Capturing Information Needs of Care Providers to Support Knowledge Sharing and Distributed Decision Making

Background

This paper reports on work carried out to elicit information needs at a trans-disciplinary, nurse-managed health care clinic that serves a medically disadvantaged urban population. The trans-disciplinary model provides a “one-stop shop” for patients who can receive a wide range of services beyond traditional primary care. However, this model of health care presents knowledge sharing challenges because little is known about how data collected from the non-traditional services can be integrated into the traditional electronic medical record (EMR) and shared with other care providers. There is also little known about how health information technology (HIT) can be used to support the workflow in such a practice.

Objectives

The objective of this case study was to identify the information needs of care providers in order to inform the design of HIT to support knowledge sharing and distributed decision making.

Methods

A participatory design approach is presented as a successful technique to specify requirements for HIT applications that can support a trans-disciplinary model of care.

Results

Using this design approach, the researchers identified the information needs of care providers working at the clinic and suggested HIT improvements to integrate non-traditional information into the EMR. These modifications allow knowledge sharing among care providers and support better health decisions.

Conclusions

We have identified information needs of care providers as they are relevant to the design of health information systems. As new technology is designed and integrated into various workflows it is clear that understanding information needs is crucial to acceptance of that technology.     

Applying justice and commitment constructs to patient�Chealth care provider relationships

Objective

To examine patients’ experiences of fairness and commitment in the health care context with an emphasis on primary care providers.

Design

Qualitative, semistructured, individual interviews were used to gather evidence for the justice and commitment frameworks across a variety of settings with an emphasis on primary care relationships.

Setting

Rural, urban, and semiurban communities in Nova Scotia.

Participants

Patients (ages ranged from 19 to 80 years) with varying health care needs and views on their health care providers.

Methods

Participants were recruited through a variety of means, including posters in practice settings and communication with administrative staff in clinics. Individual interviews were conducted and were audiotaped and transcribed verbatim. A modified grounded theory approach was used to interpret the data.

Main findings

Current conceptualizations of justice (distributive, procedural, interpersonal, informational) and commitment (affective, normative, continuance) capture important elements of patient–health care provider interactions and relationships.

Conclusion

Justice and commitment frameworks developed in other contexts encompass important dimensions of the patient–health care provider relationship with some exceptions. For example, commonly understood subcomponents of justice (eg, procedural consistency) might require modification to apply fully to patient–health care provider relationships. Moreover, the results suggest that factors outside the patient–health care provider dyad (eg, familial connections) might also influence the patient’s commitment to his or her health care provider.     

Who knows more about immunization?: Survey of public health nurses and physicians

Objective

To report the findings of a knowledge survey of nurse and physician immunization providers.

Design

Cross-sectional postal survey assessing demographic characteristics and vaccine knowledge.

Setting

British Columbia (BC).

Participants

Nurse and physician immunization providers in BC.

Main outcome measures

Knowledge of vaccine-preventable diseases, vaccines in general, and vaccine administration and handling practices.

Results

Survey responses were received from 256 nurses and 292 physicians (response rates of 48.6% and 18.3%, respectively). Most nurses (98.4%) reported receiving immunization training outside of the academic setting compared with 55.6% of physicians. Overall, nurse immunizers scored significantly higher than physician immunizers on all 3 domains of immunization knowledge (83.7% vs 72.8%, respectively; P < .001). Physicians scored highest on the vaccine-preventable disease domain and least well on the general vaccine domain. Nurses with more experience as health care providers scored higher. Physicians scored higher if they were female, served patient populations predominantly younger than 5 years, or received immunization training outside of academic settings.

Conclusion

In BC, nurse immunizers appear to have higher overall immunization knowledge than physicians and are more likely to receive immunization training when in practice. Physician immunizers might benefit most from further training on vaccines and vaccine administration and handling.     

Enhancing continuity of information: Essential components of consultation reports

OBJECTIVE

To identify elements of data that have been shown to contribute to continuity of information between primary care providers and medical specialists providing care to adult asthma patients.

DESIGN

Systematic review of the literature followed by a 2-round modified Delphi consensus process.

SETTING

Province of Ontario.

PARTICIPANTS

Eight expert panelists, including 3 practising family physicians, a medical specialist knowledgeable in the treatment of asthma, a family physician previously involved in provincial initiatives related to primary care reform, an e-health technologist, a developer of evidence-based guidelines, and an operations and programs specialist.

METHODS

We completed a systematic literature review to identify important components of consultation reports. We then engaged an 8-member panel in a 2-round modified Delphi consensus process, which led to the identification of components deemed essential to good continuity of information.

MAIN FINDINGS

After 2 rounds, expert panelists reached consensus on 15 components, referred to here as minimum essential elements, of consultation reports generated by medical specialists in response to referring primary care providers’ consultation requests.

CONCLUSION

The expert panelists considered inclusion of the minimum essential elements in consultation reports essential to achieving good continuity of information. We assembled these elements in a suggested format for a consultation report. The format can be easily modified by practitioners caring for patients with other chronic diseases.     

Adopting electronic medical records: Are they just electronic paper records?

Objective

To understand the key challenges to adoption of advanced features of electronic medical records (EMRs) in office practice, and to better understand these challenges in a Canadian context.

Design

Mixed-methods study.

Setting

Manitoba.

Participants

Health care providers and staff in 5 primary care offices.

Methods

Level of EMR adoption was assessed, and field notes from interviews and discussion groups were qualitatively analyzed for common challenges and themes across all sites.

Main findings

Fifty-seven interviews and 4 discussion groups were conducted from November 2011 to January 2012. Electronic medical record adoption scores ranged from 2.3 to 3.0 (out of a theoretical maximum of 5). Practices often scored lower than expected on use of decision support, providing patients with access to their own data, and use of practice-reporting tools. Qualitative analysis showed there were ceiling effects to EMR adoption owing to how the EMR was implemented, the supporting eHealth infrastructure, lack of awareness or availability of EMR functionality, and poor EMR data quality.

Conclusion

Many practitioners used their EMRs as “electronic paper records” and were not using advanced features of their EMRs that could further enhance practice. Data-quality issues within the EMRs could affect future attempts at using these features. Education and quality improvement activities to support data quality and EMR optimization are likely needed to support practices in maximizing their use of EMRs.     

Medical students’ views on training in intellectual disabilities

OBJECTIVE

To examine undergraduate medical training in the field of intellectual disabilities (ID) from the perspective of clinical clerks.

DESIGN

Cross-sectional self-administered survey.

SETTING

Clerkship rotations at Queen’s University in Kingston, Ont, and the University of Toronto in Ontario in 2006.

PARTICIPANTS

A total of 196 upper-year undergraduate medical students (clerks).

MAIN OUTCOME MEASURES

Contact with people with ID, training in the field of ID, perceptions of current training in ID, and views on ways to improve the curriculum in the area of ID.

RESULTS

Most students (85.6%) had received some didactic and clinical training in managing patients with ID, but most of these (93.3%) believed that curriculum enhancements, especially more contact with patients with ID and more time in the curriculum for training in care of people with ID, were necessary.

CONCLUSION

This study found that the curriculum enhancements long recommended by experts in the field of ID were also desired by clinical clerks. This finding adds considerable weight to the recommendation that improvements in training in ID should be incorporated into undergraduate medical education programs.     

Methods for a study of Anticipatory and Preventive multidisciplinary Team Care in a family practice

BACKGROUND

T o examine the methodology used to evaluate whether focusing the work of nurse practitioners and a pharmacist on frail and at-risk patients would improve the quality of care for such patients.

DESIGN

Evaluation of methodology of a randomized controlled trial including analysis of quantitative and qualitative data over time and analysis of cost-effectiveness.

SETTING

A single practice in a rural area near Ottawa, Ont.

PARTICIPANTS

A total of 241 frail patients, aged 50 years and older, at risk of experiencing adverse health outcomes.

INTERVENTION

At-risk patients were randomly assigned to receive Anticipatory and Preventive Team Care (from their family physicians, 1 of 3 nurse practitioners, and a pharmacist) or usual care.

MAIN OUTCOME MEASURES

The principal outcome for the study was the quality of care for chronic disease management. Secondary outcomes included other quality of care measures and evaluation of the program process and its cost-effectiveness. This article examines the effectiveness of the methodology used. Quantitative data from surveys, administrative databases, and medical records were supplemented with qualitative information from interviews, focus groups, work logs, and study notes.

CONCLUSION

Three factors limit our ability to fully demonstrate the potential effects of this team structure. For reasons outside our control, the intervention duration was shorter than intended; the practice’s physical layout did not facilitate interactions between the care providers; and contamination of the intervention effect into the control arm cannot be excluded. The study used a randomized design, relied on a multifaceted approach to evaluating its effects, and used several sources of data.

TRIAL REGISTRATION NUMBER

{"type":"clinical-trial","attrs":{"text":"NCT00238836","term_id":"NCT00238836"}}NCT00238836 (CONSORT).     

An Information Systems Model of the Determinants of Electronic Health Record Use

Objectives

The prominence given to universal implementation of electronic health record (EHR) systems in U.S. health care reform, underscores the importance of devising reliable measures of factors that predict medical care providers’ use of EHRs. This paper presents an easily administered provider survey instrument that includes measures corresponding to core dimensions of DeLone and McClean’s (D & M) model of information system success.

Methods

Study data came from self-administered surveys completed by 460 primary care providers, who had recently begun using an EHR.

Results

Based upon assessment of psychometric properties of survey items, a revised D&M causal model was formulated that included four measures of the determinants of EHR use (system quality, IT support, ease of use, user satisfaction) and five indicators of provider beliefs about the impact on an individual’s clinical practice. A structural equation model was estimated that demonstrated a high level of inter-correlation between the four scales measuring determinants of EHR use. All four variables had positive association with each of the five individual impact measures. Consistent with our revised D&M model, the association of system quality and IT support with the individual impact measures was entirely mediated by ease of use and user satisfaction.

Conclusions

Survey research provides important insights into provider experiences with EHR. Additional studies are in progress to investigate how the variables constructed for this study are related to direct measures of EHR use.     

Characteristics of men and women with diabetes: observations during patients' initial visit to a diabetes education centre

OBJECTIVE

To determine whether men and women with type 2 diabetes have different psychosocial, behavioural, and clinical characteristics at the time of their first visit to a diabetes education centre.

DESIGN

A questionnaire on psychosocial and behavioural characteristics was administered at participants’ first appointments. Clinical and disease-related data were collected from their medical records. Bivariate analyses (χ² test, t test, and Mann-Whitney test) were conducted to examine differences between men and women on the various characteristics.

SETTING

Two diabetes education centres in the greater Toronto area in Ontario.

PARTICIPANTS

A total of 275 men and women with type 2 diabetes.

RESULTS

Women were more likely to have a family history of diabetes,previous diabetes education, and higher expectations of the benefits of self-management. Women reported higher levels of social support from their diabetes health care team than men did, and had more depressive symptoms, higher body mass, and higher levels of high-density lipoprotein cholesterol than men did.

CONCLUSION

The results of this study provide evidence that diabetes prevention, care, and education need to be targeted to men and women differently. Primary care providers should encourage men to attend diabetes self-management education sessions and emphasize the benefits of self-care. Primary care providers should promote regular diabetes screening and primary prevention to women, particularly women with a family history of diabetes or a high body mass index; emphasize the importance of weight management for those with and without diabetes; and screen diabetic women for depressive symptoms.     

Emergency care capacity in Freetown,Sierra Leone: a service evaluation

Background

There is an increasing global recognition of the role of emergency medical services in improving population health. Emergency medical services remain underdeveloped in many low income countries, particularly in sub-Saharan Africa. There have been no previous evaluations of specialist emergency and critical care services in Sierra Leone.

Methods

Emergency care capacity was evaluated at a sample of seven public and private hospitals in Freetown, the capital of Sierra Leone. A structured set of minimum standards necessary to deliver emergency and critical care in the low-income setting was used to evaluate capacity. The key dimensions of capacity evaluated were infrastructure, human resources, drug and equipment availability, training, systems, guidelines and diagnostics. A score for each dimension of capacity was calculated based on the availability of a list of specified indicators within each dimension. In addition, an Emergency Care Capacity Score was calculated to demonstrate a composite measure of capacity based on the various indicator scores. This method has been used by the World Health Organisation in evaluating the availability and readiness of healthcare systems in low- and middle-income countries.

Results

Substantial deficiencies in capacity were demonstrated across the range of indicators and predominantly affecting publically funded facilities. Capacity was weakest in the domain of infrastructure, with an average score of 43%, while the strongest areas of capacity overall were in drug availability, 82%, and human resources, 79%. A marked disparity was noted between public and private healthcare facilities with consistently lower capacity in the former. The overall Emergency Care Capacity Score was 66%.

Conclusion

There are substantial deficiencies in emergency care systems in public hospitals in Freetown which are likely to compromise effective care. This represents a serious barrier to access to emergency healthcare. Emergency care systems have an important role in improving population health and as such should a priority for local policy makers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12873-015-0027-4) contains supplementary material, which is available to authorized users.     

Emergency department use: Is frequent use associated with a lack of primary care provider?

Objective

To determine if having a primary care provider is an important factor in frequency of emergency department (ED) use.

Design

Analysis of a central computerized health network database.

Setting

Three EDs in southern New Brunswick.

Participants

All ED visits during 1 calendar year to an urban regional hospital (URH), an urban urgent care centre (UCC), and a rural community hospital (RCH) were captured.

Main outcome measures

Patients with and without listed primary care providers were compared in terms of number of visits to the ED. A logistic regression analysis was used to determine factors predictive of frequent attendance.

Results

In total, 48 505, 41 004, and 27 900 visits were made to the URH, UCC, and RCH, respectively, in 2009. The proportion of patients with listed primary care providers was 36.6% for the URH, 37.1% for the UCC, and 89.4% for the RCH. Among ED patients at all sites, frequent attenders (4 or more visits to an ED in 1 year) were significantly more likely (59.6% vs 45.1%, P < .001) to have listed primary care providers. Other factors that predicted frequent use included attendance at a rural ED, female sex, and older age.

Conclusion

This study characterizes attendance rates for 3 EDs in southern New Brunswick. Our findings highlight interesting differences between urban and rural ED populations, and suggest that frequent use of the ED might not be related to lack of a listed primary care provider.     

Providing high-quality care in primary care settings: How to make trade-offs

Objective

To gain a deeper understanding of how primary care (PC) practices belonging to different models manage resources to provide high-quality care.

Design

Multiple-case study embedded in a cross-sectional study of a random sample of 37 practices.

Setting

Three regions of Quebec.

Participants

Health care professionals and staff of 5 PC practices.

Methods

Five cases showing above-average results on quality-of-care indicators were purposefully selected to contrast on region, practice size, and PC model. Data were collected using an organizational questionnaire; the Team Climate Inventory, which was completed by health care professionals and staff; and 33 individual interviews. Detailed case histories were written and thematic analysis was performed.

Main findings

The core common feature of these practices was their ongoing effort to make trade-offs to deliver services that met their vision of high-quality care. These compromises involved the same 3 areas, but to varying degrees depending on clinic characteristics: developing a shared vision of high-quality care; aligning resource use with that vision; and balancing professional aspirations and population needs. The leadership of the physician lead was crucial. The external environment was perceived as a source of pressure and dilemmas rather than as a source of support in these matters.

Conclusion

Irrespective of their models, PC practices’ pursuit of high-quality care is based on a vision in which accessibility is a key component, balanced by appropriate management of available resources and of external environment expectations. Current PC reforms often create tensions rather than support PC practices in their pursuit of high-quality care.     

Front-office staff can improve clinical tobacco intervention: Health coordinator pilot project

Objective

To learn whether front-line personnel in primary care practices can increase delivery of clinical tobacco interventions and also help smokers address physical inactivity, at-risk alcohol use, and depression.

Design

Uncontrolled before-and-after design.

Setting

Vancouver, BC, area (4 practices); northern British Columbia (2 practices).

Participants

Six practices, with 1 staff person per practice serving as a “health coordinator” who tracked and, after the baseline period, delivered preventive interventions to all patients who smoked. To assess delivery of preventive interventions, each practice was to sample 300 consecutive patient records, both at baseline and at follow-up 15 months later.

Interventions

Front-office staff were recruited, trained, paid, and given ongoing support to provide preventive care. Clinicians supplemented this care with advice and guided the use of medication.

Main outcome measures

Effectiveness of the intervention was based on comparison, at baseline and at follow-up, of the proportion of patients with any of the following 6 proven intervention components documented in their medical records: chart reminder, advice received, self-management plan, target quit date, referral, and follow-up date (as they applied to tobacco, physical inactivity, at-risk alcohol use, and depression). A Tobacco Intervention Flow Sheet cued preventive care, and its data were entered into a spreadsheet (which served as a smokers’ registry). Qualitative appraisal data were noted.

Results

For tobacco, substantial increases occurred after the intervention period in the proportion of patients with each of the intervention components noted in their charts: chart reminder (20% vs 94%); provision of advice (34% vs 79%); self-management plan (14% vs 57%); target quit date (5% vs 11%); referral (6% vs 11%); and follow-up date (7% vs 42%). Interventions for physical inactivity and depression showed some gains, but there were no gains for at-risk alcohol use. Front-line staff, patients, and clinicians were enthusiastic about the services offered.

Conclusion

Selected front-office personnel can substantially increase the delivery of evidence-based clinical tobacco intervention and increase patient and staff satisfaction in doing so. How far these findings can be generalized and their population effects require further study.     

Mayhem on the ice: Do players’ injuries put team staff at risk of injury?

OBJECTIVE

To investigate the potential for serious injury and the nature of injuries incurred as team staff or support personnel cross ice surfaces to get to players’ benches or to attend to injured players.

DESIGN

Hybrid study, case series with survey.

MAIN OUTCOME MEASURES

Circumstances and nature of reported injuries.

RESULTS

Over 4 seasons, 988 injuries to team staff or support personnel were reported, including 94 concussions, 5 injuries to internal organs, 226 fractures, and 86 separations or dislocations. Most of the injuries were incurred by team staff or support personnel responsible for the welfare of players (managers, trainers, therapists, and emergency medical staff).

CONCLUSION

Team staff and support personnel incur serious injuries as a result of falls on the ice. Several preventive strategies can be put in place: changes in rink design, policies restricting access to the ice surface, and encouraging team staff and support personnel who must cross the ice surface to attend to injured players to wear gait-stabilizing devices.     

Systematic review of clinical features of suspected colorectal cancer in primary care

Objective

To systematically review the diagnostic accuracy of clinical features associated with colorectal cancer (CRC) presenting in primary care.

Data sources

MEDLINE and EMBASE were searched for studies in primary care that provided information on clinical features predictive of CRC. Positive predictive values were used to guide the determination of clinical features associated with increased risk of CRC.

Study selection

Systematic reviews or primary studies that provided possible clinical features predictive of CRC were included.

Synthesis

Clinical features of patients presenting in primary care that are associated with increased risk of CRC, listed in descending order of association, included palpable rectal or abdominal mass; rectal bleeding combined with weight loss; iron deficiency anemia; rectal bleeding mixed with stool; rectal bleeding in the absence of perianal symptoms; rectal bleeding combined with change in bowel habits; dark rectal bleeding; rectal bleeding and diarrhea; and change in bowel habits. Being male and increasing age were also, in general, associated with increased risk of CRC.

Conclusion

Recognition of clinical features associated with increased risk of CRC by FPs might help with earlier identification and referral among patients presenting in primary care. This review might help inform providers and CRC diagnostic assessment programs about indications for assessment and further investigation.     

Practice patterns of graduates of a CCFP(EM) residency program: A survey

Objective

To determine the practice settings of graduates of a residency program that leads to a Certificate of Special Competence in Emergency Medicine (CCFP[EM]).

Design

Web-based survey using standard Dillman methodology.

Setting

Canada.

Participants

All graduates of the CCFP(EM) residency training program at the University of Toronto (U of T) in Ontario between 1982 and 2009.

Main outcome measures

Practice type and location, job satisfaction, and nonclinical EM activities of graduates of a CCFP(EM) residency program.

Results

Of 146 graduates surveyed, 88 responded (response rate of 60.3%). All of the respondents indicated that they had practised EM at some point after completing the CCFP(EM) program at U of T. At survey completion, 76.7% were practising EM. Of the EM-practising cohort, 93.9% worked in urban or suburban hospitals as opposed to rural settings. Those practising EM expressed high levels of job satisfaction, with 83.3% reporting a score of 8 or higher on a 10-point satisfaction scale. Most (57.0%) of the graduates of the CCFP(EM) residency program at U of T had participated in leadership activities in EM on local, provincial, or national levels.

Conclusion

Most graduates of the CCFP(EM) residency program continue to practise EM, and most of them practise in urban and suburban environments. The low attrition rate of CCFP(EM) graduates should be regarded as a success of the CCFP(EM) program, and the geographic distribution of all physicians, including EM providers, warrants further study to help plan future physician resources in Canada.     

Care of adults with developmental disabilities: Effects of a continuing education course for primary care providers

Objective

To evaluate the effects of an interdisciplinary, guideline-based continuing education course on measures related to the care of adults with developmental disabilities (DD).

Design

Before-and-after study with a control group.

Setting

Ontario.

Participants

Forty-seven primary care providers (physicians, registered nurses, and nurse practitioners).

Intervention

Participants either only received reference material about primary care of people with DD (control group) or participated in a continuing education course on primary care of people with DD in addition to receiving the reference material (intervention group).

Main outcome measures

Participants reported on 5 key measures related to care of adults with DD: frequency of using guidelines, frequency of performing periodic health examinations, frequency of assessing patients who present with behaviour changes, level of comfort while caring for adults with DD, and knowledge of primary care related to adults with DD.

Results

Over time, the intervention group showed significant increases in 4 of the 5 key measures of care compared with the control group: the frequency of guideline use (P < .001), frequency of assessment of patients’ behaviour change (P = .03), comfort level in caring for people with DD (P = .01), and knowledge of primary care related to adults with DD (P = .01).

Conclusion

A continuing education course on primary care of adults with DD is a useful interdisciplinary model to train health professionals who provide primary care services to these patients.     

Burden of acute otitis media on Canadian families

Objective

To estimate the burden of acute otitis media (AOM) on Canadian families.

Design

Telephone survey using random-digit dialing.

Setting

All Canadian provinces between May and June 2008.

Participants

Caregivers of 1 or more children aged 6 months to 5 years.

Main outcome measures

Caregivers’ reports on the number of AOM episodes experienced by the child in the past 12 months, as well as disease characteristics, health services and medication use, time spent on medical consultations (including travel), and time taken off from work to care for the sick children.

Results

A total of 502 eligible caregivers were recruited, 161 (32%) of whom reported at least 1 AOM episode for their children and 42 (8%) of whom reported 3 or more episodes during the past 12 months. Most children (94%, 151 of 161) visited with health professionals during their most recent AOM episodes. The average time required for medical examination was 3.1 hours in an emergency department and 1.8 hours in an outpatient clinic. Overall, 93% of episodes resulted in antibiotics use. A substantial proportion of caregivers (38%) missed work during this time; the average time taken off work was 15.9 hours.

Conclusion

In Canada, episodes of AOM are still associated with substantial use of health services and indirect costs to the caregivers.     

Managing Conflicts of Interest in Continuing Medical Education: a Comparison of Policies

Background:

Altruism is a central underpinning of professional behavior; however physicians may face instances in which their secondary (financial) interest is in competition with their primary (patient health, research integrity, professional education) interests. Most medical institutions have developed policies to manage conflicts of interest, but chiropractic institutions, organizations and providers may not be well-acquainted with such policies.

Purpose:

To compare the policies of the Department of Veterans Affairs (VA) and the North American Spine Society (NASS) regarding management of conflicts of interest in continuing medical education (CME).

Methods:

A qualitative review of published policies of the VA and NASS was performed. The policies of each organization were retrieved and reviewed, and data were entered into a spreadsheet for comparison. Content experts at each organization were contacted to provide additional information.

Results:

The VA and NASS provide explicit, similar policies to manage conflicts of interest in CME. Proposed speakers are required to disclose the nature and value of financial relationships relevant to content of their planned talk/presentation. Procedures for committee review, mitigation of conflict, or prohibiting the participation of a given speaker have been described. Disclosure must be made to the attendees of an educational activity in printed materials and at the time of presentation.

Conclusion:

The VA and NASS appear similar in their policies to manage conflicts of interest in CME. The policies of the VA and NASS may provide examples for the chiropractic profession to consider in relation to chiropractic continuing educationKey Indexing Terms: Chiropractic, Education, Continuing, Conflict of Interest