Which functionalities are available in the electronic health record systems used by French general practitioners? An assessment study of 15 systems

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Highlights

Abstract

Objective

Whereas an unprecedented effort is currently under way worldwide for the implementation of electronic health record (EHR) systems, their capabilities are poorly understood, especially in primary care. The objective of this study was to assess the main functionalities of the EHR systems used in French general practices.

Methods

Among the 20 EHR systems marketed in France, we assessed the 15 systems used by more than 1500 general practitioners in the Provence-Alpes-Côte d’Azur region in the southeast part of France. Each EHR system was assessed in a general practice office, using two clinical vignettes describing virtual patient consultations. The evaluation criteria were derived from the EuroRec requirements for EHR system quality. The assessment scale included 37 criteria grouped into three sets: background data, consultation data, and exchange functionalities. The scoring system used, totalling 64 points, was based on the validation of the criteria and was adjusted based on the possibility of standardising the data. A high score indicated a good EHR system quality.

Results

The median global score was 32 points out of a possible 64 (range: 20–39). The median score was 12 points out of 22 (range: 6–15) for the background data set, 16 points out of 32 (range: 9–22) for the consultation data set, and four points out of 10 (range: 0–6) for the exchange functionalities. No association was found between the number of users and the assessment score of the EHR systems (p = 0.79). One third of the EHR systems lacked a problem list and only one of them supported the episode of care.

Conclusion

Functionalities noticeably vary among the EHR systems currently used in French primary care. Whereas these systems are globally very focused on drug prescriptions, several core functionalities are frequently lacking. They are also poorly interoperable for healthcare professionals and patients. Further research is necessary to assess their actual use.

Introduction

Electronic health record (EHR) systems are part of an evolving concept comprising a wide range of information systems, from files compiled in single units of care to longitudinal collections of patient electronic health data [1]. EHR systems’ primary use is to support the continuation of efficient and quality integrated health care, based on reminder functions for patients’ health histories and on automated decision support systems, which provide alerts and advice on diagnosis or treatment [1], [2], [3]. Their secondary uses include quality assessment, safety monitoring, health policy planning, and medical research [4], [5]. If shared, the information collected in EHR systems can also support communication between healthcare providers [6].

All these uses can be facilitated by the integration of core functionalities (SOAP model, problem list, episode of care) and the standardisation of health information. The SOAP model is the possibility to enter notes in a template to document patients’ concerns and the health issues managed during encounters. In the SOAP model, the S stands for the symptoms presented by the patient, O for the clinical findings of the practitioner (objective data), A for the practitioner's assessment of health issues and P for the plan of care, which includes performed and prescribed procedures [7], [8]. The problem list is composed of “active” and “inactive” health problems; a problem is considered to be active if it has the attention of the practitioners or of the patient, as reflected by present treatment, subsequent diagnostic investigations, disease monitoring, or the known progressive course of a disease [9], [10]. The episode of care is defined as the time interval during which healthcare activities are performed by one healthcare provider to address one professionally defined health issue [11]. This concept supports the continuity of information, which in turn supports the continuity of care [12].

In addition, the use of standardised terminologies, associated with controlled vocabularies, is a prerequisite to achieve semantic interoperability of EHR information [2]. Standardisation improves the reliability of medical data, especially if the data are to be shared with other healthcare providers [6], [13] or used for administrative functions or research [14]. Standardised data are also required to run clinical decision support systems [15].

In 2007, 87% of European general practitioners (GPs) were equipped with computers in their consultation rooms. In France, the level of computerisation has been estimated at 83%, varying from 78% in solo practices to 100% in group practices of four or more GPs. However, computers are only used (in any manner) in 66% and 72% of consultations by European and French GPs, respectively [16]. In the U.S.A. in 2007, only 35% of office-based physicians declared that they used EHR systems, which infrequently included a “full functional system” (4%) or even a “basic system” (12%). Furthermore, their use of any EHR system varied from 21% in solo practices to 74% in practices with 11 or more physicians [17]. Apart from the capital costs, the primary reported barrier for adopting EHR systems in ambulatory care was these systems’ inadequacy for meeting physicians’ needs [18].

It is now admitted that the actors involved should focus on increasing the adoption of robust EHR systems that allow the use of specific features, rather than simply deploying EHR systems regardless of their functionality [19]. Whereas an unprecedented effort is in progress to implement EHR systems worldwide, the capabilities of EHR systems are poorly understood (apart from decision support systems [20]), especially in primary care. Our objective was therefore to assess the main functionalities of the EHR systems used in French general practices.

Section snippets

Assessment data

Among the more than 20 EHR systems marketed in France [21], we included in the study the 15 systems that were used by more than 1500 GPs in the Provence-Alpes-Côte d’Azur region of southeast France. Each EHR system was assessed by one author (RS) between February and April 2009. We tested data entry according to two standard clinical vignettes describing virtual patient consultations (Box 1). Each EHR system was assessed in a general practice office over a 2-h period.

Assessment scale

The evaluation criteria

Results

The median global score was of 32 points out of 64 (range: 20–39) (Fig. 1). The median score was 12 points out of 32 (range: 6–15) for the “background data” set (Fig. 2), 16 points out of 32 (range: 9–22) for the “consultation data” set (Fig. 3), and four points out of 10 (range: 0–6) for the “exchange functionalities” (Fig. 4). All of the EHR systems included fields for entering medical history and socio-professional status, but only three included fields for mass screening data. Patient and

Main findings

This evaluation of 15 French EHR systems showed a low global level of performance (median score of 32 out of 64) and a large disparity (range: 20–39). Among these systems, none had maximal scores simultaneously in the three sets of functionalities assessed (background data, consultation data, exchange functionalities).

Regarding the background data, nine or more of the 15 EHR systems had no specific fields for ethnicity, familial links, risk factors or mass screening achievements. Among the

Conclusion

The EHR systems assessed in this study seemed not to fit the growing needs of French general practitioners. These systems are globally very focused on drug prescriptions, while functionalities related to the quality and the continuity of care, such as the SOAP data model, problem list or episodes of care, are frequently lacking. They are also poorly interoperable for healthcare professionals and patients. The actual use of various EHR systems by general practitioners remains to be assessed.

Author contributions

David Darmon, Rémy Sauvant, Pascal Staccini, and Laurent Letrilliart performed the work described in this article and collaboratively authored this article.

Conflict of interest statement

Laurent Letrilliart has worked as a consultant on ICPC-2 for Cegedim Strategic Data in 2010.

Summary points

What was already known on the topic?

  • French general practitioners are increasingly equipped with computers in their offices.

  • The quality of the EHR systems they use is poorly known.

What does this study add to our knowledge?

  • The functionalities are highly variable from one French EHR system to another.

  • The data are often weakly structured, apart from drug prescription data.

Acknowledgement

We thank François Mennerat for his methodological help and Laurent Laforest for his review of the manuscript.

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