Monitoring reasons for encounter via an electronic patient record system: the case of a rural practice initiative.

The objective of this brief communication was to tabulate common reasons for encounter in a Greek rural general practice, as result of a recently adopted electronic patient record (EPR) application. Twenty encounter reasons accounted for 3,797 visits (61% of all patient encounters), whereas 565 other reasons accounted for the remaining 2,429 visits (39%). Number one reason for encounter was health maintenance or disease prevention seeking services, including screening examinations for malignancies, immunization and provision of medical opinion reports. Hypertension, lipid disorder and ischemic heart disease without angina were among the most common reasons for seeking care. A strengths/weaknesses/opportunities/threats (SWOT) analysis on the key role of an EPR system in collecting data from rural and remote primary health care settings is also presented.

Information technology (IT) is increasingly seen as an important venue for improving quality of health care and patient safety 1-3. An essential component of IT is the electronic patient record (EPR), defined as a systematic collection of electronic health information about individual patients or populations 4. It can be shared across free-standing health care units as well as integrated delivery networks and may include a range of data, such as medical history, medication and allergies, laboratory test results, radiology images, vital signs, and billing information. In comparison to conventional paper-based records, EPR systems may decrease medical errors 2 and allow general practitioners to pursue more effective interventions during their daily routines 1. Furthermore, EPR data can be tabulated for surveillance of communicable diseases or community risk factors, statistical reporting of quality improvement efforts and strategic planning of resource allocation. The use of EPR for the management of clinical information and classification of the reasons for seeking primary health care (PHC) is becoming imperative, particularly for countries with limited resources, facing severe austerity measures, such as Greece 5.

Although several studies have been carried out in Europe with a focus on healthcare utilization, PHC utilization should always be examined in the light of conceptual models to capture this complex, multidimensional concept 6-10. According to Andersen's behavioral model, people may be predisposed to using health services but also need some means of obtaining them 11. Thus, the rural/urban nature of the community in which a patient lives can be viewed as one of the enabling factors. An application of the behavioral model in a study of PHC utilization in Gaza Strip, Palestine, showed that frequent use was associated with older age, marital status, poor living conditions, unemployment, higher income, poorly rated health status and current smoking habits 12.

The aim of this letter is to tabulate common reasons for encounter in a Greek rural general practice, as result of a recently adopted EPR application. It is further intended to demonstrate via a SWOT analysis the key role of an EPR system in collecting, analyzing and evaluating clinical data from rural and remote PHC settings.

Systematic use of EPR in Greece is not yet available despite some sporadic efforts. A previously developed EPR, within the context of a PhD thesis at the University of Crete 13, was installed in the Alonakia PHC setting as an individual unit initiative, a rural area in Northern Greece. Data were collected between June 2008 and January 2011. Dataset entry included reasons for encounter, medical interventions, lab test results and vital signs. Direct coding was performed by the GP using the International Classification of Diseases in Primary Care (ICPC-2) 14 as well as the International Classification of Diseases (ICD-10) classification 15.

A SWOT (Strengths/Weaknesses/Opportunities/Threats) analysis outlining expected benefits and risks from the implementation of an EPR system in regards to reasons for patient encounter is presented in Figure .

A total of 1,084 patients were registered in the EMR system accounting for 6,226 encounters over the study period. Male to female ratio was 0.7:1. The median age for men was 59.0 years (range 2-102 years) and for women 62.3 years (range 0.9-97 years) respectively. The most common reasons for encounter are shown in Table . Twenty encounter reasons accounted for 3,797 visits (61% of all patient encounters), whereas 565 other reasons accounted for the remaining 2,429 visits (39%). The number one reason for encounter was health maintenance or prevention seeking services, including screening examinations for malignancies and need for immunization. Hypertension, lipid disorder, ischemic heart disease without angina, type 2 diabetes mellitus and osteoporosis were listed as the top five reasons for encounter among all chronic disorders. The most frequent symptoms, classified as reasons for encounter, were abdominal pain, vertigo/dizziness and cough.

The emerging utilization pattern and morbidity profile of the rural population in our study shares quite a few similarities with the outcomes reported from other rural and urban general practice settings 16-19. Despite the differences in methodology followed in previous studies, women accounted for the majority of visits in both rural and urban settings, with hypertension being the most frequent reason for encounter. The unexpectedly high demand for health promotion and/or disease preventive services from our rural patients was comparable, to some extent, to that reported by Mariolis et al 19, in their comparison study of urban vs. rural PHC settings.

In terms of the most frequently occurring symptoms, acute upper respiratory infection was in accordance with the finding from the urban setting 17, whereas vertigo was a common finding for both the urban study 17 and another rural study from Southeastern Greece 18. A significant increase in outpatient clinic visits due to symptoms of vertigo and tinnitus has also been found in a recent urban study, lending support to similar observations from different sources of data 20.

EPR system use can provide a first glimpse concerning the health profile and the needs of a rural population, highlighting similarities and differences between rural versus urban PHC service seekers. Adoption of the same EPR system and methodology by neighboring PHC facilities may help threefold: a) individual health professionals could focus on the most common everyday encounter problems, enhancing their clinical performance, b) health teams could improve their planning, implementation and evaluation efforts in regards to community outreach and health promotion initiatives, and c) regional health authorities could develop a projection model, predicting future utilization patterns for PHC services, while taking measures to reduce unnecessary demand and to expand the clinical capacity of primary care providers.

Supporting individual unit efforts, while disseminating the knowledge and experience gained by inquiring primary care providers, could prove to be a priceless alternative to professional inertia in a country struggling with overgrowing PHC demands and drastically shrinking resources.

Table 1

Distribution of cases by reason for rural general practice encounter.

Reason for encounter	ICPC-2	Cases (n)	Percentage (%)*
Health maintenance/ prevention**	A98	1191	19.1
Hypertension uncomplicated	K86	380	6.1
Lipid disorder	T93	376	6.0
Abdominal pain epigastric	D02	239	3.8
Ischemic heart disease without angina	K76	224	3.6
Osteoporosis	L95	158	2.5
Diabetes non-insulin dependent	T90	154	2.5
Upper respiratory infection acute	R74	115	1.8
Vertigo / Dizziness	N17	114	1.8
Oesophagus disease	D84	104	1.7
Cough	R05	88	1.4
Back syndrom without radiating pain	L84	85	1.4
Depressive disorder	P76	82	1.3
Acute bronchitis/bronchiolitis	R78	78	1.3
Anxiety disorder/anxiety state	P74	75	1.2
Osteoarthrosis of knee	L90	70	1.1
Benign prostatic hypertrophy	Y85	66	1.1
Constipation	D12	65	1.0
Chronic obstructive pulmonary disease	R95	62	1.0
Other		2429	39.0
No disease***	A97	71	1.1
Total		6226	100

*Rounded decimals

**Including ICD-10 codes for neoplasm screening examinations and immunizations.

***Including ICD-10 codes for general medical examination and issue of medical opinion report.