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Recording problems and diagnoses in clinical care: developing guidance for healthcare professionals and system designers.

ABSTRACT: BACKGROUND:Accurate recording of problems and diagnoses in health records is key to safe and effective patient care, yet it is often done poorly. Electronic health record systems vary in their functionality and ease of use, and are not optimally designed for easy recording and sharing of clinical information. There is a lack of professional consensus and guidance on how problems and diagnoses should be recorded. METHODS:The Professional Record Standards Body commissioned work led by the Royal College of Physicians Health Informatics Unit to carry out a literature review, draft guidance, carry out an online consultation and round table discussion, and produce a report including recommendations for systems. A patient workshop was held to explore patient preferences for mechanisms for sharing diagnosis information between primary and secondary care. RESULTS:Consensus was reached among medical specialties on key elements of diagnosis recording, and draft guidance was produced ready for piloting in a variety of care settings. Patients were keen for better ways for diagnosis information to be shared. DISCUSSION:Improving the recording of diagnoses and problems will require a major effort of which the new guidance is only a part. The guidance needs to be embedded in training, and clinical systems need to have improved, standardised functionality. Front-line clinicians, specialist societies, clinical informaticians and patients need to be engaged in developing information models for diagnoses to support care and research, accessible via user-friendly interfaces.

SUBMITTER: Shah AD

PROVIDER: S-EPMC7062352 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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Recording problems and diagnoses in clinical care: developing guidance for healthcare professionals and system designers.

Shah Anoop Dinesh AD Quinn Nicola J NJ Chaudhry Afzal A Sullivan Ralph R Costello Julian J O'Riordan Dermot D Hoogewerf Jan J Orton Martin M Foley Lorraine L Feger Helene H Williams John G JG

BMJ health & care informatics 20191201 1

<h4>Background</h4>Accurate recording of problems and diagnoses in health records is key to safe and effective patient care, yet it is often done poorly. Electronic health record systems vary in their functionality and ease of use, and are not optimally designed for easy recording and sharing of clinical information. There is a lack of professional consensus and guidance on how problems and diagnoses should be recorded.<h4>Methods</h4>The Professional Record Standards Body commissioned work led ...[more]

PMID: 31874855

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Project description:Healthcare professionals provide care to patients and during that process, record large quantities of data in patient records. Data in an Electronic Health Record should ideally be recorded once and be reusable within the care process as well as for secondary purposes. A common approach to realise this is to let healthcare providers record data in a standardised and structured way at the point of care. Currently, it is not clear to what extent this structured and standardised recording has been adopted by healthcare professionals and what barriers to their adoption exist. Therefore, we developed and validated a multivariable model to capture the concepts underlying the adoption of structured and standardised recording among healthcare professionals.Based on separate models from the literature we developed a new theoretical model describing the underlying concepts of the adoption of structured and standardised recording. Using a questionnaire built upon this model we gathered data to perform a summative validation of our model. Validation was done through partial least squares structural equation modelling (PLS-SEM). The quality of both levels defined in PLS-SEM analysis, i.e., the measurement model and the structural model, were assessed on performance measures defined in literature.The theoretical model we developed consists of 29 concepts related to information systems as well as organisational factors and personal beliefs. Based on these concepts, 59 statements with a 5 point Likert-scale (fully disagree to fully agree) were specified in the questionnaire. We received 3584 responses. The validation shows our model is supported to a large extent by the questionnaire data. Intention to record in a structured and standardised way emerged as a significant factor of reported behaviour (??=?0.305, p?<?0.001). This intention is influenced most by attitude (??=?0.512, p?<?0.001).This model can be used to measure the perceived level of adoption of structured and standardised recording among healthcare professionals and further improve knowledge on the barriers and facilitators of this adoption.

Project description:BACKGROUND:There is little information about how healthcare professionals feel about providing palliative care for patients with a substance use disorder (SUD). Therefore, this study aims to explore: 1) the problems and needs experienced by healthcare professionals, volunteers and experts-by-experience (HCP/VE) during their work with patients with SUD in a palliative care trajectory and; 2) to make suggestions for improvements using the quality of care model by Donabedian (Structure, Process, Outcome). METHODS:A qualitative study was conducted, consisting of six focus group interviews which consisted of HCP/VE working with patients with SUD in a palliative care phase. At the end of the focus group interviews, participants structured and summarized their experiences within a Strengths, Weaknesses, Opportunities and Threats (SWOT) framework. Interview transcripts (other than the SWOT) were analysed by the researchers following procedures from the Grounded Theory Approach ('Grounded Theory Lite'). SWOT-findings were not subjected to in-depth analysis. RESULTS:HCP/VE stated that within the Structure of care, care networks are fragmented and HCP/VE often lack knowledge about patients' multiplicity of problems and the time to unravel these. Communication with this patient group appears limited. The actual care-giving Process requires HCP/VE a lot of creativity and time spent seeking for cooperation with other caregivers and appropriate care settings. The latter is often hindered by stigma. Since no formalized knowledge is available, care-delivery is often exclusively experience-based. Pain-medication is often ineffective due to active substance use. Finally, several Outcomes were brought forward: Firstly, a palliative care phase is often identified only at a late stage. Secondly, education and a (mobile) team of expertise are desired. Thirdly, care for the caregivers themselves is often de-prioritized. CONCLUSIONS:Better integration and collaboration between the different professionals with extensive experience in addiction, palliative and general curative care is imperative to assure good palliative care for patients with SUD. Currently, the resources for this care appear to be insufficient. Development of an educational program and social mapping may be the first steps in improving palliative care for patients with severe SUD.

Project description:BACKGROUND:Trauma and injury contribute to 11% of the all-cause mortality in Afghanistan. The study aimed to explore the perceptions of the healthcare providers (pre and in-hospital), hospital managers and policy makers of the public and private health sectors to identify the challenges in the provision of an effective trauma care in Kabul, Afghanistan. METHODS:A concurrent mixed method design was used, including key-informant interviews (healthcare providers, hospital managers and policy makers) of the trauma care system (N?=?18) and simultaneous structured emergency care system assessment questionnaire (N?=?35) from July 15 to September 25, 2019. Interviews were analyzed using content analysis approach and structured questionnaire data were descriptively analyzed. RESULTS:Four themes were identified that describe the challenges: 1) pre-hospital care, 2) cohesive trauma management system, 3) physical and human resources and 4) stewardship. Some key challenges were found related to scene and transportation care, in-hospital care and emergency preparedness within the wider trauma care system. Less than 25% of the population is covered by the pre-hospital ambulance system (n?=?23, 65.7%) and there is no communication process between health care facilities to facilitate transfer (n?=?28, 80%). Less than 25% of patients with an injury requiring emergent surgery have access to surgical care in a staffed operating theatre within 2 h of injury (n?=?19, 54.2%) and there is no regular assessment of the ability of the emergency care system to mobilize resources (human and physical) to respond to disasters, and other large-scale emergencies (n?=?28, 80%). CONCLUSION:This study highlighted major challenges in the delivery of trauma care services across Kabul, Afghanistan. Systematic improvement in the workforce training, structural organization of the trauma care system and implementing externally validated clinical guidelines for trauma management could possibly enhance the functions of the existing trauma care services. However, an integrated state-run trauma care system will address the current burden of traumatic injury more effectively within the wider healthcare system of Afghanistan.

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Recording problems and diagnoses in clinical care: developing guidance for healthcare professionals and system designers.

Publications

Recording problems and diagnoses in clinical care: developing guidance for healthcare professionals and system designers.

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