ObjectivesTo investigate the effect of providing patients online access to their electronic health record (EHR) and linked transactional services on the provision, quality and safety of healthcare. The objectives are also to identify and understand: barriers and facilitators for providing online access to their records and services for primary care workers; and their association with organisational/IT system issues.SettingPrimary care.ParticipantsA total of 143 studies were included. 17 were experimental in design and subject to risk of bias assessment, which is reported in a separate paper. Detailed inclusion and exclusion criteria have also been published elsewhere in the protocol.Primary and secondary outcome measuresOur primary outcome measure was change in quality or safety as a result of implementation or utilisation of online records/transactional services.ResultsNo studies reported changes in health outcomes; though eight detected medication errors and seven reported improved uptake of preventative care. Professional concerns over privacy were reported in 14 studies. 18 studies reported concern over potential increased workload; with some showing an increase workload in email or online messaging; telephone contact remaining unchanged, and face-to face contact staying the same or falling. Owing to heterogeneity in reporting overall workload change was hard to predict. 10 studies reported how online access offered convenience, primarily for more advantaged patients, who were largely highly satisfied with the process when clinician responses were prompt.ConclusionsPatient online access and services offer increased convenience and satisfaction. However, professionals were concerned about impact on workload and risk to privacy. Studies correcting medication errors may improve patient safety. There may need to be a redesign of the business process to engage health professionals in online access and of the EHR to make it friendlier and provide equity of access to a wider group of patients.A1. Systematic review registration numberPROSPERO CRD42012003091.

BackgroundOnline access to medical records by patients can potentially enhance provision of patient-centred care and improve satisfaction. However, online access and services may also prove to be an additional burden for the healthcare provider. AimTo assess the impact of providing patients with access to their general practice electronic health records (EHR) and other EHR-linked online services on the provision, quality, and safety of health care. Design and settingA systematic review was conducted that focused on all studies about online record access and transactional services in primary care. MethodData sources included MEDLINE, Embase, CINAHL, Cochrane Library, EPOC, DARE, King's Fund, Nuffield Health, PsycINFO, OpenGrey (1999-2012. The literature was independently screened against detailed inclusion and exclusion criteria; independent dual data extraction was conducted, the risk of bias (RoB) assessed, and a narrative synthesis of the evidence conducted. ResultsA total of 176 studies were identified, 17 of which were randomised controlled trials, cohort, or cluster studies. Patients reported improved satisfaction with online access and services compared with standard provision, improved selfcare, and better communication and engagement with clinicians. Safety improvements were patient-led through identifying medication errors and facilitating more use of preventive services. Provision of online record access and services resulted in a moderate increase of e-mail, no change on telephone contact, but there were variable effects on face-to-face contact. However, other tasks were necessary to sustain these services, which impacted on clinician time. There were no reports of harm or breaches in privacy. ConclusionWhile the RoB scores suggest many of the studies were of low quality, patients using online services reported increased convenience and satisfaction. These services positively impacted on patient safety, although there were variations of record access and use by specific ethnic and socioeconomic groups. Professional concerns about privacy were unrealised and those about workload were only partly so.

Two reviewers independently searched 11 international databases during the period 1999-2012. A range of papers including descriptive studies using qualitative or quantitative methods, hypothesis-testing studies and systematic reviews were included. A detailed eligibility criterion will be used to shape study inclusion. A team of experts will review these papers for eligibility, extract data using a customised extraction form and use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) instrument to determine the quality of the evidence and the strengths of any recommendation. Data will then be descriptively summarised and thematically synthesised. Where feasible, we will perform a quantitative meta-analysis. Prospero (International Prospective Register of Systematic Reviews) registration number: crd42012003091.

Background The European Union (EU) has introduced a new process to identify medicines that are being monitored particularly closely by regulatory authorities. The black triangle will be used in all EU Member States to identify medicines subject to additional monitoring, such as belimumab. Purpose To check the effectiveness and safety of belimumab. Materials and methods A retrospective study from July 2012 to March 2013 of patients who were treated with belimumab. To begin the treatment, the patients were required to meet the criteria set by the European Medicines Agency. Their test results (immunoglobulins, antinuclear antibodies (ANA), anti-DNA, C3 and C4 levels) and medical records (subjective opinion of the patient, prednisone doses, adverse effects) were used to monitor the patients. The results were collected at the beginning of the treatment, three and six months later and the subjective opinion of the patient at the end of the study. Results Five women were treated (median age 36[25–50]), but only four were included because one abandoned the treatment due to thrombosis. At the beginning of the treatment the patients had the following values: ANA+, anti-DNA+, low C3 and C4. The treatment resulted in a reversal of the ANA and anti-DNA values, from positive to negative. Regarding the C3 levels, a median of 90 mg/dl[71–103] was obtained in the first month. Within 3 months this value rose to 106 mg/dl[86–121], which meant an increase of 16 mg/dl. Another 3 months later, a median of 112 mg/dl[101–123] was achieved (increase of 6 mg/dl). The prednisone dose was halved around week 36[32–40] of the treatment. Most frequent adverse effects were: fatigue, nausea, diffuse aching, arthralgia. Conclusions Analytical parameters improved in every case. Three patients referred subjectively to an improvement in symptoms. One of the patients abandoned the treatment due to thrombosis, which cannot be related only to the treatment (until that point, the test values had been improving) No conflict of interest.

BackgroundParenteral nutrition (PN) is an essential supportive treatment for patients who are unable to meet their nutrition requirements through oral or enteral nutrition. Many studies have noted that PN is often inappropriately prescribed, thereby increasing the risk of associated complications and costs.PurposeTo determine the quality of prescription of PN in our hospital, based on the ESPEN 2009 guidelines and the pharmacy cost.Material and methodsA prospective, observational study of PN episodes in adults was over a 3-month period. The use of PN was classified as ‘appropriate’ or “inappropriate”. Variables collected included: demographic data, underlying diagnoses, indication for PN, number of days on PN and complications related to PN in inappropriate use such as phlebitis, metabolic complications and bacteraemia associated with central venous catheter (BAC). We calculated the cost of the number of inappropriate PN treatments provided.ResultsWe reviewed the indications for 90 PN treatments. The patients were 53% male with median age of 63.9 years (range, 27 to 96 years), with a principal diagnosis of digestive tract neoplasia (37.8%). In 37.8% of the cases PN was “inappropriate”; the most common indications were prolonged fasting (22.9%), palliative care (20%) and patient refusal to eat (8%). The median duration of “inappropriate” PN prescription was 4.9 days (range, 1 to 17 days). Six patients (17.6%) had complications; 3 cases of BAC, four metabolic complications, and two cases of phlebitis. The number of inappropriate PN treatments was 163 units which cost the pharmacy €6,130.57 for the PN.ConclusionPN is associated with complications; because of this the indication for PN should comply with the main clinical practice guidelines and requires monitoring by experienced professionals in multidisciplinary Nutritional Units.In addition, cost savings could be achieved if PN was provided only to the patients who meet these guidelines.References and/or acknowledgementsThanks to my co-workers.No conflict of interest.