CONNECTING HOSPITALS AND HEALTH CENTRES COULD

BENEFIT MOST OF PORTO’S CHILDREN POPULATION

Current Trends in Paedriatic Patients’ Mobility between Institutions Requires

Implementation of Electronic Patient Records

Ana Edral

, Ana Sofia Matos

, Beatriz Soares

, Carlos Leite

, Joana Almeida

, João Girão

, João

Nunes

, Maria Isabel Pereira

, Miguel Lobato

, Mónica Silva

, Rita Boaventura

, Sofia Faria

Ricardo Cruz-Correia

1,2

Faculdade de Medicina,Universidade do Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal

Center for Research in Health Information Systems and Technologies

Keywords: Computerized patient record, medical record linkage, paediatrics, health institutions, Multi Institutional

Systems.

Abstract: Nowadays, data is spread across many institutions. Aim: This study aims to establish the need for the

implementation of a regional Electronic Patient Record (EPR) in Porto area, to support the mobility, and the

characteristics of the population that attends Porto’s Paediatric Unit (UPP) Methods: The study is

crossectional with a consecutive sampling method. A questionnaire was applied during three days. The

study population consisted of children attending to Paediatrics Emergency of Porto (UPP). Individuals

accompanying those children were approached, in the waiting room in order to answer the designed

questionnaire about the patient. Individuals who refused to answer, entered directly to the emergency room

or did not complete the interview were excluded. Results: 151 patients entered the emergency room during

the shifts, 126 were approached, 25 were immediately non available, 6 refused answering and 8 were

incomplete – the response rate was 74%. The age mean was 4 years old, with 46% being under 2. Within

children who visited UPP, 37% have been referred: 63% from health centres, 26% from other hospitals and

the remaining from private care institutions; 25% of the patients went only to health centres for outpatient

care; 56% attended UPP from 2 to 5 times in the last 14 months. Conclusions: Implementing an EPR

accessible in health centres and the UPP is relevant for the population studied, especially those under 2

years of age.

1 INTRODUCTION

As information and communication technologies

have advanced, interest in mobile health care

systems has grown. (Yoo, Kim, Park, Choi, & Chun,

2003).

It happens that a citizen often resorts to more

than one medical institution, leading to repeated

medical exams and anamnesis. Thus, patient's data is

spread over the places where they have received

clinical services (Katehakis, Sfakianakis, Tsiknakis,

& Orphanoudakis, 2001), such as hospitals, private

clinics, pharmacies, etc. (Lambrinoudakis &

Gritzalis, 2000). On the other hand, increasing

evidence suggests that error in medicine is frequent

and may result in substantial harm. (Bates et al.,

2001 )

To overcome this problem, we need solutions

that integrate data (Yoo et al., 2003). Changes have

been made, and nowadays, the physical location of a

patient record can be replaced by a virtual one (van

Bemmel, van Ginneken, Stam, & van Mulligen,

1998), by linking databases from different health

institutions attended. When used, computer-based

decision supports significantly improved decision

quality (Sintchenko, Coiera, Iredell, & Gilbert,

2004) and helped to reduce the frequency and

consequences of errors in medical care (Bates et al.,

2001 ; Koppel et al., 2005).

305

Edral A., Soﬁa Matos A., Soares B., Leite C., Almeida J., Gir

ao J., Nunes J., Isabel Pereira M., Lobato M., Silva M., Boaventura R., Faria S. and

Cruz-Correia R. (2008).

CONNECTING HOSPITALS AND HEALTH CENTRES COULD BENEFIT MOST OF PORTO’S CHILDREN POPULATION - Current Trends in Paedriatic

Patients’ Mobility between Institutions Requires Implementation of Electronic Patient Records.

In Proceedings of the First International Conference on Health Informatics, pages 305-309

 SciTePress

These procedures and attempts are expected to

allow coordination of information and correction of

gaps in communication (considered to be vital

(Branger, van’t Hooft, & van der Wouden, 1995)) in

cases that patients are receiving shared care, which

involves more than one physician (Branger, van

Hooft, Duisterhout, & van der Lei, 1994) (the

number of those cases has increased along time,

thanks to the rising of interdisciplinary practice and

tests (Hildebrand et al., 2006)). EPRs can also prove

themselves important for improvement of quality

and reduction of the health's care cost (Kahn, 1997)

and improvement of the safety and efficiency of

clinical care (Shapiro et al., 2006). EPRs are also

believed to be crucial for the creation of large

databases of de-identified aggregated data for

research (Overhage et al., 2002). However, some

studies demonstrated that the application of these

new systems may bring some problems, namely the

difficulty felt by some emergency physicians to

remember their passwords and the time required to

search for the information, stressed as significant

barriers to access clinical information online

(Schneider, 2001).

As far as children are concerned, they are one of

the major groups (along with elderly people) who

usually request a large amount of health services

(INE, 2007 ) and are involved in emergency

situations probably due to the unpredictability of

their behaviour. Therefore, the exchange of

electronic information regarding a patient who may

be unconscious or unaware of his pathological

previous condition (cardiac malformation, for

example) could prove to be vital in the urgent care

scenario.

For that matter, assessing the number of

institutions visited by children as well as the

proportion that goes to a second health care centre is

an issue of major importance as it may allow, in the

future, concluding about the number of people that

would benefit of such a method.

UPP (Urgência Pediátrica do Porto - Paediatric

Unit of Porto) is a centralized healthcare institution

for all emergency paediatric events in Porto district.

This study aims to establish the need for the

implementation of a regional Electronic Patient

Record (EPR) in the Porto area, to support the

mobility and the characteristics of the population

that attends UPP.

The paper is organized in several sections: a first

section of introduction and objective; secondly a

participants and methods section in which its

described the study, the applied questionnaire and

the population; thirdly a results section which

presents the results concerning mobility for hospitals

and mobility for other institutions; fourthly a

discussion section, presenting the authors

interpretation of results and study’s limitations; next

a conclusion section highlighting the main study

conclusions; followed by acknowledgments and

references.

2 PARTICIPANTS AND

METHODS

2.1 Study Design and Population

This is a cross-sectional survey with a consecutive

sampling method. Data collection was done in a

single moment by interviews to people

accompanying children attending the UPP, about

events occurred since January of 2006 until the date

of interview.

The study population consisted of children

attending to Paediatric Emergency of Porto (children

under the age of 14).

2.2 Data Collection Methods

The questionnaire was applied to all individuals at

the waiting room of UPP, except the ones who

refused to answer or those who were immediately

non available (entered directly to be attended). Some

of the questionnaires were incomplete because, in

the mean time, the interviewee was called to receive

medical care.

The questionnaire was applied on the 8th, 11th

and 12th March (a Sunday and two working days),

with two shifts a day, between 8 to 10 a.m. and 8 to

10 p.m. Three interviewers in the waiting room of

UPP, approached people who were accompanying

children and felt capable of answer our

questionnaire. The first stage of the interview was to

explain the purposes of the study and ask a consent

declaration to be signed (elaborated by the Hospital

Ethics Committee). The next stage was to proceed

with the questionnaire. The interviews lasted about 5

minutes.

2.3 Questionnaire

Data collected from the interviews included

questions about the person who was answering

(profession, kinship and years of school) and about

the child they were accompanying (age, address,

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gender). The remaining questions were targeted to

the purpose of the study - type and number of health

institutions visited since January 2006 (hospitals,

health centres, private clinics) as well as physicians’

specialities.

The variables obtained from the questionnaire

are age, gender, address, number of each type of

healthcare institution attended (hospitals, health

centres and private clinics) and also a description of

the visited ones. Other variables obtained about the

interviewee (the person accompanying the child)

are: profession, kinship and years of school.

Age was categorized in age groups. The

variables about the number of different healthcare

institutions attended were obtained by questioning

how many different health care institutions were

visited, however a list was provided, being some

enumerated to help the individuals remember them.

Different institutions not existent in the list were

also added.

2.4 Statistical Analysis

The data was submitted to statistic treatment with

SPSS 14.0 for windows. Socio-demographic data

(age, place of living, employment, qualifications)

was presented in frequency distribution; other data,

concerning the aim of the study (mobility, referrals,

and type of institutions) was mainly submitted to

cross frequency tables and absolute frequency

distributions.

Figure 1: Living places distribution (n=112).

3 RESULTS

3.1 Sample Description

Data was collected in 4 hours shifts, for 3 days, on

March

2007. A hundred and fifty one people entered

the UPP and, of those, 25 (17%) went directly to the

doctor’s room. Only 126 (83%) stayed in the waiting

room where the interviews took place: 6 (4%)

refused, 120 (79%) accepted to answer it. Some of

them were called to walk into the doctor’s room

while answering, so that we obtained 8 (5%)

incomplete questionnaires and only 112 (74%) were

complete (considered the valid ones). The response

rate was 74% (112 out of 151).

The sample was composed by 48 (43%) female

and 64 (57%) male children. Fifty one (46%)

individuals were under or 2 years old and 61 (54%)

were over 2 years old. The mean age was 4 years

old. These individuals were living mainly in the

Porto region (see Figure 1).

3.2 Mobility for Hospitals

In the study, the mean number of times children

attended UPP is 1,74 (б = 0,61), 39 (35%) children

were visiting UPP for the first time since January

2006, 63 (56%) visited it 2, 3, 4 or 5 times and the

other 10 (9%) visited it more than 5 times.

Of the individuals who visited UPP, 41 (37%)

were referred from other institutions: 27 (63%) from

Health Centers, 11 (26%) from Hospitals and 5

(12%) from Private Clinics. The mean of the number

of references is 0,49 (б = 0,76).

Crossing the number of times children attended

UPP with the number of references, it’s seen that the

individuals who visited it more times are the ones

who got a higher number of references. However the

majority of individuals were not even referred (63%)

to other institutions.

Twenty-seven (24%) individuals attended the

emergency service of others hospitals and 85 (76%)

didn’t. Of those who did, 6 (22%) had been at

Hospital de Valongo, 3 (11%) at Centro Hospitalar

de Vila Nova de Gaia, 3 (11%) at Hospital Geral de

Santo António, 1 (4%) at Hospital Pedro Hispano, 1

(4%) at Hospital Maria Pia and 13 (48%) at others.

Thirty-two (29%) of the children needed

hospitalization and 80 (71%) didn’t. Of the ones

who needed it, only 11 (34%) were referred for it

and the other 21 (66%) didn’t.

CONNECTING HOSPITALS AND HEALTH CENTRES COULD BENEFIT MOST OF PORTO’S CHILDREN

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Electronic Patient Records

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3.3 Mobility in Other Health

Institutions

Crossing the attendance of the health institutions’

data analyzed in three types of institutions (Private

Clinics, Health Centers and Outpatient Department)

there are 12 (11%) people who attended the three

health institutions and only 3 (3%) of these of people

did not attend any of those, 28 (25%) of the

individuals attended only Health Centers, 14 (12%)

only attended Private Clinics, 26 (23%) private

clinics and health centres, 17 (15%) health centres

and hospitals (see Table 1).

There were 83 (74%) individuals that attended

Health Centres within their residence areas. 56

(50%) had visited Private Clinics, mostly Private

Consultants for paediatrics; other private clinics

include: general clinics, otorhinolaryngology,

ophthalmology, orthopaedics, psychology and

dermatology were also attended by those children

(see Table 2).

When dealing with the outpatient department,

there is mobility among various institutions as may

be seen in the Table 3.

The distribution of the number of visits to UPP

crossed with the age of the children is described in

Table 4.

4 DISCUSSION

The interviewees, as expected, were mainly from the

Porto region.

Considering that 97% of patients that attended

UPP had already gone to at least one medical

consultation, it is valid to assume that these

individuals would, somehow, benefit from a system

that integrates data. Although this value seems to be

high, it must be kept in mind that it probably

accounts for mandatory vaccination consultations or

seeking a second consult concerning the same issue.

Comparing the attendance to health centres only

(25%) to the attendance to private clinics only

(15%), we realized that approximately double the

individuals chose health centres over private clinics.

Our results also showed that, within patients who

had been referred, a high percentage was referred

from health centres (63%). Health centres are also,

apart from hospitals, the type of institutions that

people most visit in their residence areas (74%). It

would then be of special interest to implement an

EPR in health centres. Implementing an integrated

EPR would allow a rapid and less error-prone

information exchange especially in an emergency

situation when previous clinical information is of the

up-most importance.

The age factor seems to have some influence in

the number of visits to UPP, since individuals until

the age of 2 have the higher frequency of 2-5 visits

Table 1: Cross table of the attendance of Private Clinics,

Health Centres and Outpatient Department (n=112).

Attended a

Health Centre

Attended a

Private

Clinic

Yes No

Attended

Outpatient

Department

(hospitals)

12 (11%) 4 (4%) Yes

Yes

26 (23%) 14 (12%) No

17 (15%) 8 (7%) Yes

28 (25%) 3 (3%) No

Table 2: Table of the number of visits to Health Centers

and Private Clinics with its specialities.

Institution Cases (n)

Health Centre 83

Private Clinics 56

Paediatrics 53

General Clinics 4

Otorhinolaryngology 2

Ophthalmology 2

Orthopaedics 2

Psychology 1

Dermatology 1

Table 3: Table of the different institutions attended for

outpatient department.

Institution Cases (n)

H. São João 14

H. Pedro Hispano 10

H.G. Santo António 9

H. Maria Pia 4

Others 5

Missing 1

Table 4: Distribution (number of cases and percentage)

of the number of visits to UPP by age (n=112).

Number of visits to UPP

Age 1

Visit 2-5 >5 Total

≤2 14 (13%) 36 (32%) 1 (1%) 51 (46%)

>2 25 (22%) 27 (24%) 9 (8%) 61 (54%)

Total 39 (35%) 63 (56%) 10 (9%) 112 (100%)

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(32% against 24% of the ones aged over 2). This

supports the idea that these individuals should be

considered as a target population for the

implementation of electronic integrated databases.

Regarding the different institutions chosen by

individuals for outpatient care, several are attended;

Hospital Pedro Hispano, Hospital Geral Santo

António, are the most visited.

When attending private clinics, the most

requested speciality is paediatrics, as it was

expected.

In a previous similar study done by students of

the Faculty of Medicine of University of Porto on

elderly population, it was shown that there should be

an exchange of information between health

institutions in the Porto region. Our study

emphasizes this notion because children in this area

visit a great number of institution but choose to one

emergency care facility (UPP) only; as such, the

main conclusion of the study is that integrated EPR

between hospitals and health centres would most

benefit of children population in Porto region.

4.1 Limitations

The UPP’s waiting room, where interviews took

place, was itself a limitation to the receptivity of the

interviewees due to emotional distress associated

with an emergency situation impairing their ability

to answer accurately.

The current organization of Porto’s paediatric

emergency referrals (a centralized healthcare facility

for all events), may difficult the generalization to

other cities.

5 CONCLUSIONS

Implementing an Electronic Patient Records

accessible in health centres and the UPP is relevant

for the population studied, especially those under 2

years of age.

ACKNOWLEDGEMENTS

The authors wish to thank Prof. Dr. Almeida Santos

(director of UPP) for all the collaboration in this

study, and Prof. Dr. Altamiro Costa Pereira for

reviewing the article.

This study was supported by POCTI/0753/2004

- Unit I&D CINTESIS nº 753/2004 from Fundação

para a Ciência e a Tecnologia.

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