Summary points
“What was already
Documentation and information management are fundamental aspects of patient care. Health information technology (Health IT) such as electronic medical records (EMRs), decision aids, computerized order entry and electronic prescribing have rapidly become part of daily practice for many physicians [1]. A 2006 Cochrane review concluded that Health IT has been shown to significantly improve quality by increasing guideline adherence, enhancing disease surveillance, and decreasing medication errors [2]. While data on the impact of EMRs on clinical care is increasing, there is less information investigating the use of EMRs in clinical research [3].
The University of Michigan Health System (UMHS) has stored clinical information in CareWeb [4], an in-house developed electronic documentation creation and viewing system. Since 1998, UMHS has utilized CareWeb as a unified EMR. Patient encounters, problem lists and medication data are largely encoded as free text. This allows clinicians to easily and rapidly enter data, either by dictating or typing, without the constraints of a controlled medical vocabulary or predefined document structure. In 2007 alone, over 108 million lines of text representing 2.6 million clinical documents were entered into CareWeb. These patient data are not coded, making extraction of this information challenging.
Given the time and effort required for manual chart review, attempts have been made to apply search engine technology to the EMR [5], [6], [7]. Existing approaches are often not optimal given concerns with: (1) impracticality of use for patient data containing hundreds of documents (e.g. search in MS Word); (2) presentation of results in manner that makes it difficult to efficiently review medical records and keep information for each patient distinct (e.g. text processing applications such as jEdit); and (3) inability to search for words based on the case sensitivity associated with many medical terms, as well as security concerns arising from creation of an external data index (e.g. Lucene). The electronic medical record search engine (EMERSE) was created at UMHS to provide a secure and efficient way to utilize the EMR for research and clinical data abstraction [8]. EMERSE offers an intuitive user interface for searching the EMR. Search results from EMERSE are shown in a format consistent with the organization of the EMR, segregated by individual patients and separate categories for demographics, the problem summary list, clinical notes, and pathology and radiology reports. One of its most powerful features is the ability to perform batch searches across multiple patients. “Bundles”, or groups of search terms, can be created to perform standardized searches of patient lists. EMERSE search bundles enable the user to search for or ignore phrases, as well as include case-sensitive searches and wildcard matches. Using the bundle, the system searches the record for these terms, and produces context-sensitive search results or “hits”. EMERSE functions to protect health information; unlike manual chart reviews, records that are not of interest are ignored, not appearing as “hits”.
Currently EMERSE is being used in more than 150 research studies in a variety of medical departments across our entire health system of 3 hospitals, 30 health centers and 120 clinics. Our study team is utilizing EMERSE for several research studies on later-life depression for two main purposes: (1) to quickly and efficiently screen thousands of patients for study eligibility in a manner that protects personal health information; and (2) to search or “mine” the free-text medical record to examine patient health variables that could not previously be studied in large-scale administrative data.
While we and many other study teams at our institution have found EMERSE to be invaluable, the standard in clinical research remains manual chart reviews performed by trained chart abstractors. Methods created for EMR information extraction need to be of similar accuracy and faster than manual review of medical records in order to add value.
The purpose of this study was to compare the clinical accuracy and speed of eligibility chart reviews performed using EMERSE with those done manually through the EMR. Based on our experience with this tool in several studies, we hypothesized that using EMERSE would be faster than manual chart reviews while maintaining clinical accuracy.
As the first step in a NIMH and IRB-approved study, we use our EMR to screen for eligibility by identifying patients who attended appointments in participating family medicine and internal medicine clinics in the prior week. Eligibility participation criteria include (1) age 60 and older, (2) primary care provider recommendation of new depression treatment within the previous month, (3) White or African American race, and (4) no history of dementia, bipolar disorder or schizophrenia. These
For all raters, use of EMERSE resulted in a considerable time savings regardless of level of experience (see Table 1); chart reviews using EMERSE were significantly faster than traditional manual review (p = 0.03). The time savings were greater for the raters with more experience (raters 1 and 2), yet even the most inexperienced rater (rater 3) saved over an hour by using EMERSE.
In terms of valid eligibility decision-making, the percent agreement of raters with the gold standard using either
In this study, use of a medical record search engine, EMERSE, was shown to be as clinically accurate and significantly faster than manual chart abstraction for the purposes of eligibility chart reviews. Rater experience did not adversely impact level of clinical accuracy between the two methods.
These results indicate that a medical record search engine such as EMERSE has tremendous utility for reducing the time required for chart screening in clinical research both for prospective subject
Using technologies such as an electronic medical record search engine to augment manual chart reviews for patient eligibility determination can result in significant time savings while preserving the ability to make valid decisions. The major power of EMERSE is not from a more advanced and sophisticated search algorithm, but rather from a user interface designed explicitly to help users search the entire medical record in a way that protects health information. Summary points “What was already
This research was supported by an NIMH grant (R21MH073002) awarded to Dr. Helen Kales. Portions of this manuscript were presented as a poster presentation at the American Association for Geriatric Psychiatry Annual Meeting, Orlando, FL, March 2008.