Abstract
Background The availability of patient information to practitioners forms the basis of informational continuity of care. Changes in family practice that now encourage multiphysician clinics have meant that informational continuity of care has become crucial because it is likely that a patient will not continuously see the same doctor. Therefore a review of the nature of informational continuity is useful.
Aim To answer the question ‘How is informational continuity developed in general practice?’.
Design of study A rigorous systematic review of relevant electronic databases.
Method Databases were searched for articles answering the research question. Articles focused on family medicine and informational continuity of care were included. Data from reviewed articles were independently extracted and reviewed by two researchers. Conceptual and evidence-based articles were included.
Results Initially, 193 articles were obtained from all five bibliographic databases; 57 were retained following title and abstract review. Of these, 34 articles were included in the final systematic review. Results show that informational continuity of care is developed using paper/electronic records and remembered information collectively, through a series of doctor–patient consultations over time. Obstacles to its development are practitioners not recording patient information and patients not disclosing important details.
Conclusion These findings have implications for newer styles of primary care that may have a negative impact in the successful management of chronic illnesses in particular.
INTRODUCTION
Continuity of care is seen as an indicator of ‘general practice quality’ by the professional bodies of general practice in countries such as the UK, Canada, the US, and Australia.1–4 The term continuity of care covers many different aspects of continuity, specifically informational, longitudinal, and relational/interpersonal aspects.5,6 Informational continuity is understood to be the availability of patient information to providers throughout a healthcare system.7,8
With recent changes in family practice in some countries that now encourage large multiphysician group clinics and increased around-the-clock access to care, developing informational continuity of care has become crucial because in such care contexts it is likely that a patient will not continuously see the same doctor. Because of this, it is useful to review what we know about the nature of informational continuity of care within general practice, in order to inform decisions regarding service restructuring and the development of future primary care services. This paper reports the findings of a systematic review answering the question: ‘How is informational continuity developed in family practice?’.
METHOD
The systematic review search strategy consisted of thoroughly searching the following electronic databases: MEDLINE (OVID) (1966 – week 1, May, 2006), CINAHL (OVID) (1982 – week 1, May, 2006), EMBASE (1980 – week 1, May, 2006) and PSYCHINFO (1806 – week 1, May, 2006), and Web of Science (1900 – week 1, May, 2006). Databases were searched using keywords that were agreed upon by the investigators after first being independently identified (Table 1). The databases selected for the search were also agreed upon by the investigators. Articles in English deemed relevant to the search were retrieved. Reference lists of reviewed articles were manually examined for further studies.
Table 1 Search strategy employed.
Titles obtained from the initial searches were independently reviewed by both investigators. Articles focusing on issues outside of general practice or other aspects of continuity of care were immediately excluded. After independently selecting titles for inclusion, the investigators met to determine which articles were to have abstract review. Following abstract review, a further meeting was held to determine inclusion for full article review. Articles selected for full review were read by both investigators and data extracted independently using the same extraction form.
Because of the nature of this review and the types of articles that were identified, the focus was on systematically reviewing the content of articles selected for full review rather than the study or protocol design. Numerous meetings were held during the full review stage to confirm both extracted information and also inclusion in or exclusion from the review. During this stage, the merits and qualities of articles over which there was disagreement were discussed until both reviewers were in agreement. Following this, all extracted information recorded on the data-extraction forms were recorded on an electronic spreadsheet.
How this fits in
Informational continuity of care is developed using paper/electronic records and remembered information collectively, through a series of doctor–patient consultations over time. Obstacles to its development are practitioners not recording patient information and patients not disclosing important details. These findings have implications for newer styles of primary care which may negatively impact the successful management of chronic illnesses in particular.
RESULTS
Initially, 193 articles were obtained from all five bibliographic databases; 57 were retained following title and abstract review (Box 1). Of these, 34 articles were included in the final systematic review. Twenty articles read in full were excluded because they did not contain the elements required for inclusion once the full paper was examined, and three articles were unobtainable. The κ score for agreement by reviewers at the title/abstract stage was 0.673 (standard error [SE] 0.17, P = 0.004).
Box 1 Results of search strategy.
Of the 34 included articles, three reported on mixed-method studies,9–11 eight on qualitative studies,12–19 10 on quantitative studies,20–29 and the remaining 13 were commentary or review articles.30–42 Since there was little published literature on informational continuity of care, the researchers were compelled to include conceptual pieces (for example, commentaries and review articles) in this review. These pieces were often written by leaders in the field of continuity; the researchers therefore felt justified in including information extracted from these articles in the review. The work for 15 articles was undertaken in the UK, 12 in the US, three in Canada, and one each in Malaysia, Australia, Norway, and the Netherlands. The reviewed articles are summarised in Table 2.
Table 2 Reviewed articles (opinion-based conceptual articles (for example, essays, commentaries, reviews, editorials) are indicated by italics.
The systematic review revealed important but scattered details about the development and use of informational continuity of care within family practice. These are presented next under the themes that arose from the article review.
Nature of the continuous record
In primary care, the medical record forms the basis upon which informational continuity of care is built. This record is constructed using ‘mature information’ (that is historical medical information as opposed to current information only),41 and established throughout multiple consultations over time with the patient and his or her family.28,30,41 Information can be stored in paper records, electronically, or in practitioners' memories. Computerised (for example, electronic medical records [EMRs]) and paper records store different types of information.20 Informational continuity may be better when doctors have to ‘hand over’ records to other care providers, otherwise they may rely on memory alone.41 While GPs are traditionally medical information coordinators, nurses or receptionists are also involved in developing informational continuity of care because of their roles in record keeping.16
Importance of the doctor's memory
Although GPs frequently use recorded information, they also use remembered information to produce better health outcomes for the patient,25 and enhance the effectiveness of their care.29,31 They draw specifically on their own stored knowledge of patients' medical histories and social/lifestyle circumstances.30 Importantly, the duration and depth of the doctor–patient relationship shapes information transfer and record keeping, taking at least a few years to establish a good knowledge base.14 Such a knowledge base, and the use of remembered information, is particularly important at extremes of life, including in the palliative care context.32 Having informational continuity of care is also useful when treating patients experiencing mental illness,31 and psychological disorders.21 Here, lack of specific knowledge has been regarded as a hindrance to patient management.21 Another general hindrance is that doctors typically ask long-term patients for details of their medical histories and social/lifestyle circumstances only on rare occasions,9 which leaves them without such details to store as remembered information.
Patient input into recorded information
The duration and depth of the doctor–patient relationship shapes information transfer and record keeping, taking at least a few years to establish a good knowledge base.14 Patient input into record keeping is normal. Actually, 30% of patients enjoy discussing what is to be entered into their records.17 Such input may also be given in written form. New patients, for example, may complete their own medical history form for inclusion in their record.9 During periods when the formal record cannot be accessed (for example, during file transfer between clinics), a patient's own notes may be particularly welcomed.42 However, patients often select information about what they believe is important to be recorded, typically prioritising biomedical factors over socio-contextual or personal ones.18,34 It is not clear, in general, how well a patient's own augmentative notes will be received by his/her doctor.16,30,32
DISCUSSION
This systematic review reveals that informational continuity of care can be best developed using paper and electronic records and remembered information Although GPs have input, patients and practice staff also contribute to its development. Patients may want to have more of a say in what information gets recorded, but there is little opportunity for this unless asked for specifically by a practitioner — something that may jeopardise developing informational continuity of care. Other obstacles to developing continuity of care identified by the review include: practitioners not recording information shared by patients in the form of notes or information transmitted verbally; patients not disclosing important details, due to lack of knowledge about what practitioners perceive as important; and practitioners not asking about patients' lifestyles often enough. There may be reasons as to why these events are not occurring as frequently as they should, such as time pressures encountered by practitioners, the complexity of cases, and clinic procedure issues.
Patients' lifestyle and psychosocial information, though important for many reasons, is difficult to systematically store in the permanent record and may be more easily held as remembered information. If this is the case, then more suitable venues for storing this information should be developed that are easy to access and update. Education could assist patients with determining what lifestyle and psychosocial information to share with practitioners, including that which is specific to particular health conditions. Practitioners having greater ease of access to this information, including by request and also that which is offered up-front by patients, could assist in the improvement of informational continuity of care.
Despite the increasing desire to shift to computerised medical information storage via the EMR in many health systems, the impact of this on informational continuity of care has yet to be fully explored. Although computerised records are clearly helpful in situations where there are many care providers, as has been pointed out above, such records may not be able to capture all the nuances of hand-held and remembered information in an easily retrievable way. Furthermore, the authors' own research with chronically ill patients and their caregivers has revealed that the use of computers during consultations for purposes such as accessing EMRs could negatively affect both the conversational flow and, ultimately, information sharing.43 Specifically, recording information on computers during consultations was thought to lead to more-impersonal interactions. This clearly has negative implications for the development of informational continuity of care. Given the lack of consideration paid to this issue in the reviewed articles, this is an important area for further exploration.
Given that the population of the Western world is aging,44 that we are burdened by more chronic and psychosocial disease,44,45 and the knowledge that informational continuity of care is particularly important in psychosocial, complex, and palliative care situations, newer clinic arrangements not attentive to the development of such continuity could be problematic. In clinics where patients are seen by different practitioners who do not have access to long-term remembered information, the provision of quality care to these populations, and others, may be challenged. Although attempts are being made to improve access to primary care,46 mandating that patients see multiple providers may be hindering the delivery of quality care. However, this has not been extensively researched. Future research should therefore look at the quality of informational continuity in various care settings from both providers' and patients' perspectives, in different models of healthcare delivery.
Ultimately, the doctor–patient relationship still remains the main vehicle that facilitates information transfer and the development of informational continuity of care in general practice. New models of care that facilitate and not hinder its development within general practice must be encouraged and developed.
Notes
Funding body
A Canadian Institutes of Health Research (CIHR) Interdisciplinary Capacity Enhancement (ICE) subgrant (through the Health Care, Technology & Place [HCTP] CIHR Strategic Training Institute) provided research funding. Valorie Crooks received stipendiary funding through a CIHR Strategic Training Postdoctoral Fellowship in HCTP and a Canadian Health Services Research Foundation/CIHR Postdoctoral Fellowship in Health Services Research during the study period. Gina Agarwal was funded by a postdoctoral fellowship award from the Canadian Diabetes Association and also received stipendiary funding through a CIHR Strategic Training Postdoctoral Fellowship in HCTP during the study period
Ethical approval
McMaster University Health Sciences Research Ethics Board Approval (06–173)
Competing interests
The authors have stated that there are none.
- Received February 7, 2008.
- Revision received April 4, 2008.
- Accepted July 21, 2008.
- © British Journal of General Practice, 2008.
