ICU. Available in http://epr.med.up.pt. Accessed in March 2006.http://epr.med.up.pt [2] Serviço de Bioestatítica e Informática Médica da FMUP. Panfleto de divulgação do ICU. Available in http://epr.med.up.pt. Accessed in March 2006.http://epr.med.up.pt

7. To evaluate the use of ICU system by medical doctors working at Hospital of S. João Aim

8. Methods FlowchartGantt chart

9. Study participants 1108 medical doctors (two categories: “medical staff” and “staff in pre- graduation internship”) currently working at HSJ. These medical doctors are in a list from The Human Resources Department. Target population: Sampling method: simple random sampling. Sample: 100 medical doctors. Study design: Observational and transversal study.

10. Data collection methods Elaboration of a questionnaire Application of four pilots (questionnaire correction after applying each pilot) Application of the definitive questionnaire (personal and structured interview) Questionnaire

11. Analyzed variables Use frequency of ICU (times per month) – comparison with the use frequency of other information systems of HSJ (namely SAM, CLINIDATA and Radiology Information System). Use frequency of ICU (usually, rarely and never) in emergency room, outpatient and inpatient. Way of access to ICU Importance degree of several characteristics of ICU (from 0 to 10) Visualization degree of reports from several departments (from 1 to 9) Reasons why not use ICU ICU impact in the medical doctor’s professional life and in HSJ Changes suggested to ICU

12. Statistical analysis Data introduction in software SPSS, version 14 for windows. To calculate the answer rate - frequency table To analyze use frequency of four information systems of HSJ (times per month) - averages To analyze sex, age and medical service type - frequencies To analyze the ICU use frequency in emergency room, outpatient and inpatient and the way of access to ICU - frequencies To analyze the importance degree of several ICU characteristics; the visualization degree of reports provided by nine departments - averages The two development questions (1- ICU impact, 2- changes suggested)- we read all the answers and grouped them in frequency tables

13. Results and Discussion

14. Sample description SituationNumber Not found 21 Not working in HSJ anymore 14 Had already finished the medical internship11 Not available5 Not a medical doctor (errors in the list)4 Refused to answer3 Labour license1 Holidays1 Sickness1 Not working due to a personal reason1 Answered to the questionnaire 38 Total 100 Answer rate= 53% (38/(100-14-11-4))

15. Description of the medical doctors who answered (n=38) Sex: 55% were women AgePercentage Between 20 and 40 years old 45% Between 41 and 50 years old 26% Older than 50 years old 26% Age unknown 1 person Age

16. 27 work in non surgery services 10 work in surgery services 1 person works in a support service Medical service type Description of the medical doctors who answered(n=38) Type of service Have already used ICU Average / month Non surgery1936 Surgery860 Support00 19 out of 27 medical doctors who work in non surgery services have already used ICU – 70% 8 out of 10 medical doctors who work in surgery services have already used ICU – 80% The average of use frequency per month is higher in surgery services. ICU is more frequently used in surgery services. p > 0,05 – this is not statistically significant

17. System Percentage of medical doctors who have already used the system Average of use frequency per month ICU 71%41 SAM 79%74 CLINIDATA 90%58 Radiology IS 95%99 Use frequency of four information systems of HSJ ICU has been used by 71% of medical doctors. So, 29% have never used it. We verified that all these medical doctors didn’t know the system at all. ICU is the least used information system whereas Radiology Information System is the most used one. Description of the medical doctors who answered(n=38)

18. Result: ICU is the least used information system of the four Evidence: The number of medical doctors who have never used it is the highest. It has the lowest average of use frequency per month. Possible explanation: It is the most recent and, therefore, the least known system (all the medical doctors who have never used ICU didn’t know it). The non usage isn’t due to computer illiteracy or lack of appropriate computer hardware, because all the medical doctors who have never used ICU, use other information system.

19. Using ICU isn’t mandatory as using SAM is in outpatient - SAM tends to be more used than ICU. In fact, we can see that, despite the average of use frequency of SAM is much greater than that of ICU, there isn’t a great difference between the percentages of medical doctors who have ever used these systems. There are alternative systems allowing access to reports also available in ICU (e.g.: reports from Clinical Pathology) - these systems can replace some ICU functions. Result: ICU is the least used information system

20. Use frequency of ICU in emergency room, inpatient and outpatient ICU is more frequently used in inpatient and less used in emergency room. Description of the medical doctors who use ICU (n=27)

21. In outpatient and, even more, in inpatient this contact is longer and there is a greater need to monitor the patient and to consult past information; the kind of information provided by ICU is more appropriated for inpatient situations than in an emergency room Result: ICU is more used in inpatient Possible explanation: In emergency room the contact between medical doctor and patient is more fleeting - there is less time to consult the clinical history of the patient.

22. Way of access to ICU The most used way of access is a link on the desktop. Description of the medical doctors who use ICU (n=27)

23. Importance degree of several ICU characteristics (from 0 to 10) from the medical doctors’ point of view Medical doctors think that the two most important ICU characteristics are its capacity to integrate information from several departmental information systems and its capacity to decrease the time spent acceding to clinical information. Description of the medical doctors who use ICU (n=27)

24. Possible explanation: Nowadays, medical doctors face two main problems in their clinical practise: the patient’s clinical information is spread in various departmental information systems increasing the time spent to obtain the useful information. Result: the most valued ICU characteristics

25. Visualization degree of reports from several departments (from 1 to 9) The most visualized reports are those from Immunohemotherapy, Clinical Pathology and Anatomo-pathology. Description of the medical doctors who use ICU (n=27)

26. Possible explanation: These reports have general information that can be used by many different medical specialities, whereas the other departments provide more specific reports. Result: the most visualized type of reports

27. This is according to the opinions about ICU characteristics. Description of the medical doctors who use ICU (n=27) Opinion about ICU impactn It is easier to accede to the clinical information of a patient 23 It decreases the time spent to accede to laboratorial and clinical information 15 Negative impact 2 No answer1 Total41

28. Suggestion of changes to ICU The major suggestions are increasing the number of departments from which is possible to visualize reports and decreasing some technical problems. Description of the medical doctors who use ICU (n=27) Changes suggested n No suggestion15 Increase the number of departments from which it’s possible to visualize reports 6 Decrease technical problems that, sometimes, damage the partial or total use of ICU 5 Decrease the reports update time3 Every report available in ICU should be complete1 Total30

29. Even though it is a less spread system, ICU brings advantages to those who use it as they would like to see more departments connected with this system. Result: The most suggested change

30. Discussion: summary ICU is more used in inpatient because here there is a greater following of the patient. The reports from Immunohemotherapy, Clinical Pathology and Anatomo-pathology provide more general information and so are the most visualized. ICU is less used than the other compared systems, maybe because it’s the most recent and less known, unlike some systems it isn’t mandatory, and there are alternatives to some reports. ICU is more frequently used in surgery services.

31. Limitations The list we were given by the Human Resources Department was out of date. Many medical doctors didn’t answer the questionnaire because of the several previously discribed reasons. Therefore, the results may not represent the behaviour of the target population. For example, the answer rate of the medical doctors who work in surgery services (10 answered questionnaires in 11 possible gives an answer rate of 91%) is greater than the answer rate of medical doctors who work in clinical services (27 answered questionnaires in 56 possible gives an answer rate of 48%), which probably has an impact in our final results.

32. Acknowledgments Thanks to: Medical doctors who participated for their cooperation Dr. Ricardo Cruz Correia for helping us with this project Prof. Dr. Altamiro da Costa Pereira for his suggestions Dr. Clara Tavares for assisting with the graphs.