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
, Maria Isabel Pereira
, Miguel Lobato
, Mónica Silva
, Rita Boaventura
, Sofia Faria
Ricardo Cruz-Correia
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
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.
As information and communication technologies
have advanced, interest in mobile health care
systems has grown. (Yoo, Kim, Park, Choi, & Chun,
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).
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).
Patients’ Mobility between Institutions Requires Implementation of Electronic Patient Records.
In Proceedings of the First International Conference on Health Informatics, pages 305-309
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
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
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
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,
HEALTHINF 2008 - International Conference on Health Informatics
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’
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
Figure 1: Living places distribution (n=112).
3.1 Sample Description
Data was collected in 4 hours shifts, for 3 days, on
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.
POPULATION - Current Trends in Paedriatic Patients’ Mobility between Institutions Requires Implementation of
Electronic Patient Records
3.3 Mobility in Other Health
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.
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
Yes No
12 (11%) 4 (4%) 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%)
HEALTHINF 2008 - International Conference on Health Informatics
(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
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.
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.
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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POPULATION - Current Trends in Paedriatic Patients’ Mobility between Institutions Requires Implementation of
Electronic Patient Records