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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Virtual Databases for studying Real Life Health Problems
Comments on the Article on Electronic Data Collection by Wilson Pace et. al.
Electronic data capture for QI
Wireless solutions will dominate e-research
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Chris van Weel, The Netherlands Professor of family medicine, Radboud University Medical Centre Nijmegen, the Netherlands
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The possibility of electronically accessing data from clinical practice is a fascinating prospect. What until recently remained buried in the graveyard of personal notes has now in an electronic medical record environment the potential of being shared, in patient care, research or health care policy. This in particular true for where patients’ data are integrated – the records of the primary care physician. That is the reason that the opening of primary care medical records takes central stage in recent policy documents, for example the report of the Netherlands Health Council on the future Dutch general practice in a European context [1]. The Dutch minister of health in response proposed the family phyicisian's (FP) records as the focus point of information – a view echo-ed by researchers in the field of genetics. The need of integrated patient information, together with the technology to deliver it, may easily become one of the most powerful drives for family medicine research and this offers an exciting prospect for practice-based research networks (PBRN). Pace and Staton’s review [2] of the technical implications of electronic data collection in PBRNs from their personal experience and the literature comes at the right time. Now this is an option, the PBRN infrastructure should better be optimized for it and what experience is available, better be shared. But PBRNs and family medicine research are more than an electronic structure and it is important to keep sight of the larger picture. Long before the electronic era was information collected in and retrieved from practice and at least two lessons learned in that past might still hold true in the electronic era: that of their validity and of the ownership of data collected by practitioners during their patient care. Information should mean what it is supposed to mean in the context of the care for patients and the long and often tumultuous history of the classification of primary care [3] may illustrate that this is not uncalled-for: research requires the translation of the clinical interaction into terminology that allows proper study of the essentials of family practice. Diagnostic criteria [4] and definitions [5] play a key role in this process and have contributed more than the technology of data transport to PBRNs delivering valid data and successful studies [6, 7]. This is where PBRNs differ essentially from ‘family practice production data’ that every practice generates in the process of patient care. Such data can also be collected and analyzed, but there remains uncertainty of their value in translating them into an analysis of the process or outcome of care. Hence the metaphorical mining or fishing expedition. Pace and Staton express a lot of trust in technology to change databases in useful study material by retrieving, linking, or otherwise manipulating data electronically. I bag to differ and see a core contribution in PBRNs from the participating FPs and their staff. That brings-in the importance of the ownership of data. ‘Ownership’ should not be seen as a mere acknowledgement of who actually delivered the data. Essential is that FPs and their staffs do so in the context of their care for patients, relating the information they collect to their clinical observations and decisions. The more FPs in this way code and classify patient data themselves directly in their (currently: electronic) practice record, the greater the synergism between the clinical and research data. Material that has been collected with professional care by an FP in the full understanding of their clinical value and meaning is the best guarantee of reliable research output of PBRNs. Electronic technology can facilitate this process in a fascinating way, but that adds to the need of robust data input by (clinically and scientifically) involved FPs. References: 1. The Netherlands Health Council. European Primary Care. The Hague, 2004. http://www.gezondheidsraad.nl/pdf.php?ID=1119 (successfully accessed 09 June 2005). 2. Pace WD, Staton EW. Electronic data collection options for practice- based research networks. Ann Fam Med 2005; 3 (Suppl 1): S21-S29. 3. Wonca International Classification Committee. International Classification of Primary Care, ICPC-2. Second edition. Oxford, Oxford Press, 1998. 4. Anonymous. ICHPPC-2 defined. Inclusion criteria for the use of the rubrics of the International Classification of Health Problems in Primary Care. Oxford: Oxford University Press, 1983. 5. Bentzen, N. (Ed) Wonca Dictionary of General/Family Practice. Copenhagen: Maanedsskrift for Praktisk Laegegering, 2003. See also:http://www.globalfamilydoctor.com/dictionaryW/Dictionary of General- Family Practice.htm (successfully accessed 09 June 2005). http://www.annfammed.org/cgi/content/full/2/suppl_2/s5 6. Okkes IM, Oskam SK, Lamberts H. The probability of specific diagnoses for patients presenting with common symptoms to Dutch family physicians. J Fam Pract 2002; 51: 31-36. 7. Grauw WJC de, Gerwen van WHEM, Lisdonk van de EH, Hoogen van den HJM, Bosch van den WJHM, Weel van C. Outcomes of audit- enhanced monitoring of patients with type 2 diabetes., J Fam Pract 2002; 51: 459-464. Competing interests: None declared |
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Atif Zafar, Indianapolis, IN MD, Indiana University School of Medicine, William Tierney
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This is a nice overview of the challenges of implementing electronic data collection in the inherently "mobile" workflow environments of PBRNs. The article correctly points to the notions of "embedding technology into existing workflows" and not to "instantiate new workflows in order to accomodate new technologies". Assuming a clear need to collect data electronically because of the inherent benefits related to data analysis, data quality control, data access and reporting, specific types of devices and data formats should be used for specific types of data collection activities. Pre-population of form fields with available electronic data (using a direct link from an EMR to extract the relevant data points) can help reduce the data entry burden and improve the accuracy of the data entry process. New technologies, such as wireless computing and mobile devices, although promising are still challenging to adopt. Problems such as loss of network connectivity at critical times, inherently insecure wireless data transfers, need to develop "shadow" databases and record locking still abound. Javascript enabled cell-phones are inherently inefficient for use in PBRNs because (a) the screen size is too small to display viable questions, (b) the processor speed is too slow to accomodate real- time data collection that does not interfere with workflows and (c) the data transmission using traditional cell-phone connectivity is highly insecure. A model for traditional paper-based data entry that nicely accomodates workflow but captures data electronically using clever optical character recognition features has been presented by some of the Regenstrief investigators (http://www.iupui.edu/~chsrp/Publications/Paul/CHICA%20Paper%20Final.pdf). If workflows can accomodate them, Tablet PC based forms that accomodate quick pen-based handwriting and structured data (check-boxes, radio-buttons, drop-down lists etc.) are quite time-efficient. Given that the pen-interface is layered on top of the operating system, any existing software that runs on Microsoft Windows (web-based or standalone application - i.e. MS Access) can quickly be "pen-enabled" using these devices. Whatever device you happen to use, the goal should be to integrate it into existing workflows as efficiently as possible, ideally capturing only those data elements that currently do not exist electronically. Competing interests: None declared |
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Anton J Kuzel, Richmond, Virginia, USA Physician, Virginia Commonwealth University
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Wilson Pace and Elizabeth Stratton have done a great job of surveying the means for electronic data capture for PBRN work. Pace and colleagues have successfully employed web-based incident reporting to collect stories of medical errors in primary care, and have provided this information back to participating practices. This example, and the themes of the article by Mold and Peterson in this same supplement, made me think of the possibilities for electronic data capture for quality improvement in practices with EHRs. Most are designed to quickly and easily report out on markers of prevention and chronic disease management (e.g., immunization rates, glycohemaglobin levels), but what might happen if such practices also had the ability to electronically capture ideas and impressions real time while patient care is delivered, and do so in a way that is linked with the record of the patient visit? Might it be possible to embed this kind of "journal" entry within the record, but remove it from any other outside use of the record? What if patients could add entries about their experience of illness and of care at the time of the visit, and link this with the descriptions created by health professionals? Imagine the kinds of "quality improvement" efforts that could flow from this sort of data and understanding. Thank you, Wilson and Elizabeth, for the stimulating article, and keep breaking new ground. Competing interests: None declared |
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Zsolt J Nagykaldi, PhD, Oklahoma City, OK, USA Univ of Okla HSC Dept of Fam Med, Stephanie Fulton, Thomas L. Wilding and Frances Groen
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Dear Editor, I would like to congratulate Dr. Pace and Elizabeth Staton on their PBRN electronic data collection review and analysis. This review provides a very useful description of most popular data collection options available, their advantages and disadvantages. Using the right technology at the right place and the right time as well as selecting and training users is indeed crucial for feasible and reliable data collection. Based on our experience in OKPRN, we strongly believe that rapidly improving wireless options will dominate Health IT and e-research solutions to capture data especially in exam rooms and on the go. One such option the article has not focused on is smartphones (PDA and mobile phone combos). Some current models provide substantially enhanced resources including SSL and client side Java script -enabled wireless browser applications that are almost as powerful as a desktop browser. This approach makes the problematic conduit -based mobile device synchronization obsolete. Zsolt Nagykaldi, PhD Research Associate, Clinical IT Specialist University Of Oklahoma Health Sciences Center Department Of Family And Preventive Medicine Oklahoma Center For Family Medicine Research 900 NE 10th Street Oklahoma City, OK 73104 Phone: (405) 271-8000 Ext.:1-32212 Fax: (405) 271-1682 Competing interests: None declared |
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