1 Family History and Electronic Medical Records in Primary Care J. LeClair, E. Piekarz, D. Meyer, W. G. Feero Maine-Dartmouth Family Practice Residency Program, Fairfield, ME

2 Background  Family history is an accepted starting point for screening and risk assessment for inherited disease.  Obtaining a three-generation pedigree/genogram is an accepted standard for family history data. (Wattendorf et al., 2005; AAFP ACF Genomics 2005)

3 Background  Family history collected at about 50% of new visits and 22% of established visits.  Average duration of visit, 10 minutes; average duration of family history discussion, 2.5 minutes. Acheson et al., 2000  Genograms present in only 11% of charts  Presence or absence of CRC and breast cancer noted in 40% of charts Medalie et al., 1998

4 Background  Only 29% of PCPs feel prepared to take family history and draw pedigrees. Suchard et al., 1999 Suchard et al., 1999  Even when collected, often fail to recognize high-risk family history Sweet et al., 2002; Frezzo et al., 2003, Murff et al Sweet et al., 2002; Frezzo et al., 2003, Murff et al Rich et al., Reconsidering the family history in primary care. J Gen Intern Med 19( ), 2004.

5 Background  Rapid advances in genetics are likely to make obtaining family history data more important for patient management.  Electronic medical record systems are fast becoming the standard for record keeping in primary care.

6 Little is known about how electronic medical records affect ascertainment of family history in primary care.

7 Hypothesis Implementation of an electronic medical record will alter the amount of family history obtained in a primary care setting.

8 Methods  Charts were selected from new patient visits to faculty at a rural family practice residency program (~60% govt. or self pay)  Charts were reviewed for family history data pre- and post-EMR implementation (Touchworks TM by Allscripts)  Essentially a “paired” study design  Charts were reviewed by three investigators using a scoring tool created for this study

9 Family History Chart Review Pt age _________ Pt sex _________ Attending ________ Site of visit ________ Any family history data present? Yes (1) No (0) If graphical history, circle yes or no for each one of the following 1. Graphical three-generation pedigree/genogram present? Yes (3) No (0) 2. Graphical two-generation pedigree/genogram present? Yes (2) No (0) 3. Graphical one-generation pedigree/genogram present? Yes (1) No (0) If text history, circle yes or no for each one of the following 4. Text history including three generations? Yes (3) No (0) 5. Text history including two generations? Yes (2) No (0) 6. Text history one generation? Yes (1) No (0) If both text and graphical history please check here ____

10 Definitions for scoring: one generation = patient + brothers/sisters OR patient plus parents, no siblings mentioned two generation =patient + brothers/sisters + parents/aunts/uncles OR patient + brothers/sisters + children OR patient + parents/aunt/uncles OR patient + children OR patient + grandparents three generation = patient + brother/sisters + parents/aunts/uncles + grandparents OR patient + brothers/sisters + parents/aunts/uncles + children four generation =score as three All others score only as family history data present. Examples: “No family history of cancer or heart disease.” “Family history of diabetes.” Max score 4, Minimum 0

11 ABCBAC

12 Results  76 charts selected at 2 practice sites, 70 reviewed (92%)  Errors in registration!

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20 *Represents only one reviewer

21 Conclusions  Current family history standards were poorly adhered to in both paper and EMR environments.  Electronic medical record implementation decreased the amount of documented family history data.

22 Conclusions  Possible barriers to obtaining family history data may include lack of time, lack of facility with EMR systems, low perceived value of family history data, and the design of the EMR systems.  Further research is needed to determine if these results generalize to other medical specialties and EMR platforms.