A Study to the Impact of Accuracy Problem Lists in Electronic Health Records on Correctness and Speed of Clinical Decision-making Performed by Dutch Healthcare Providers

NCT ID: NCT05657002

Last Updated: 2022-12-23

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

Get a concise snapshot of the trial, including recruitment status, study phase, enrollment targets, and key timeline milestones.

Recruitment Status

COMPLETED

Clinical Phase

NA

Total Enrollment

160 participants

Study Classification

INTERVENTIONAL

Study Start Date

2022-12-01

Study Completion Date

2022-12-21

Brief Summary

Review the sponsor-provided synopsis that highlights what the study is about and why it is being conducted.

The primary objective of this study is to determine whether patient records with complete, structured and up-to-date problem lists ('accurate problem lists'), result in better clinical decision-making, compared to patient records that convey the same information in a less structured way where the problem list has missing and/or duplicate diagnoses ('inaccurate problem lists'). The secondary objective is to determine whether the time required to make a correct decision is less for patient records with accurate problem lists compared to patient records with inaccurate problem lists.

Detailed Description

Dive into the extended narrative that explains the scientific background, objectives, and procedures in greater depth.

A problem list in Electronic Health Records (EHRs) is considered an essential feature in the collection of structured data. The problem list provides a centralized summary of each patient's medical problems and these problems or diagnoses are selected from the terminology underlying the problem list, such as SNOMED CT. If well maintained and structured, the problem list is a valuable tool for reviewing records of (unfamiliar) patients as it quickly shows the required information when needed. While studies have shown that the use of structured formats can serve as prompt for extra details, greater consistency of information and clinical decision-making there is little evidence whether a patient record with complete and structured problem lists results in more accurate and faster clinical decision making.

In the study (ADAM's APPLE: Adequate Data registration And Monitoring, subproject: Accurate Presentation of Problem List Elements), the investigators will perform a crossover randomized controlled trial in which a laboratory experiment will be performed among individual healthcare professionals to assess the impact of patient records with accurate and inaccurate problem lists on clinical decision-making. The participants will be presented with two records of two different patients in a training environment of the software system EPIC, one of them with an accurate problem list and the other that conveys the complete information in the patient record (in free text notes) but with an inaccurate problem list with missing diagnoses and duplicate information. The participants do not know which of the two records includes the accurate problem list and which record includes the inaccurate problem list. Participants are asked to decide whether or not to prescribe two medications for those two patients. One medication is not allowed per patient because the patient is allergic to that medication, which is documented on the allergy list. For the first patient record, the other medication is not allowed, because of a contraindicated diagnosis and for the second patient record the other medication is not allowed, because of a side effect that has occurred using that medication in the medical history. Based on the correctness of the motivation for correct answers and the time to the right answers, the research question if accurate problem lists in patient records lead to better and faster decision-making is answered.

Prior to this study, two healthcare professionals in the research team determined suitable use cases and questions for this study. These use cases were based on real-world unstructured versions of patient records. Two optimized accurate problem lists were also created for both patient records, which was defined according to the problem list policy at our institution (i.e. all current active problems and relevant medical history should be documented on the problem list).

Conditions

See the medical conditions and disease areas that this research is targeting or investigating.

Clinical Decision-Making Decision Making, Computer-assisted Medical Records, Problem-Oriented Quality of Health Care Evidence-Based Practice Data Accuracy Documentation / Standards Documentation / Statistics & Numerical Data Forms and Records Control / Standards Humans International Classification of Diseases / Standards

Study Design

Understand how the trial is structured, including allocation methods, masking strategies, primary purpose, and other design elements.

Allocation Method

RANDOMIZED

Intervention Model

CROSSOVER

Participants will be presented with 2 patient records in EPIC, one with an accurate problem list and the other that conveys the complete information in the patient record (in free text notes) but with an inaccurate problem list with missing diagnoses and duplicates. Each participant answers a total of 4 questions for 2 separate patient cases (2 questions per case), one of those cases having the inaccurate and the other having the accurate problem list. Using 2 separate patient cases rather than one was decided to prevent a memory effect, i.e., participants would have had time to understand the patient's conditions described in the record which could impact the time required to answer questions in round 2. Additionally, the order in which patients cases are provided is not randomized, since in practice it also happens that a new patient is followed up by another new patient which requires professionals to systematically go through two separate records with little time in between.
Primary Study Purpose

HEALTH_SERVICES_RESEARCH

Blinding Strategy

SINGLE

Participants
Participant will be blinded, they do not know in what group they belong (thus which record they receive with the accurate or inaccurate problem list) and the participants are not informed that impact of problem list accuracy is investigated.

An independent researcher produced a randomization schema where per block of 10 participants a balanced random order of "patient A with accurate problem list + patient B with inaccurate problem list" or "patient A with inaccurate problem list + patient B with accurate problem list" is produced. The investigator (ESK) follows this list for the consecutive participants and gives access to the appropriate patient records as defined by the randomisation schema. The independent researcher checks afterwards whether the right order is followed based on time stamps and randomisation schema.

We performed a power analysis before conducting any experiment, which resulted in a required number of 157 participants.

Study Groups

Review each arm or cohort in the study, along with the interventions and objectives associated with them.

accurate problem list, then inaccurate problem list

in round 1, the participants will use the patient record of patient A, with an accurate problem list and answer the question: can the patient be prescribed Medication X and Y where medication X is a control question and medication Y is related to a contraindicated diagnosis (on problem list)

In round 2, the participants will use the patient record of patient B, with an inaccurate problem list and answer the question: can the patient be prescribed Medication X and Y where medication X is a control question and medication Y is related to medical history (not on problem list)

Group Type ACTIVE_COMPARATOR

patient A with accurate problem list

Intervention Type OTHER

A problem list that contains a diagnosis code that is contraindicated with a type of medication (Y). Also, all other relevant diagnoses and medical history for the patient are up-to-date on the problem list, which was defined according to the problem list policy at our institution (i.e. all current active problems and relevant medical history should be documented on the problem list). Additionally, the problem list is included in eight out of thirteen notes using so-called smart phrases that can automatically import a (part of a) problem list. One note includes the problem list with the diagnosis relevant for the question asked.

patient B with inaccurate problem list

Intervention Type OTHER

A problem list that does not contain the diagnosis code and corresponding details explaining medical history of this diagnosis caused by a type of medication (Y). Additionally, the problem list is included in three out of thirteen notes using so-called smart phrases that can automatically import a (part of a) problem list. The relevant diagnosis is not documented on the problem list and hence is not included in the imported problem list in the notes.

The expert panel provided and anonymized two real-world representative examples of hematology patient records that included inaccurate problem lists and that had many free-text notes. An 'inaccurate problem list' is defined as a problem list where diagnoses are missing resulting in missed trigger medication or order-alerts, where diagnoses are 'active' although they should be closed or removed and/or where the problem list contained duplicated diagnoses.

inaccurate problem list, then accurate problem list

in round 1, the participants will use the patient record of patient A, with an inaccurate problem list and answer the question: can the patient be prescribed Medication X and Y where medication X is a control question and medication Y is related to a contraindicated diagnosis (not on problem list)

In round 2, the participants will use the patient record of patient B, with an accurate problem list and answer the question: can the patient be prescribed Medication X and Y where medication X is a control question and medication Y is related to medical history (on problem list)

Group Type ACTIVE_COMPARATOR

patient A with inaccurate problem list

Intervention Type OTHER

A problem list that does not contain the diagnosis code that is contraindicated with the type of medication (Y). Additionally, the problem list is included in eight out of thirteen notes using so-called smart phrases that can automatically import a (part of a) problem list. The relevant diagnosis is not documented on the problem list and hence is not included in the imported problem list in the notes.

The expert panel provided and anonymized two real-world representative examples of hematology patient records that included inaccurate problem lists and that had many free-text notes. An 'inaccurate problem list' is defined as a problem list where diagnoses are missing resulting in missed trigger medication or order-alerts, where diagnoses are 'active' although they should be closed or removed and/or where the problem list contained duplicated diagnoses.

patient B with accurate problem list

Intervention Type OTHER

A problem list that contains the diagnosis code and corresponding details explaining medical history of this diagnosis caused by a type of medication (Y). Also, all other relevant diagnoses and medical history for the patient are up-to-date on the problem list, which was defined according to the problem list policy at our institution (i.e. all current active problems and relevant medical history should be documented on the problem list). Additionally, the problem list is included in three out of thirteen notes using so-called smart phrases that can automatically import a (part of a) problem list. One note includes the problem list with the diagnosis and details relevant for the question asked.

Interventions

Learn about the drugs, procedures, or behavioral strategies being tested and how they are applied within this trial.

patient A with accurate problem list

A problem list that contains a diagnosis code that is contraindicated with a type of medication (Y). Also, all other relevant diagnoses and medical history for the patient are up-to-date on the problem list, which was defined according to the problem list policy at our institution (i.e. all current active problems and relevant medical history should be documented on the problem list). Additionally, the problem list is included in eight out of thirteen notes using so-called smart phrases that can automatically import a (part of a) problem list. One note includes the problem list with the diagnosis relevant for the question asked.

Intervention Type OTHER

patient B with inaccurate problem list

A problem list that does not contain the diagnosis code and corresponding details explaining medical history of this diagnosis caused by a type of medication (Y). Additionally, the problem list is included in three out of thirteen notes using so-called smart phrases that can automatically import a (part of a) problem list. The relevant diagnosis is not documented on the problem list and hence is not included in the imported problem list in the notes.

The expert panel provided and anonymized two real-world representative examples of hematology patient records that included inaccurate problem lists and that had many free-text notes. An 'inaccurate problem list' is defined as a problem list where diagnoses are missing resulting in missed trigger medication or order-alerts, where diagnoses are 'active' although they should be closed or removed and/or where the problem list contained duplicated diagnoses.

Intervention Type OTHER

patient A with inaccurate problem list

A problem list that does not contain the diagnosis code that is contraindicated with the type of medication (Y). Additionally, the problem list is included in eight out of thirteen notes using so-called smart phrases that can automatically import a (part of a) problem list. The relevant diagnosis is not documented on the problem list and hence is not included in the imported problem list in the notes.

The expert panel provided and anonymized two real-world representative examples of hematology patient records that included inaccurate problem lists and that had many free-text notes. An 'inaccurate problem list' is defined as a problem list where diagnoses are missing resulting in missed trigger medication or order-alerts, where diagnoses are 'active' although they should be closed or removed and/or where the problem list contained duplicated diagnoses.

Intervention Type OTHER

patient B with accurate problem list

A problem list that contains the diagnosis code and corresponding details explaining medical history of this diagnosis caused by a type of medication (Y). Also, all other relevant diagnoses and medical history for the patient are up-to-date on the problem list, which was defined according to the problem list policy at our institution (i.e. all current active problems and relevant medical history should be documented on the problem list). Additionally, the problem list is included in three out of thirteen notes using so-called smart phrases that can automatically import a (part of a) problem list. One note includes the problem list with the diagnosis and details relevant for the question asked.

Intervention Type OTHER

Eligibility Criteria

Check the participation requirements, including inclusion and exclusion rules, age limits, and whether healthy volunteers are accepted.

Inclusion Criteria

* Healthcare professionals who are allowed to prescribe medication, thus hold a position as: medical specialist, medical resident, nurse specialist or physician assistant, research-specialists
* Healthcare professionals must have followed at least the 'basic EHR Epic course'. This electronic health record course lasts for three days and includes how to send letters, register diagnoses in a record, request testing, all in the software system EPIC, which concludes with an exam on the theory.

Exclusion Criteria

* Non-Dutch speaking employees as the patient cases and the exercises are described in Dutch
Eligible Sex

ALL

Accepts Healthy Volunteers

Yes

Sponsors

Meet the organizations funding or collaborating on the study and learn about their roles.

Eva Klappe

OTHER

Sponsor Role lead

Responsible Party

Identify the individual or organization who holds primary responsibility for the study information submitted to regulators.

Eva Klappe

PhD Candidate

Responsibility Role SPONSOR_INVESTIGATOR

Principal Investigators

Learn about the lead researchers overseeing the trial and their institutional affiliations.

Eva Klappe, MSc

Role: PRINCIPAL_INVESTIGATOR

Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)

Locations

Explore where the study is taking place and check the recruitment status at each participating site.

Amsterdam UMC, Location AMC

Amsterdam, North Holland, Netherlands

Site Status

Countries

Review the countries where the study has at least one active or historical site.

Netherlands

Other Identifiers

Review additional registry numbers or institutional identifiers associated with this trial.

2019-AMC-JK-7

Identifier Type: OTHER_GRANT

Identifier Source: secondary_id

Amsterdam UMC 2019-AMC-JK-7

Identifier Type: -

Identifier Source: org_study_id