A personal look at Electronic Medical Records

1. A personal look at Electronic Medical Records Working with a laptop the last 21 years – a rewarding digital experience

2. The start • Working at the allergy out-patient clinic of Ste Justine Hospital in Montreal where I remained until end of 2000, inspired by my friend and fellow allergist-pediatrician, Dr Zave Chad, who was at the same hospital at the time, I also started working with an Apple laptop computer while seeing patients. I used Filemaker Pro®, a database application, to design a patient case history similar to what I would enter in writing in the hospital chart. • With professional help from a FilmakerPro specialist, the following customized program was set up.

3. The medical record The patient case history was designed, in French, the data typed in the different fields while seeing the patient. The same at the office. I called it ‘Data entry.’ Here’s what it looks like:

4. The medical record (cont’d) At the end of each session, by pressing a button on the ‘Data entry’ page, the patients seen were transferred to a new file called simply ‘Patients-tous’ (all patients) which would eventually consist of the database. Patients prescribed immunotherapy were selected and by another button put in another file called, ‘Vaccins prescrits’ and once the treatment ordered, placed in a file called, ‘PRI’ (patients receiving immunotherapy). Each file could be accessed and follow-up notes added.

7. Database analysis By sorting all the records entered by ascending date of entry, each year was analyzed. Entries were made back in 1991, but that year was not included in the analysis because of too many errors in many of the fields, or incomplete case histories. It was decided that the years analyzed would be 1992 to 2012 The following formula was used: 01/01/1992…12/31/2012 which gave us: 30,150 patients

8. Total patients seen: 30,150

9. Database analysis (cont’d) Looking into the field ‘Impr.-Diag.’ (‘Impression-Diagnostic’ or probable diagnosis) Filemamker Pro was asked to “find” the number of patients seen for: • Asthma with asthm(short for asthma or in French asthme.) • Rhinitiswith rhin (abbreviated for rhinitis, rhino-conjunctivitis and rhino-sinusitis). • Pollinosiswith pollin • Urticaria with urtic • Eczemawith ecz • Dermatitis with dermi (again in French,covering all forms of dermatitis, including eczema.) This gave us:

10. Database analysis (cont’d)

11. Database analysis (cont’d) • While each search was made, e.g. for asthma, giving us the total cases seen for asthma, a ‘re-find’ was asked for positive allergy skin tests by adding a + in the field ‘Tests d’allergie’. • This would give us the number of patients seen for asthma with positive skin tests (usual inhalant allergies.) Tests for foods were done where specified.) • This procedure was done for the different diagnoses.

12. Database analysis (cont’d) DiagnosisAllergy tests positive in: Rhinitis: 14,969 (49.6%) 10,381 (69.3%) Pollinosis: 8,228 (27.2%) 7,223 (87.7%) Asthma: 7,802 (25.8%) 5,929 (75.9%)Urticaria: 5,655 (18.7%) 2,864 (50.6%) Dermatitis: 1,136 (3.7%) 583 (51.3%) Eczema: 537 (1.7%) 268 (49.9%)

13. Database analysis (cont’d)

14. Database analysis (cont’d) Each one of the fields in the ‘Patients-tous’ (in French in layout used) could be analyzed using the “Find” options of the program FilemakerPro®. • Date patient was seen (‘date’) • Date of birth (‘date de naiss.’) • Elements of the history, treatment, and its effect (‘histoire’) • Past hx (‘ant. pers.’) • Family hx (‘ant. Héréd.’) • Environment (‘mileu’) • Allergy tests done and results (‘tests d’allergie’) • Diagnosis (‘Impr.-Diagn.’), etc.

15. Find options: age of patients To find the age of patients seen, first thing to do was take each year separately. In the field ‘Date’ the patients were seen, let’s say, in the year 1998, could be accessed with the following formula: Month/Day/Year…Month/Day/Year, or 1/1/1998…12/31/1998 To get the age of the patients seen that year, a ‘re-find’ was asked after having used the formula above, by adding the following formula in the ‘Date de naiss.’ (DOB) for children 12 years and less in 1998: 860101…981231 Date of birth as it appears on the RAMQ (Quebec Medicare Card) YY (last two digits)MMDD…YYMMDD

16. Age of patients (cont’d) For teens, again for the year 1998, the formula to be used in the ‘Date de naiss.’ field, as a ‘re-find’ would be: 790101…851231 For adults aged 20 and over: <781231  This procedure would be used, adjusted, for each year for the three main groups. This is the result:

18. Total patients 1992-2012 3,690 (12.2%) 15,743 (52.2%) 10,476 (34.7%)

19. Database analysis (cont’d) • Note: • Total of children by individual search year by year: 10,476 • Total of teens, analyzed year by year: 3,690 • Total of adults aged 20 and over, also searched year by year: 15,743 Adding the totals of the three groups gives us a net number of patients: 29,909 (a difference of 0.99%, due to difficulty of being precise in the ages using date seen and date of birth, in a particular calendar year).

20. Asthma 2,345 (71%)

21. Asthma (cont’d)Children: 73.4% are allergic to cat, 51.7% to dog

22. CHILDREN allergic to cat or dog and living with the pet

23. Asthma 918 (84.9%)

24. Asthma (cont’d) Teens: 83.7% allergic to cat, 62.5% allergic to dog

25. TEENS with asthma, allergic to cat or dog and living with the pet

26. Asthma 2,622 (77.8%)

27. Asthma (cont’d) Adults 20 and over: 81% allergic to cat, 64.8% allergic to dog

28. ADULTS over 20 with asthma, allergic to cat or dog and living with the pet

29. Asthma 374 (57.67%)

30. Asthma (cont’d) Adults 50 and over: 62.2% allergic to cat, 54.8% allergic to dog

31. Rhinitis 3,080 (66.8%)

32. Rhinitis 1,692 (81.7%)

33. Rhinitis 5,524 (67.3 %)

34. Rhinitis 931 or 47.8%

35. Urticaria 1045(38.9%)

36. Urticaria 128 (23.6%)

37. Urticaria 502(20.9%)

38. Urticaria 81 (12.4%)

39. Eczema/dermatitis 184 (31.4%)

40. Eczema/dermatitis 19 (14.2%)

41. Eczema/dermatitis 72 (10.8%)

42. Eczema/dermatitis 16 (7%)

43. GI symptoms GI SYMPTOMS were searched only in children, and the total from 1992 to 2012 was: • Vomiting in 282, with food allergies possibly related in 153 (54.2%) • Abdominal pain in 70, food allergies possibly related in 22 (31.4% • Diarrhea in 51, food allergies possibley related in 10 (19.6%)

47. Anaphylaxis This diagnosis was found only in 372 patients out of 30,152 Children in 85 Teens in 33 20 and over in 241 50 and over in 70 Overall very small numbers, in part due to the fact that organ-specific diagnoses were used rather than ‘anaphylaxis.’

48. Anaphylaxis (cont’d) • Etiology: • In children: foods mostly: peanut, nuts, egg, milk, fish, sesame, shrimp, buckwheat, kiwi, drugs, e,g. acetaminophen probably in one, and stinging insects. • In teens: suspected EIA (“Exercise Induced Anaphylaxis”) in many cases, some food allergies: peanut, nuts, celery, egg, parsley, mustard, carrot, pistachio, Rx possibly in one, and stinging insects. • 20 and over: some food allergies (peanut, nuts, seafood, mustard) stinging insects, but many suspected allergy to Rx (NSAID, ACE inhibitors, antibiotics, etc.)

49. In summary, so far, total patients presenting with • asthma make up a little over 25% of patients seen, and a very high percentage seem to be allergic, in the three main groups, 70 to almost 85%; in the over 50 group, 649 out of 4004 or 16.2% had asthma, over 57% still showed positive allergy tests. • rhinitismake up near 50% of patients seen,66 to 81% seem allergic • the remaining 25% consist of urticaria, eczema/dermatitis incl.contact dermatitis, angioedema, stinging insect allergy, GI symptoms, etc. • urticaria(20 to a little over 23% show positive food tests) • eczema/dermatitis (12 to 31% cases show positive food tests.)

50. Tests for peanut allergy 830 (50.7%)