Electronic health records and support for primary care teamwork

Objective Consensus that enhanced teamwork is necessary for efficient and effective primary care delivery is growing. We sought to identify how electronic health records (EHRs) facilitate and pose challenges to primary care teams as well as how practices are overcoming these challenges.Methods Practices in this qualitative study were selected from those recognized as patient-centered medical homes via the National Committee for Quality Assurance 2011 tool, which included a section on practice teamwork. We interviewed 63 respondents, ranging from physicians to front-desk staff, from 27 primary care practices ranging in size, type, geography, and population size.Results EHRs were found to facilitate communication and task delegation in primary care teams through instant messaging, task management software, and the ability to create evidence-based templates for symptom-specific data collection from patients by medical assistants and nurses (which can offload work from physicians). Areas where respondents felt that electronic medical record EHR functionalities were weakest and posed challenges to teamwork included the lack of integrated care manager software and care plans in EHRs, poor practice registry functionality and interoperability, and inadequate ease of tracking patient data in the EHR over time.Discussion Practices developed solutions for some of the challenges they faced when attempting to use EHRs to support teamwork but wanted more permanent vendor and policy solutions for other challenges.Conclusions EHR vendors in the United States need to work alongside practicing primary care teams to create more clinically useful EHRs that support dynamic care plans, integrated care management software, more functional and interoperable practice registries, and greater ease of data tracking over time.     

A process evaluation of implementing a vocational enablement protocol for employees with hearing difficulties in clinical practice

Objective: A multidisciplinary vocational rehabilitation programme, the Vocational Enablement Protocol (VEP) was developed to address the specific needs of employees with hearing difficulties. In the current study we evaluated the process of implementing the VEP in audiologic care among employees with hearing impairment. Design: In conjunction with a randomized controlled trial, we collected and analysed data on seven process parameters: recruitment, reach, fidelity, dose delivered, dose received and implemented, satisfaction, and perceived benefit. Study sample: Sixty-six employees with hearing impairment participated in the VEP. The multidisciplinary team providing the VEP comprised six professionals. Results: The professionals performed the VEP according to the protocol. Of the recommendations delivered by the professionals, 31% were perceived as implemented by the employees. Compliance rate was highest for hearing-aid uptake (51%). Both employees and professionals were highly satisfied with the VEP. Participants rated good perceived benefit from it. Conclusions: Our results indicate that the VEP could be a useful treatment for employees with hearing difficulties from a process evaluation perspective. Implementation research in the audiological setting should be encouraged in order to further provide insight into parameters facilitating or hindering successful implementation of an intervention and to improve its quality and efficacy.     

An Academic Internist Looks at Euthanasia

This paper points out that to persons unfamiliar with the context and suffering of dying patients, their loved ones, and last, but by no means least, the health care team can only discuss the very concrete question of euthanasia in an abstract way unaware of the fact that this question must, in the final analysis, be differently addressed in different specific patients and under specific circumstances. This paper poses questions which must be addressed and will rarely find a good answer but at least the best among a series of unpalatable options. It again points out the important and legitimate place that emotions play in decision-making.     

结直肠肿瘤多学科协作诊治模式的数据体系构建与运作策略

目的阐述在结直肠肿瘤多学科协作（MDT）诊治模式下,如何构建数据体系及其运作策略。方法阐明构建数据体系的原因,结合实践描述结直肠肿瘤数据体系的基本构成及如何支持数据体系的运行,探讨结直肠肿瘤MDT数据体系的价值反馈,并提出对数据体系建立未来的展望。结果通过会诊、随访、院内临床的支持及合理地实现MDT模式中信息化流程的建设,数据体系运行能正常进行。结论数据体系作为整个结直肠肿瘤MDT项目的基础,能够通过医疗模式的改变表现出医疗价值和社会价值。     

Results of a survey of the role of multidisciplinary team coordinators for colorectal cancer in England and Wales

OBJECTIVE: Over the last 6 years, multidisciplinary teams (MDTs) have been established and play a key role in organizing the delivery of cancer care in the UK. There are no published data on the roles of their co-coordinators. To seek the views of colorectal multidisciplinary team co-ordinators (MDTCs) on what they do and how they do it. METHOD: Questionnaires were sent to the colorectal MDTC, or equivalent, in all 180 NHS hospital trusts in England and Wales where colorectal cancer surgery is performed. RESULTS: There was a 70% response rate. Seventy-one per cent of trusts now have a dedicated MDTC, whereas in 2002, only 40% had one. MDTCs generally keep their information on databases, but these differ, and are not coordinated with data entry into the national colorectal cancer database of the Association of Coloproctology of Great Britain and Ireland. In only 26 trusts does the MDTC communicate decisions to primary care, and the patients seem almost completely excluded from this process. CONCLUSION: The recently formed national MDTC Forum should grasp the opportunity of coordinating all of this well-intentioned but pluralistic activity to the benefit of patients, primary care and hospital teams. An effective MDTC with a robust database will be the key in achieving cancer waiting time targets with useful audit, thereby improving patient care.     

Auditing your acute pain service—a UK NHS model

This audit has been conducted in order to provide an evidence base that clarifies the strengths and weaknesses of acute pain management at a UK hospital. Consequently, it sets the strategic direction for service improvement. Awarding up to three stars has identified the quality of each component that constitutes the acute pain service. Six different components were audited and star ratings have been awarded as shown below:

• Pain tool (including patient and staff understanding): no stars.

• Pain team (including education and clinical support): two stars.

• Intermittent opioid analgesia (sub-cut and oral morphine): two stars.

• Epidural patient controlled analgesia (EPCA): two stars.

• Intravenous patient controlled analgesia (IVPCA): two stars.

• Single-dose intrathecal opioid analgesia: three stars.

These star ratings were pulled together in order to award the acute pain service an overall rating. Consequently, the acute pain service was awarded two stars. The findings of this audit identify that this acute pain service provides a safe way to deliver hi-tech pain relief at ward level and can be relied upon to provide good quality pain management. However, too many patients are likely to miss out on the full benefits of the service due to the weaknesses as identified. The quality of the pain relief is impeded across the hospital due to low patient expectation and poor patient education, and also due to a lack of relevant knowledge amongst nursing staff. Developments in the role of the acute pain nurse, staff training and education programs, and a reduction in the variety of pain management pumps are combining to facilitate the opportunities required to address the weaknesses and to build on the strengths of the acute pain service.     

Promoting inter-agency collaborátion in child services

Summary Effective collaboration between agencies is often difficult to achieve. Children and their families/carers, who have complex therapeutic needs, present particular difficulties in that agencies need to work together, if they are to produce a co-ordinated and integrated package of care. A Multi-Agency-Consultation-Team (MACT) was set up in an attempt to overcome some of these problems of interagency co-operation. This paper describes the protocol, types of children referred and the recommendations made by the team. Follow-up of these children at 4 months suggests that a MACT does have a role to play in developing high quality services.