The ALFA (Activity Log Files Aggregation) toolkit: a method for precise observation of the consultation

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de Lusignan S, Kumarapeli P, Chan T, Pflug B, van Vlymen J, Jones B, Freeman GK. The ALFA (Activity Log Files Aggregation) toolkit: a method for precise observation of the consultation. J Med Internet Res. 2008 Sep 8; 10(4):e27

Question

What tools are available to evaluate and compare electronic patient record (EPR) systems to assist in a rational system choice? The authors spend significant effort describing the shortcomings of current EPR measurement tools.

Objective

To develop an objective measurement system of different EPR system features on the length of the time taken to code data, prescribe, and record BP data during a patient-physician consultation.

Methods

The authors studied filming of 22 live consultations by 4 general practitioners (GPs) using different EPR systems. The researchers compared the time taken and variations during coded data entry, prescribing, and blood pressure (BP) recording and contrasted those using Unified Modeling Language (UML) sequence diagrams. Nonparametric tests were used to make statistical comparisons.

Main Results

Multiple observational outputs were entered into the ALFA aggregation tool, which allows simultaneous navigation and viewing of multiple files. The GP using the EMIS LV system took the longest time to code data (mean 11.5 s, 95% CI 8.7-14.2). Nonparametric comparison of EMIS LV with the other systems showed a significant difference, with EMIS PCS (P = .007), iSoft Synergy (P = .014), and INPS Vision (P = .006) facilitating faster coding. In contrast, prescribing was fastest with EMIS LV (mean 23.7 s, 95% CI 20.5-26.8), but nonparametric comparison showed no statistically significant difference.

Conclusions

The ALFA method allows a precise observation of the clinical consultation and enables a comparison of core elements of EPR systems. Pilot data suggests its capacity to demonstrate differences between systems. Its outputs could provide the evidence base for making more objective choices between systems.

Comments

The study was conducted using a small sample size of non-calibrated, non-trained general practitioners using only four British EPR systems. Nonparametric tests were used to make statistical comparisons, however a nonparametric statistical power analysis was not calculated. Also, subjects were not randomly assigned to experimental versus control groups. Furthermore, each computer system was used by only one GP hence it is impossible to discern whether differences were clinician-related or system-related. While this is a nice attempt to more objectively measure EPR systems, this study suffers from a lack of scientific and statistical rigor and should be regarded as a technique pilot study.

Steven D. Hokett