Handheld Technology to Improve Patient Care: Evaluating a Support System for Preference-based Care Planning at the Bedside

Objective: Despite an increasing movement toward shared decision making and the incorporation of patients'' preferences into health care decision making, little research has been done on the development and evaluation of support systems that help clinicians elicit and integrate patients'' preferences into patient care. This study evaluates nurses'' use of choice, a handheld-computer–based support system for preference-based care planning, which assists nurses in eliciting patients'' preferences for functional performance at the bedside. Specifically, it evaluates the effects of system use on nurses'' care priorities, preference achievement, and patients'' satisfaction.Design: Three-group sequential design with one intervention and two control groups (N=155). In the intervention group, nurses elicited patients'' preferences for functional performance with the handheld-computer–based choice application as part of their regular admission interview; preference information was added to patients'' charts and used in subsequent care planning.Results: Nurses'' use of choice made nursing care more consistent with patient preferences (F=11.4; P<0.001) and improved patients'' preference achievement (F=4.9; P<0.05). Furthermore, higher consistency between patients'' preferences and nurses'' care priorities was associated with higher preference achievement (r=0.49; P<0.001).Conclusion: In this study, the use of a handheld-computer–based support system for preference-based care planning improved patient-centered care and patient outcomes. The technique has potential to be included in clinical practice as part of nurses'' routine care planning.With the recent movement toward shared decision making in health care, a number of models, methods, and evaluative strategies to foster shared decision making have been developed. In the clinical, health services, and methodological literature, shared decision making refers to the concept of involving patients and their health care providers in making treatment decisions that are informed by the best available evidence about treatment options and that consider patients'' preferences.Devices to assist patients in shared decision making have been called “decision aids,”¹ and cumulative evidence supports their effectiveness. Studies evaluating decision aids for patients have reported higher scores on cognitive functioning and social support,² more active and satisfying participation in decision making,³ better scores on general health perceptions and physical functioning,⁴ improved knowledge,⁵ and reduced decisional conflict.¹ However, decision aids have so far been confined to the relatively narrow segment of decisions about single episodes of screening or treatment choices. Little attention has been given to the development of systems that help clinicians elicit and integrate patients'' preferences into the ongoing processes of care over time and as part of clinical practice.Although decision aids have been shown to be helpful to patients, it has been argued that decision support systems for eliciting patients'' preferences could also support clinicians in making care decisions consistent with patients'' preferences, and that successful efforts in this direction would lead to better patient outcomes.^6,7 However, the development of decision support systems designed to support clinicians in eliciting and integrating patients'' preferences into their clinical practice has received little attention. Developments of decision support systems for clinicians have mainly been devoted to knowledge-based systems designed to produce patient-specific options and recommendations, such as computer-based clinical guidelines. Other examples of clinical decision support systems include systems that apply rules to detect undesirable trends and events during treatment, offer reminders and messages about diagnostic and therapeutic possibilities, and alert clinicians to potential serious situations.⁸Evidence shows that clinical decision support systems can enhance clinicians'' compliance with system recommendations and to some degree improve clinical patient outcomes.^9,10 Yet such systems rarely offer systematic methods for eliciting patients'' preferences or incorporate algorithms for the integration of patients'' preferences into care planning. Furthermore, there has been only limited research addressing 1) whether the use of computer-based decision support systems to assist in the elicitation of patients'' preferences would in fact prompt clinicians to make care decisions consistent with patients'' preferences, and 2) whether decisions based on the use of such tools would improve patient outcomes. Developing and testing the effects of clinical support systems for preference elicitation and care planning on clinical decisions and patient outcomes can, therefore, make an important contribution to research in this area and, ultimately, to patient-centered care.This paper reports the results of nurses'' use of Choice (Creating better Health Outcomes by Improving Communication about Patients'' Expectations), a handheld-computer–based support system for preference-based care planning, which helps nurses elicit patients'' preferences for functional performance at the bedside—specifically, the effects of its use on nurses'' care priorities and patient outcomes of preference achievement and satisfaction.     

从现代医学技术伦理视域析"看病贵"

现在,大多数的医生诊断不再是望闻问切,而是让患者先进行本不需要的各项化验检查。医生完全依赖于现代医学技术。这是形成"看病贵"的重要原因之一。笔者分析了几种原因的形成,并提出了一些解决的办法。     

Advancing Personalized Health Care through Health Information Technology: An Update from the American Health Information Community's Personalized Health Care Workgroup

The Personalized Health Care Workgroup of the American Health Information Community was formed to determine what is needed to promote standard reporting and incorporation of medical genetic/genomic tests and family health history data in electronic health records. The Workgroup has examined and clarified a range of issues related to this information, including interoperability standards and requirements for confidentiality, privacy, and security, in the course of developing recommendations to facilitate its capture, storage, transmission, and use in clinical decision support. The Workgroup is one of several appointed by the American Health Information Community to study high-priority issues related to the implementation of interoperable electronic health records in the United States. It is also a component of the U.S. Department of Health and Human Services'' Personalized Health Care Initiative, which is designed to create a foundation upon which information technology that supports personalized, predictive, and pre-emptive health care can be built.     

Puvalluttuq: An Epidemic of Tuberculosis at Eskimo Point, Northwest Territories

An explosive epidemic of tuberculosis in a small isolated settlement is described. This outbreak, in a population of 329 Eskimos and 16 whites, produced 80 cases of active tuberculosis, involving 55% of all the house-holds. Forty-five of these patients were children under 10 years of age and only five were persons over 30. These patients probably were infected by one highly infectious individual.     

基于连续性记录与评估工具的我国养老机构老年人照护费用及影响因素研究

背景 随着我国老龄化的日益严峻,老年人的照护费用将给社会和家庭带来沉重的经济负担.探讨养老机构老年人照护费用的影响因素,将有助于根据实际情况进行医疗决策、提供针对性的照护服务、合理分配医疗资源、规划长期护理保险和财政投入等,这对于老年人、家属、医疗照护服务提供者、养老照护机构、国家财政和医疗保险部门等都非常重要.目的 ...     

A National Action Plan to Meet Health Care Quality Information Needs in the Age of Managed Care

Dale V. Shaller, MPA; Richard S. Sharpe, MPA; Richard D. Rubin, AB

JAMA. 1998;279:1254-1258.

Concerted national action is needed to meet the growing demand for health care quality information among all health care stakeholders. We propose a coordinated national network of independent, public-private quality measurement alliances established through strong purchaser and consumer leadership at the state, regional, or local levels. These independent alliances could assume a variety of organizational forms, but all would undertake specific quality measurement and consumer information projects to meet local health care market needs by drawing on various combinations of the emerging national standardized quality measures. Local implementation of quality measures based on national standards will facilitate cross-market benchmarking and multistate comparisons useful not only to state and local market constituencies, but to national employers, health plans, provider organizations, and the federal government as well. Successful models of such alliances already exist that demonstrate the feasibility of this national strategy, but concerted national leadership and federal matching funding will be needed to meet the scope of implementation required in markets across the country.

     

浅谈应用目标管理的方法提高医疗质量的体会

哈尔滨医科大学附属第一医院在积极开展医疗质量管理年活动和医院等级评审的要求下,为提高医院的医疗质量,应用目标管理的方法分宣教、实施、总结反馈三个阶段进行,着重从积极开展医德医风教育、重点提高护理人员服务质量、不断提高医疗技术水平、加强各项医疗制度落实、加强医疗安全教育等方面着手,通过不断纠正工作中的偏差,从而提高医院的医疗质量管理水平。     

Bringing Community Involvement into a Cretan Primary/Hospital Care Center: An Evaluation of Population Habits and Attitudes Toward Health Care

In a small Cretan township hospital combining secondary and primary care, a questionnaire was distributed to a consecutive visitor sample. The questionnaire requested information on the participants' personal smoking and other life habits, perceptions and expectations of the delivery of the health care services, and attitudes toward their own doctors and others who provide various health services. Three hundred and one individuals of both sexes who were 15 years and older participated in the study (participation rate, more than 97%). An interesting and varied response was recorded, covering a wide range of perceptions, opinions, and attitudes not only toward the services, but also toward the staff. Although a high confidence in and appreciation of both the primary care and hospital sections appeared in the study results, these attitudes should not be allowed to deteriorate. Therefore, specific actions should be undertaken: constant upgrading of the existing organizational context, implementation of promotional and educational programs, and use of the questionnaire as an effective tool for periodically assessing the population's attitudes, experiences, and expectations.     

信息非对称对医护人员信息资源利用的影响研究

由于医院图书馆与医护人员之间存在信息非对称,导致医护人员无法充分利用信息资源,也说明医院图书馆在信息资源建设、信息服务等方面存在不足。本文通过实地调查,分析造成该现状的原因,提出减少医院图书馆与医护人员之间信息非对称的对策与措施。     

依托门诊信息系统 优化就诊工作流程

门诊工作是医院医疗工作的重要组成部分，也是社会紧密联系的服务窗口，门诊人员的流量大，就诊患者多，辗转过程繁，工作流程杂，要求效率高，其医疗技术水平的高低与服务质量的优劣，不仅是衡量一个医院综合服务水平的重要场所，而且直接关系到医院的生存与发展。     

A Study of Pre-Decision Evaluation Using Influence Diagram: An Estimation of the Benefits of Influenza Vaccination

The purpose of this study is to develop a decision analysis model based on the influence diagram and estimate the benefits receiving of influenza vaccination. We collected more than 300,000 samples of elders aged over 65 years in Taiwan and then analyzed the health expenditure of the elders with and without influenza vaccination. We incorporate clinical results and the knowledge of physicians by an influence diagram. We divided our samples into four different age groups and the results showed that the total healthcare expenses for receiving influenza vaccination are more than the expenses for not receiving influenza vaccination for all age groups, we found there is a trend that the difference decreases if the age is older. We performed the one-way sensitivity analysis and Monde Carlo sensitivity analysis further and the results showed that the expected health expenditure is mostly sensitive to the hospitalization under the different condition.     

累积计算法测定双相基础体温对排卵日的评估

用基础体温BBT和B超监测排卵对72名月经周期正常妇女的100个月经周期预测排卵。其中48个周期做了LH峰值测定。以累积统计法微机测定BBT升高的第一天(估计排卵日);用B超监测卵泡破裂作为排卵日(D-O)。比较BBT升高的第一天与D-O的关系:结果表明BBT升高第一日波动在D-1到D+3范围内占83%周期。如在BBT升高后的5天作为避孕期,则避孕可靠性复盖了83%周期。如对需用BBT作指导避孕的对象进行选择,累积分析法的可靠性更会提高。     

百会压灸治疗痰浊中阻型眩晕63例

运用各医司徒铃教授压灸百会的经验，治疗痰浊中阻型眩晕６３例，治疗次数最少１次，最多９次。结果，痊愈２０例，显效１９例，有效１５例，无效９例，总有效率为８５．７％，显效率为６１．９％，无效率为１４．３％。表明百会压灸具有治疗眩晕的作用。     

腰突穴臭氧注射治疗腰椎间盘突出症的临床疗效和肌电图分析

目的观察腰突穴臭氧注射治疗腰椎间盘突出症(lumbar disc herniation,LDH)的疗效。方法 48例LDH患者均接受腰突穴臭氧注射,治疗前后用肌电图检测其腓总神经及胫神经的运动神经传导速度(motor nerve conduction velocity,MNCV)、神经远端潜伏期(distal latency,DL)。结果经过3次腰突穴臭氧注射治疗后,48例患者临床治愈25例,好转20例,无效3例,总有效率为93.8%。与治疗前比较,LDH患者治疗后胫神经、腓总神经MNCV显著增快(P0.05),DL显著缩短(P0.05)。结论腰突穴臭氧注射能够有效改善LDH患者临床症状,提高神经传导速度,促进患者康复。     

Introducing a Module for Laboratory Test Order Entry and Reporting of Results at a Hospital Ward: An Evaluation Study Using a Multi-Method Approach

The medical record system DocuLive EPR was installed at a “typical” ward at the Central Hospital of Akershus. Modules for laboratory order entry and reporting of results were evaluated prospectively using several information sources (hospital information systems, telephone records, user survey, semi-structured interviews with key informants). The main findings are discussed, and the lessons learned from the evaluation project are presented.