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[Gnumed-devel] Gnumed's design suitable for complex encounter requiremen

From: Jim Busser
Subject: [Gnumed-devel] Gnumed's design suitable for complex encounter requirements
Date: Wed, 23 Dec 2009 21:55:11 -0800

Dr. Simon de Lusignan – head of general practice at a UK teaching centre and editor of the UK-based journal Informatics in Primary Care – and colleagues previously developed an open source observational tool to measure the influence of the doctor’s consulting style and the computer system on the outcomes of the clinical consultation

They have now presented (November 2009 annual meeting of the North American Primary Care Research Group in Montreal) an analysis of doctor, computer and patient interactions in four EMRs (note: none of them were GNUmed).

A Canadian publication called the Medical Post featured a story based the plenary session presentation.The full story is available online (link below, needs  a login) but here are some excerpts:
… He and researchers digitally recorded 167 consultation by 15 GPs... they were then able to compare the interaction between doctors and what was being entered into four different EMR software systems. [T]hey found often “there’s tons of navigation for very little use.”

… Also, consultations rarely happened in a structured, ordered manner like the EMR’s recording system. Patients would jump from topic to topic or symptom to symptom.

… In half a dozen of the consultations they recorded, the person accompanying the patient also wanted medical attention.

… Interruptions were just a normal part of a consultation. All but two of the GPs were interrupted and six were interrupted more than once. There were 13 phone calls. “This is the reality of primary-care practice and we should be designing systems that take account of this,” he said.

Worse, from the point of view of a researcher who wants to extract data, many of the consultations didn’t involve any imputing [sic] of easily harvested coded data. Many consultations resulted in nothing more than text entry.

Where GNUmed stands in relation to the above:

1) on the issue of jumping from topic to topic or from symptom to symptom, GNUmed recognizes and supports this through its multi-tabbed progress note editor

2) interruptions that would require the doctor to look-up another patient may, in many EMRs, require that the doctor depart the record of the current patient and maybe even finalize pending entries to be able to bring up the record of the patient about whom the interruption pertains. With GNUmed, a separate instance can be raised and this instance kept minimized or docked for when it may be needed, such as interruptions that require a different patient to be looked up

3) on the use case where a person accompanying the patient also wants a health need met, the same second-instance approach could allow this to be handled provided care was taken to input into the wrong record. The user should be careful to minimize whichever record is not in focus within whatever is the active discussion.

4) de Lusignan apparently asked the audience whether anyone has ever put out specifications for a primary-care EMR system that make adjustments for the request of an accompanying person. I suppose that we can answer in the affirmative for GNUmed, since our project anticipated and delivered the multiple-instance to cover the general case, which includes the person accompanying the patient. True enough, the use case could be further programmed, in that once the accompanying person would be entered into the yet-to-be-built patient social web, a control-click might open one of our slave instances of GNUmed, if such spring-loading were worth the effort to develop (it being only a bit more work to look up the person in the second instance)

Further on this, people might be interested in:

Computers in the new consultation: within the first minute

In relation to the upcoming challenge of coding, we might take account of:

Variation in clinical coding lists in UK general practice: a barrier to consistent data entry?

Ability to Generate Patient Registries Among Practices With and Without Electronic Health Records
..."Because practices need registries to perform
broad-based quality improvement, they should consider
adopting EHRs that have built-in registry functionality."

Multi-tasking in practice: Coordinated activities in the computer supported doctor–patient consultation

Development of an assessment tool to measure the influence of clinical software on the delivery of high quality consultations. A study comparing two computerized medical record systems in a nurse run heart clinic in a general practice setting
Informatics for Health and Social Care 2002, Vol. 27, No. 4,
Pages 267-280 , DOI 10.1080/1463923031000081603 

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