Tolar M, Balka E. "Caring for individual patients and beyond: enhancing care through secondary use of data in a general practice setting."

Tolar M, Balka E. Caring for individual patients and beyond: enhancing care through secondary use of data in a general practice setting. Int J Med Inform 2012 Jul;81(7):461-74.
It is argued that with the introduction of electronic medical record (EMR) systems into the primary care sector, data collected can be used for secondary purposes which extend beyond individual patient care (e.g., for chronic disease management, prevention and clinical performance evaluation). However, EMR systems are primarily designed to support clinical tasks, and data entry practices of clinicians focus on the treatment of individual patients. Hence data collected through EMRs is not always useful in meeting these ends. PURPOSE: In this paper we follow a community health centre (CHC), and document the changes in work practices of the personnel that were necessary in order to make EMR data useful for secondary purposes. METHODS: This project followed an action research approach, in which ethnographic data were collected mainly by participant observations, by a researcher who also acted as an IT support person for the clinic's secondary usage of EMR data. Additionally, interviews were carried out with the clinical and administrative personnel of the CHC. RESULTS: The case study demonstrates that meaningful use of secondary data occurs only after a long process, aimed at creating the pre-conditions for meaningful use of secondary data, has taken place. PRECONDITIONS: Specific areas of focus have to be chosen for secondary data use, and initiatives have to be continuously evaluated and adapted to the workflow through a team approach. Collaboration between IT support and physicians is necessary to tailor the software to allow for the collection of clinically relevant data. Data entry procedures may have to be changed to encourage the usage of an agreed-upon coding scheme, required for meaningful use of secondary data. And finally resources in terms of additional personnel or dedicated time are necessary to keep up with data collection and other tasks required as a pre-condition to secondary use of data, communication of the results to the clinic, and eventual re-evaluation. CONSEQUENCES: Changes in the work practices observed in this case which were required to support secondary data use from the EMR included completion of additional tasks by clinical and administrative personnel related to the organization of follow-up tasks. Among physicians increased awareness of specific initiatives and guideline compliance in terms of chronic disease management and prevention was noticed. Finally, the clinic was able to evaluate their own practice and present the results to varied stakeholders. CONCLUSIONS: The case describes the secondary usage of data by a clinic aimed at improving management of the clinic's patients. It illustrates that creating the pre-conditions for secondary use of data from EMRs is a complex process which can be seen as a shift in paradigms from a focus on individual patient care to chronic disease management and performance measurement. More research is needed about how to best support clinics in the process of change management necessitated by emerging clinical management goals.

To document the changes in work practices of the personnel of a community health center that were necessary in order to make EMR data useful for secondary purposes - chronic disease management and practice performance management.

Tools Used
Type Clinic
Primary care
Small and/or medium
Other Information
Community health center in Vancouver, BC. Staffed by 6 physicians, one clinical pharmacist, one nurse practitioner, a team of medical office assistants, the medical office administrator and one executive director.
Type of Health IT
Electronic medical records (EMR)
Type of Health IT Functions
Utilization of data collected through the EMR system to support activities beyond one-to-one clinical encounters, such as identification of patients with chronic diseases, who would then be invited to participate in group visits, or monitoring of the clinic's performance in achieving evidence based indicators.
Context or other IT in place
The EMR system has been in place since 2004 and supports the storage and retrieval of administrative and clinical information (diagnoses, medication, lab results), the documentation of patient encounters as well as scheduling of appointments and billing.
Workflow-Related Findings
Practice search mechanism allows for a wide range of indicators for the quality of care to be collected and evaluated. With target areas identified, the work often fell on the office assistants to carry out follow up activities with the information generated. The office manager concluded that the office assistants feel more involved because use of the EMR makes it easier for the clinicians to communicate tasks to them.
The practice of reminding patients of preventive care measures entails additional tasks for doctors. They take the time to inform the patient about tests or other procedures and to organize the administration, i.e., by writing requisitions or printing out information sheets. They described this process as a team effort involving the office assistants who were responsible for taking on follow-up and proactive tasks. Behavior that was most impacted was that of frontline staff - making patients aware of preventive health activities (e.g., screening,) and following up with patients.
Study Design
Only postintervention (no control group)
Study Participants
Clinical staff at Community Health Center in Vancouver, BC, including clinicians and office assistants.