The patient-provider relationship and antenatal care uptake at two referral hospitals in Malawi: A qualitative study

Background

Approximately 90% of Malawian women attend antenatal care at least once during their pregnancies; however, most mothers first present during months five and six and do not adhere to the World Health Organization''s recommended four visits. The objective of this study was to explore the role the patient-provider relationship has on antenatal care uptake.

Methods

A qualitative study, consisting of interviews with 20 urban pregnant mothers and eight health workers, was conducted from September to December 2014. Two large tertiary care hospitals in the Central and Southern regions of Malawi were selected as study sites.

Results

Several factors influenced antenatal care attendance. Significant barriers reported included the patient-provider relationship, clinic wait times, family and friend support, distance from home to the clinic, transportation, cost, and number of visits. The patient-provider relationship appears to have a large impact on antenatal clinic participation. Mothers indicated that health workers often mistreat or demean them during visits. Additionally, health workers revealed that, due to staff shortages, patients often do not receive the care they deserve.

Conclusions

The results of this study suggest that, in addition to other factors, healthcare provider attitudes influence antenatal clinic attendance. Improving the patient-provider relationship may increase antenatal clinic attendance and decrease pregnancy complications during pregnancy. Professional development opportunities and quality improvement programmes are would help improve patient care and health outcomes while the continued staff shortages in the country are addressed.     

Two conformational forms of target-bound iC3b that distinctively bind complement receptors 1 and 2 and two specific monoclonal antibodies

Introduction

The complement system is an essential part of the immune system of vertebrates. The central event of the complement activation cascade is the sequential proteolytic activation of C3, which is associated with profound alterations in the molecule''s structure and conformation and is responsible for triggering most of the biological effects of complement.

Material and methods

Here, we have studied the conformation of C3 fragments deposited onto an IgG-coated surface from human serum during complement activation, using a set of unique monoclonal antibodies (mAbs) that are all specific for the C3dg portion of bound iC3b.

Results

We were able to identify two conformational forms of target-bound iC3b: the first recognized by mAb 7D18.1, and the second by mAb 7D323.1. The first species of iC3b bound recombinant complement receptor 1 (CR1), while the second bound CR2. Since CR1 and CR2 are expressed by different subsets of leukocytes, this difference in receptor-binding capacity implies that there is a biological difference between the two forms of surface-bound iC3b.

Conclusion

We propose that mAbs 7D18.1 and 7D323.1 can act as surrogate markers for CR1 and CR2, respectively, and that they may be useful tools for studying the immune complexes that are generated in various autoimmune diseases.     

Personal health records and hypertension control: a randomized trial

Purpose

To examine the impact of a personal health record (PHR) in patients with hypertension measured by changes in biological outcomes, patient empowerment, patient perception of quality of care, and use of medical services.

Methods

A cluster-randomized effectiveness trial with PHR and no PHR groups was conducted in two ambulatory clinics. 453 of 1686 (26.4%) patients approached were included in the analyses. A PHR tethered to the patient''s electronic medical record (EMR) was the primary intervention and included security measures, patient control of access, limited transmission of EMR data, blood pressure (BP) tracking, and appointment assistance. BP was the main outcome measure. Patient empowerment was assessed using the Patient Activation Measure and Patient Empowerment Scale. Quality of care was assessed using the Clinician and Group Assessment Score (CAHPS) and the Patient Assessment of Chronic Illness Care. Frequency of use of medical services was self-reported.

Results

No impact of the PHR was observed on BP, patient activation, patient perceived quality, or medical utilization in the intention-to-treat analysis. Sub-analysis of intervention patients self-identified as active PHR users (25.7% of those with available information) showed a 5.25-point reduction in diastolic BP. Younger age, self-reported computer skills, and more positive provider communication ratings were associated with frequency of PHR use.

Conclusions

Few patients provided with a PHR actually used the PHR with any frequency. Thus simply providing a PHR may have limited impact on patient BP, empowerment, satisfaction with care, or use of health services without additional education or clinical intervention designed to increase PHR use.

Clinical trial registration number

http://ClinicalTrials.gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT01317537","term_id":"NCT01317537"}}NCT01317537.     

Evaluation of computer-generated reminders to improve CD4 laboratory monitoring in sub-Saharan Africa: a prospective comparative study

Objective

Little evidence exists on effective interventions to integrate HIV-care guidelines into practices within developing countries. This study tested the hypothesis that clinical summaries with computer-generated reminders could improve clinicians'' compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa.

Design

A prospective comparative study of two randomly selected outpatient adult HIV clinics in western Kenya. Printed summaries with reminders for overdue CD4 tests were made available to clinicians in the intervention clinic but not in the control clinic.

Measurements

Changes in order rates for overdue CD4 tests were compared between and within the two clinics.

Results

The computerized reminder system identified 717 encounters (21%) with overdue CD4 tests. Analysis by study assignment (regardless of summaries being printed or not) revealed that with computer-generated reminders, CD4 order rates were significantly higher in the intervention clinic compared to the control clinic (53% vs 38%, OR=1.80, CI 1.34 to 2.42, p<0.0001). When comparison was restricted to encounters where summaries with reminders were printed, order rates in intervention clinic were even higher (63%). The intervention clinic increased CD4 ordering from 42% before reminders to 63% with reminders (50% increase, OR=2.32, CI 1.67 to 3.22, p<0.0001), compared to control clinic with only 8% increase from prestudy baseline (CI 0.83 to 1.46, p=0.51).

Limitations

Evaluation was conducted at two clinics in a single institution.

Conclusions

Clinical summaries with computer-generated reminders significantly improved clinician compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa. This technology can have broad applicability to improve quality of HIV care in these settings.     

Explaining physicians' use of EMR systems and performance in the shakedown phase

Objective

This work seeks to complement and extend prior work by using a multidisciplinary approach to explain electronic medical records (EMR) system use and consequent performance (here, patient satisfaction) among physicians during early stages of the implementation of an EMR.

Design

This was a quantitative study, with data obtained from three distinct sources: individual-level and social-network data from employees; use data from EMR system logs; and patient satisfaction data from patients and/or authorized decision-makers. Responses were obtained from 151 physicians and 8440 patient satisfaction surveys over the course of a 1-year period at the shakedown phase of an EMR system implementation.

Results

Physicians who were better connected, both directly and indirectly, to their peers—that is, other physicians—for advice on their work, used the system less than those who were less connected. In addition to such social network ties, demographic characteristics (gender and age), three personality characteristics (openness to experience, agreeableness and extroversion) and a key technology perception (perceived usefulness) predicted EMR system use.

Conclusions

For hospital administrators and other stakeholders, understanding the contributors to, and the relative importance of, various factors in explaining EMR system use, and its impact on patient satisfaction is of great importance. The factors identified in this work that influence a physician''s use of EMR systems can be used to develop interventions and applications that can increase physician buy-in and use of EMR systems.     

Openness of patients' reporting with use of electronic records: psychiatric clinicians' views

Objectives

Improvements in electronic health record (EHR) system development will require an understanding of psychiatric clinicians'' views on EHR system acceptability, including effects on psychotherapy communications, data-recording behaviors, data accessibility versus security and privacy, data quality and clarity, communications with medical colleagues, and stigma.

Design

Multidisciplinary development of a survey instrument targeting psychiatric clinicians who recently switched to EHR system use, focus group testing, data analysis, and data reliability testing.

Measurements

Survey of 120 university-based, outpatient mental health clinicians, with 56 (47%) responding, conducted 18 months after transition from a paper to an EHR system.

Results

Factor analysis gave nine item groupings that overlapped strongly with five a priori domains. Respondents both praised and criticized the EHR system. A strong majority (81%) felt that open therapeutic communications were preserved. Regarding data quality, content, and privacy, clinicians (63%) were less willing to record highly confidential information and disagreed (83%) with including their own psychiatric records among routinely accessed EHR systems.

Limitations

single time point; single academic medical center clinic setting; modest sample size; lack of prior instrument validation; survey conducted in 2005.

Conclusions

In an academic medical center clinic, the presence of electronic records was not seen as a dramatic impediment to therapeutic communications. Concerns regarding privacy and data security were significant, and may contribute to reluctances to adopt electronic records in other settings. Further study of clinicians'' views and use patterns may be helpful in guiding development and deployment of electronic records systems.     

Developing and validating a model to predict the success of an IHCS implementation: the Readiness for Implementation Model

Objective

To develop and validate the Readiness for Implementation Model (RIM). This model predicts a healthcare organization''s potential for success in implementing an interactive health communication system (IHCS). The model consists of seven weighted factors, with each factor containing five to seven elements.

Design

Two decision-analytic approaches, self-explicated and conjoint analysis, were used to measure the weights of the RIM with a sample of 410 experts. The RIM model with weights was then validated in a prospective study of 25 IHCS implementation cases.

Measurements

Orthogonal main effects design was used to develop 700 conjoint-analysis profiles, which varied on seven factors. Each of the 410 experts rated the importance and desirability of the factors and their levels, as well as a set of 10 different profiles. For the prospective 25-case validation, three time-repeated measures of the RIM scores were collected for comparison with the implementation outcomes.

Results

Two of the seven factors, ‘organizational motivation’ and ‘meeting user needs,’ were found to be most important in predicting implementation readiness. No statistically significant difference was found in the predictive validity of the two approaches (self-explicated and conjoint analysis). The RIM was a better predictor for the 1-year implementation outcome than the half-year outcome.

Limitations

The expert sample, the order of the survey tasks, the additive model, and basing the RIM cut-off score on experience are possible limitations of the study.

Conclusion

The RIM needs to be empirically evaluated in institutions adopting IHCS and sustaining the system in the long term.     

Effects of a computer-supported interactive tailored patient assessment tool on patient care, symptom distress, and patients' need for symptom management support: a randomized clinical trial

Objective

To examine the effects of a computer-assisted, interactive tailored patient assessment (ITPA) tool in oncology practice on: documented patient care, symptom distress, and patients'' need for symptom management support during treatment and rehabilitation.

Design and methods

For this repeated measures clinical trial at a university hospital in Norway, 145 patients starting treatment for leukemia or lymphoma were randomly assigned to either an intervention (n=75) or control group (n=70). Both groups used the ITPA for symptom assessments prior to inpatient and outpatient visits for up to one year. The assessment summary, which displayed patients'' self-reported symptoms, problems, and distress in rank-order of the patient''s need for support, was provided to physicians and nurses in the intervention group only but not in the control group.

Results

Significantly more symptoms were addressed in the intervention group patient charts versus those of the control group. Symptom distress in the intervention group decreased significantly over time in 11 (58%) of 19 symptom/problem categories versus 2 (10%) for the control group. Need for symptom management support over time also decreased significantly more for the intervention group than the control group in 13 (68%) symptom categories.

Conclusion

This is the first study to show that an ITPA used in an interdisciplinary oncology practice can significantly improve patient-centered care and patient outcomes, including reduced symptom distress and reduced need for symptom management support.     

Mediation of adoption and use: a key strategy for mitigating unintended consequences of health IT implementation

Objective

Without careful attention to the work of users, implementation of health IT can produce new risks and inefficiencies in care. This paper uses the technology use mediation framework to examine the work of a group of nurses who serve as mediators of the adoption and use of a barcode medication administration (BCMA) system in an inpatient setting.

Materials and methods

The study uses ethnographic methods to explore the mediators'' work. Data included field notes from observations, documents, and email communications. This variety of sources enabled triangulation of findings between activities observed, discussed in meetings, and reported in emails.

Results

Mediation work integrated the BCMA tool with nursing practice, anticipating and solving implementation problems. Three themes of mediation work include: resolving challenges related to coordination, integrating the physical aspects of BCMA into everyday practice, and advocacy work.

Discussion

Previous work suggests the following factors impact mediation effectiveness: proximity to the context of use, understanding of users'' practices and norms, credibility with users, and knowledge of the technology and users'' technical abilities. We describe three additional factors observed in this case: ‘influence on system developers,’ ‘influence on institutional authorities,’ and ‘understanding the network of organizational relationships that shape the users'' work.’

Conclusion

Institutionally supported clinicians who facilitate adoption and use of health IT systems can improve the safety and effectiveness of implementation through the management of unintended consequences. Additional research on technology use mediation can advance the science of implementation by providing decision-makers with theoretically durable, empirically grounded evidence for designing implementations.     

Research and applications: ICD-9 tobacco use codes are effective identifiers of smoking status

Objective

To evaluate the validity of, characterize the usage of, and propose potential research applications for International Classification of Diseases, Ninth Revision (ICD-9) tobacco codes in clinical populations.

Materials and methods

Using data on cancer cases and cancer-free controls from Vanderbilt''s biorepository, BioVU, we evaluated the utility of ICD-9 tobacco use codes to identify ever-smokers in general and high smoking prevalence (lung cancer) clinic populations. We assessed potential biases in documentation, and performed temporal analysis relating transitions between smoking codes to smoking cessation attempts. We also examined the suitability of these codes for use in genetic association analyses.

Results

ICD-9 tobacco use codes can identify smokers in a general clinic population (specificity of 1, sensitivity of  0.32), and there is little evidence of documentation bias. Frequency of code transitions between ‘current’ and ‘former’ tobacco use was significantly correlated with initial success at smoking cessation (p<0.0001). Finally, code-based smoking status assignment is a comparable covariate to text-based smoking status for genetic association studies.

Discussion

Our results support the use of ICD-9 tobacco use codes for identifying smokers in a clinical population. Furthermore, with some limitations, these codes are suitable for adjustment of smoking status in genetic studies utilizing electronic health records.

Conclusions

Researchers should not be deterred by the unavailability of full-text records to determine smoking status if they have ICD-9 code histories.     

Understanding differences in electronic health record (EHR) use: linking individual physicians’ perceptions of uncertainty and EHR use patterns in ambulatory care

Objective

Electronic health records (EHR) hold great promise for managing patient information in ways that improve healthcare delivery. Physicians differ, however, in their use of this health information technology (IT), and these differences are not well understood. The authors study the differences in individual physicians'' EHR use patterns and identify perceptions of uncertainty as an important new variable in understanding EHR use.

Design

Qualitative study using semi-structured interviews and direct observation of physicians (n=28) working in a multispecialty outpatient care organization.

Measurements

We identified physicians'' perceptions of uncertainty as an important variable in understanding differences in EHR use patterns. Drawing on theories from the medical and organizational literatures, we identified three categories of perceptions of uncertainty: reduction, absorption, and hybrid. We used an existing model of EHR use to categorize physician EHR use patterns as high, medium, and low based on degree of feature use, level of EHR-enabled communication, and frequency that EHR use patterns change.

Results

Physicians'' perceptions of uncertainty were distinctly associated with their EHR use patterns. Uncertainty reductionists tended to exhibit high levels of EHR use, uncertainty absorbers tended to exhibit low levels of EHR use, and physicians demonstrating both perspectives of uncertainty (hybrids) tended to exhibit medium levels of EHR use.

Conclusions

We find evidence linking physicians'' perceptions of uncertainty with EHR use patterns. Study findings have implications for health IT research, practice, and policy, particularly in terms of impacting health IT design and implementation efforts in ways that consider differences in physicians'' perceptions of uncertainty.     

Enrollment into a time sensitive clinical study in the critical care setting: results from computerized septic shock sniffer implementation

Objective

Recruitment of patients into time sensitive clinical trials in intensive care units (ICU) poses a significant challenge. Enrollment is limited by delayed recognition and late notification of research personnel. The objective of the present study was to evaluate the effectiveness of the implementation of electronic screening (septic shock sniffer) regarding enrollment into a time sensitive (24 h after onset) clinical study of echocardiography in severe sepsis and septic shock.

Design

We developed and tested a near-real time computerized alert system, the septic shock sniffer, based on established severe sepsis/septic shock diagnostic criteria. A sniffer scanned patients'' data in the electronic medical records and notified the research coordinator on call through an institutional paging system of potentially eligible patients.

Measurement

The performance of the septic shock sniffer was assessed.

Results

The septic shock sniffer performed well with a positive predictive value of 34%. Electronic screening doubled enrollment, with 68 of 4460 ICU admissions enrolled during the 9 months after implementation versus 37 of 4149 ICU admissions before sniffer implementation (p<0.05). Efficiency was limited by study coordinator availability (not available at nights or weekends).

Conclusions

Automated electronic medical records screening improves the efficiency of enrollment and should be a routine tool for the recruitment of patients into time sensitive clinical trials in the ICU setting.     

Twenty-seven years follow-up of a patient with congenital retinocephalofacial vascular malformation syndrome and additional congenital malformations (Bonnet-Dechaume-Blanc syndrome or Wyburn-Mason syndrome)

Purpose

Follow-up of vascular changes in a patient with congenital retinocephalofacial vascular malformation syndrome.

Methods

MRI and cerebral angiography.

Results

In a 36-year-old man, magnetic resonance im aging of the skull and cerebral angiography revealed left intracranial arteriovenous malformations. Follow-up observation of 27 years revealed no essential change of retinal and cerebral arteriovenous malformations. Additional congenital deficits in this patient were described.

Conclusion

Patients with retinal arteriovenous malformations should be early examined with neuroradiological methods.     

BoB,a best-of-breed automated text de-identification system for VHA clinical documents

Objective

De-identification allows faster and more collaborative clinical research while protecting patient confidentiality. Clinical narrative de-identification is a tedious process that can be alleviated by automated natural language processing methods. The goal of this research is the development of an automated text de-identification system for Veterans Health Administration (VHA) clinical documents.

Materials and methods

We devised a novel stepwise hybrid approach designed to improve the current strategies used for text de-identification. The proposed system is based on a previous study on the best de-identification methods for VHA documents. This best-of-breed automated clinical text de-identification system (aka BoB) tackles the problem as two separate tasks: (1) maximize patient confidentiality by redacting as much protected health information (PHI) as possible; and (2) leave de-identified documents in a usable state preserving as much clinical information as possible.

Results

We evaluated BoB with a manually annotated corpus of a variety of VHA clinical notes, as well as with the 2006 i2b2 de-identification challenge corpus. We present evaluations at the instance- and token-level, with detailed results for BoB''s main components. Moreover, an existing text de-identification system was also included in our evaluation.

Discussion

BoB''s design efficiently takes advantage of the methods implemented in its pipeline, resulting in high sensitivity values (especially for sensitive PHI categories) and a limited number of false positives.

Conclusions

Our system successfully addressed VHA clinical document de-identification, and its hybrid stepwise design demonstrates robustness and efficiency, prioritizing patient confidentiality while leaving most clinical information intact.     

Modeling nurses' acceptance of bar coded medication administration technology at a pediatric hospital

Objective

To identify predictors of nurses'' acceptance of bar coded medication administration (BCMA).

Design

Cross-sectional survey of registered nurses (N=83) at an academic pediatric hospital that recently implemented BCMA.

Methods

Surveys assessed seven BCMA-related perceptions: ease of use; usefulness for the job; social influence from non-specific others to use BCMA; training; technical support; usefulness for patient care; and social influence from patients/families. An all possible subset regression procedure with five goodness-of-fit indicators was used to identify which set of perceptions best predicted BCMA acceptance (intention to use, satisfaction).

Results

Nurses reported a moderate perceived ease of use and low perceived usefulness of BCMA. Nurses perceived moderate-or-higher social influence to use BCMA and had moderately positive perceptions of BCMA-related training and technical support. Behavioral intention to use BCMA was high, but satisfaction was low. Behavioral intention to use was best predicted by perceived ease of use, perceived social influence from non-specific others, and perceived usefulness for patient care (56% of variance explained). Satisfaction was best predicted by perceived ease of use, perceived usefulness for patient care, and perceived social influence from patients/families (76% of variance explained).

Discussion

Variation in and low scores on ease of use and usefulness are concerning, especially as these variables often correlate with acceptance, as found in this study. Predicting acceptance benefited from using a broad set of perceptions and adapting variables to the healthcare context.

Conclusion

Success with BCMA and other technologies can benefit from assessing end-user acceptance and elucidating the factors promoting acceptance and use.     

ICU nurses' acceptance of electronic health records

Objective

To assess intensive care unit (ICU) nurses'' acceptance of electronic health records (EHR) technology and examine the relationship between EHR design, implementation factors, and nurse acceptance.

Design

The authors analyzed data from two cross-sectional survey questionnaires distributed to nurses working in four ICUs at a northeastern US regional medical center, 3 months and 12 months after EHR implementation.

Measurements

Survey items were drawn from established instruments used to measure EHR acceptance and usability, and the usefulness of three EHR functionalities, specifically computerized provider order entry (CPOE), the electronic medication administration record (eMAR), and a nursing documentation flowsheet.

Results

On average, ICU nurses were more accepting of the EHR at 12 months as compared to 3 months. They also perceived the EHR as being more usable and both CPOE and eMAR as being more useful. Multivariate hierarchical modeling indicated that EHR usability and CPOE usefulness predicted EHR acceptance at both 3 and 12 months. At 3 months postimplementation, eMAR usefulness predicted EHR acceptance, but its effect disappeared at 12 months. Nursing flowsheet usefulness predicted EHR acceptance but only at 12 months.

Conclusion

As the push toward implementation of EHR technology continues, more hospitals will face issues related to acceptance of EHR technology by staff caring for critically ill patients. This research suggests that factors related to technology design have strong effects on acceptance, even 1 year following the EHR implementation.     

Cognitive work analysis to evaluate the problem of patient falls in an inpatient setting

Objective

To identify factors in the nursing work domain that contribute to the problem of inpatient falls, aside from patient risk, using cognitive work analysis.

Design

A mix of qualitative and quantitative methods were used to identify work constraints imposed on nurses, which may underlie patient falls.

Measurements

Data collection was done on a neurology unit staffed by 27 registered nurses and utilized field observations, focus groups, time–motion studies and written surveys (AHRQ Hospital Survey on Patient Culture, NASA-TLX, and custom Nursing Knowledge of Fall Prevention Subscale).

Results

Four major constraints were identified that inhibit nurses'' ability to prevent patient falls. All constraints relate to work processes and the physical work environment, opposed to safety culture or nursing knowledge, as currently emphasized. The constraints were: cognitive ‘head data’, temporal workload, inconsistencies in written and verbal transfer of patient data, and limitations in the physical environment. To deal with these constraints, the nurses tend to employ four workarounds: written and mental chunking schemas, bed alarms, informal querying of the previous care nurse, and informal video and audio surveillance. These workarounds reflect systemic design flaws and may only be minimally effective in decreasing risk to patients.

Conclusion

Cognitive engineering techniques helped identify seemingly hidden constraints in the work domain that impact the problem of patient falls. System redesign strategies aimed at improving work processes and environmental limitations hold promise for decreasing the incidence of falls in inpatient nursing units.     

Psychiatric Morbidity Pattern in a Child Guidance Clinic

Background

There is a paucity of Indian studies on psychiatric morbidity in children. Present work was undertaken in a child guidance clinic in armed forces.

Methods

Retrospective analysis of 213 patients who attended a child guidance clinic was done.

Results

Majority (n=138) were boys. 55.9% were referred from paediatric outpatient department while medical officers in periphery referred 38.5%. The diagnoses was mental retardation in 30.97%, behavioral and emotional disorders in 23.06% and neurotic, stress related and somatoform disorders in 15.98% cases.Key Words: Child psychiatry, Attention-deficit hyperactivity disorder, Mental retardation     

Design and development of an international clinical data exchange system: the international layer function of the Dolphin Project

Objective

At present, most clinical data are exchanged between organizations within a regional system. However, people traveling abroad may need to visit a hospital, which would make international exchange of clinical data very useful.

Background

Since 2007, a collaborative effort to achieve clinical data sharing has been carried out at Zhejiang University in China and Kyoto University and Miyazaki University in Japan; each is running a regional clinical information center.

Methods

An international layer system named Global Dolphin was constructed with several key services, sharing patients'' health information between countries using a medical markup language (MML). The system was piloted with 39 test patients.

Results

The three regions above have records for 966 000 unique patients, which are available through Global Dolphin. Data exchanged successfully from Japan to China for the 39 study patients include 1001 MML files and 152 images. The MML files contained 197 free text-type paragraphs that needed human translation.

Discussion

The pilot test in Global Dolphin demonstrates that patient information can be shared across countries through international health data exchange. To achieve cross-border sharing of clinical data, some key issues had to be addressed: establishment of a super directory service across countries; data transformation; and unique one—language translation. Privacy protection was also taken into account. The system is now ready for live use.

Conclusion

The project demonstrates a means of achieving worldwide accessibility of medical data, by which the integrity and continuity of patients'' health information can be maintained.