Patient attitudes toward using computers to improve health services delivery

BACKGROUND: The aim of this study was to examine the acceptability of point of care computerized prompts to improve health services delivery among a sample of primary care patients. METHODS: Primary data collection. Cross-sectional survey. Patients were surveyed after their visit with a primary care provider. Data were obtained from patients of ten community-based primary care practices in the spring of 2001. RESULTS: Almost all patients reported that they would support using a computer before each visit to prompt their doctor to: "do health screening tests" (92%), "counsel about health behaviors (like diet and exercise)" (92%) and "change treatments for health conditions" (86%). In multivariate testing, the only variable that was associated with acceptability of the point of care computerized prompts was patient's confidence in their ability to answer questions about their health using a computer (beta = 0.39, p = .001). Concerns about data security were expressed by 36.3% of subjects, but were not related to acceptability of the prompts. CONCLUSIONS: Support for using computers to generate point of care prompts to improve quality-oriented processes of care was high in our sample, but may be contingent on patients feeling familiar with their personal medical history

HEALTH SYSTEM PROCESSES, CLINICIAN ATTITUDES, AND REFERRALS TO TOBACCO TREATMENT PROGRAMS

Assisting smokers to quit and stay quit is the most important intervention clinicians can undertake to improve the length and quality of life of patients who use tobacco. The chronic, relapsing nature of tobacco dependence complicates tobacco treatment. Tobacco treatment counseling programs provide on-going support to help patients avoid relapse. Assistance with a referral increases the likelihood that patients will participate in counseling, but few clinicians regularly assist with referrals to tobacco treatment programs. This dissertation examined health system processes and clinician attitudes that influence the likelihood that clinicians will refer their patients for tobacco treatment counseling. Three papers examined health system processes, clinician attitudes, and frequency of referrals. A systematic review of the literature was conducted to evaluate strategies to increase the frequency of clinician referrals and effects on quit rates in primary care. The most effective strategies were those that combined clinician education with integrated referral systems. Integrated referral systems include non-clinician staff and clinician and staff prompts with algorithms or protocols for referrals. The second paper reports the findings of a pilot study using qualitative methods to explore experiences and strategies used for tobacco treatment by clinician champions practicing in independent primary care practices. Tobacco champions (N = 11) described experiences counseling patients but not assistance with referrals. Themes identified were: sources of knowledge and experience, understanding dependence, role perception, and treatment strategies. The final paper reports the findings of a cross- sectional, non-experimental study to examine clinician attitudes toward counseling, health system processes that facilitate referrals, and referrals to tobacco treatment counseling. Attitudes about the efficacy of tobacco counseling and the presence of processes that facilitate referrals predicted referrals. Clinicians sampled in these studies held favorable attitudes toward tobacco treatment but lacked confidence in the efficacy of community-based counseling for tobacco treatment. These findings have implications for health care policies to improve integration of processes that facilitate referrals and clinician education that includes information about counseling resources to improve chronic care for the treatment of tobacco dependence

New Publications from the Department of Health Policy

No abstract available

Annual report, 2005-2006

It contains the statement of R&D works undertaken, achivement made and the expenditure by the laboratory during the financial year 2005-2006

Exam Room Computers and Patient-Clinician Communication: A Wicked Problem

The present study is a primarily qualitative case study examining the patient-clinician relationship. Clinicians practicing within an oncology practice with a reputation for patient-centered care responded to questions regarding how the introduction of an electronic medical record (EMR) and an exam room computer had affected their day-to-day clinical practice. Framed as a wicked problem (a problem that could not be solved using a linear methodology), I believed clues to understanding a method for incorporating use of an exam room computer into a clinical visit while maintaining empathic communication with the patient could be found by exploring the experience of clinicians who had faced the dilemma. Only three of the nine clinicians interviewed reported routinely using the computer to document the visit while the patient was in the room. The exam room computer was perceived by the clinicians as a third interaction in addition to the patient-clinician relationship and had changed the dynamics of the clinical visit. Identified disadvantages to using an exam room computer included physical environmental factors and relational problems created by system failures or slowness where the clinician felt obligated to explain the unwelcome interruptions of the clinical visit by acknowledging to the patient the interference of the damn computer. Environmental factors interfered with empathic communication by limiting nonverbal communication, particularly eye contact. Similarly, relational factors made empathic communication more difficult by interrupting the flow of conversation or pulling the clinician\u27s attention away from the patient. The clinicians who used the exam room computer in the presence of the patient were unable to verbalize a specific technique they had discovered to unable them to maintain an empathic connection with their patients. However, in explaining how they had adapted their practice after the introduction of the exam room computer they demonstrated a strong commitment to their patients through mindfulness and reflexivity. The empathic connection between these clinicians and their patients was maintained through an awareness of how their words and behavior might be perceived by the patient, and a conscious effort to keep the patient at the center of the interaction despite distractions introduced by the computer

Annual report 2004-2005

It contains the statement of R&D works undertaken, achivement made and the expenditure by the laboratory during the financial year 2004-2005

The Recruitment of Children to Randomised Controlled Trials

Abstract Background The randomised-controlled trial (RCT) provides the best evidence for evaluating treatment effects and is accepted as a gold standard for clinical and regulatory decision making (1;2). One of the major challenges to the conduct of RCTs is the recruitment of adequate numbers of participants. Inadequate numbers reduce the power of a study to detect statistically significant treatment effects, and may cause delays, increased costs and failure to complete trials. The need for clinical trials in children has been increasingly recognised by the scientific community, resulting in increased demands for the inclusion of children in trials. For several reasons, recruiting children to trials is more challenging than recruiting adults, as consent issues are more difficult because parents make decisions about trial participation on behalf of their child. Despite general professional and community support for paediatric clinical trials, parents and paediatricians express reluctance when their own child or patient is asked to participate. Although researchers working with children commonly experience difficulty with recruiting children to RCTs, little is known about this very important subject. The method by which potential participants are approached for trial participation, the influence of their health care provider and the attitude of potential participants (or their parents, in the case of children), are critical to the understanding of the decision making process for trial participation. This thesis is one of the first major attempts to explore the issues surrounding the recruitment of children to RCTs, and is divided into four studies which address these issues. Methods Recruitment strategies used to encourage participation in randomised controlled trials (systematic review) Eligible experimental and observational studies comparing methods of recruiting participants for RCTs were identified after a comprehensive search of Medline, Embase, the Cochrane Library and reference lists. Independent data extractions were completed by two reviewers who assessed the studies for eligibility and methodological quality. Outcome measures were consent rates, proportion enrolled by each method and cost of recruitment per participant. Summary estimators of effects were calculated using a random effects model and expressed as relative risk with 95% confidence intervals. Heterogeneity was analysed using the Q statistic. Paediatricians' attitudes to children's participation in randomised controlled trials (focus group research) Qualitative analysis of focus group discussions involving 16 paediatricians and 5 trainees from a paediatric teaching hospital in Sydney was undertaken. Doctors varied in occupation, experience, research activity, age, gender, ethnicity and parenthood experience. A professional facilitator conducted the semi-structured group discussions. Recruitment ceased when informational redundancy was reached, after 4 focus groups involving 21 participants. The transcribed audiotapes were analysed by theme linkage using the constant comparative method. Australian paediatricians' and adult physicians' attitudes to randomised controlled trials (survey) A 44-item questionnaire was sent to 250 paediatricians and 250 adult physicians randomly selected from the membership list of the Royal Australasian College of Physicians. Questions assessing doctors' treatment philosophies and attitudes to trials were compared with demographic and practice variables. Parents' attitudes to children's participation in randomised controlled trials (focus group research) Qualitative analysis of focus group discussions involving 33 parents from 5 different settings (representing parents of children with a life threatening, chronic or acute illness, with experience in trials and of healthy children) was undertaken. Parents varied in age, gender, ethnicity, level of education, research experience and their child's health status. The transcribed discussions were analysed by theme linkage using the constant comparative method. Results Recruitment strategies used to encourage participation in randomised controlled trials (systematic review) Fifty papers were included (out of 8602 titles and abstracts searched) which described 8 RCTs, 2 quasi RCTs, 13 prospective cohort studies, 30 retrospective cohort studies and 2 before-after studies. These studies assessed how over 4 million people were approached for RCT participation using 87 different recruitment strategies, with 103,406 people enrolling in RCTs. Health care provider (HCP) referrals had the highest participant consent rates at the time of exposure to trial information (HCP referral versus target mailing: relative risk (RR) 1.84 (95% confidence interval (95%CI) 1.08, 3.13)). They also had the highest consent rates when potential participants respond to the recruitment material by further enquiry about the trial (HCP referral versus community presentation: RR 1.37 (1.06; 1.78); HCP referral versus worksite approach: RR 25.20 (20.19, 31.45); HCP referral versus general community approach: RR 2.53 (0.46, 14.05); HCP referral versus mailing: RR 3.29 (1.26, 8.60); HCP referral versus media: RR 2.66 (1.31, 5.41)). However, by the time potential participants attend eligibility assessment for trial participation, no difference in consent rates could be distinguished by method of recruitment. Higher proportions of study participants were recruited by methods that exposed larger numbers of potential candidates to trial information (despite their lower consent rates). The stated recruitment cost ranged from US$0 to$1108 per participant, with mailing being the most cost-effective method and community methods (such as community presentations, pamphlets and posters displayed at community sites) the least effective. Paediatricians' attitudes to children's participation in randomised controlled trials (focus group research) From the focus group discussions, paediatricians thought parents balanced perceived gains and risks when deciding about trial participation. They also believed the child's condition and parents' health beliefs and personal attributes influenced parents' decisions. Other factors thought to be important by paediatricians were the doctors' beliefs and their relationship with the investigators. Paediatricians perceived gains for trial participation including professional benefits for themselves, improved patient care, convenience for the families and themselves and scientific advancement. Perceived risks included inconvenience, inadequate resources and potential harms to the patient and the doctor-patient relationship. Paediatricians with previous research experience were most knowledgeable about RCTs and perceived greatest gains from trial participation. Paediatricians' personal treatment preferences hindered trial support. Australian paediatricians' and adult physicians' attitudes to randomised controlled trials (survey) Response rate from the paediatricians' and adult physicians' survey was 60% (300/500). Australian paediatricians and adult physicians are very similar in their treatment philosophies, and are clinician-oriented rather than research-oriented in their attitudes, with primary allegiance to their patients and preference for selecting treatment rather than referring for trial participation in the face of treatment uncertainty. Professional activities are clinically focused, with limited time assigned for research. Australian doctors perceive little reward for trial participation and claim that the opinions of referring doctors regarding RCTs does not influence them. Predictors of favourable attitudes to trial participation from the survey were time allocation for research, a history of referring patients to trials in the past and younger age (all p values less than 0.0001). Parents' attitudes to children's participation in randomised controlled trials (focus group research) When parents were interviewed, they acknowledged balancing risks and benefits when deciding about trial participation for their child. Perceived benefits include the offer of hope, better care of their child, the opportunity to access new treatments, healthcare professionals and health information, meeting others in similar circumstances and helping others. Perceived risks include potential side effects, being randomised to ineffective treatments and the inconvenience of participation. The decision for trial participation is also influenced by parental factors (parents' knowledge, beliefs and emotional response), child factors (the child's health status and preference about participation), trial factors (the use of placebos and the uncertainties of research) and doctor factors (doctor's recommendations and communication of trial information). Conclusions There are many challenges to the successful conduct of RCTs. Ways of addressing these include: using effective methods of recruiting potential study participants (such as mailing of recruitment material to potential participants) and abandoning ineffective strategies (such as community methods): fostering greater willingness for trial participation by addressing parents' and paediatricians' concerns including enhancing communication between researchers, paediatricians and parents, and improving the gains-hazard balance (by increasing incentives while decreasing inconveniences); and reforming in the health care system to raise the priority placed on clinical research by restructuring clinical research in a clinically predominant workplace and with a clinically predominant workforce. The findings from this study have implications for researchers planning RCTs for children in the future. Careful consideration of the above will enhance RCTs participation for children improving efficiency, lowering costs and ultimately improving the future health care of children

Pharmacy Manager System Implementation Strategies to Mitigate the Cost of Prescription Errors

AbstractOne of the most frequent medical errors in contemporary medicine is incorrect prescriptions, and the profits from retail pharmacy operations are adversely impacted by the costs associated with prescription errors. Independent pharmacy managers are interested in finding workable strategies to mitigate the cost of prescription errors and increase profit. Using the resource-based theory of competitive advantage (RBTCA), the purpose of this qualitative multiple-case study was to explore strategies some independent pharmacy managers in Texas use to mitigate the cost of pharmacy employee prescription errors and increase profitability. The participants were five independent pharmacy managers who implemented strategies to mitigate the cost of prescription errors. Data were collected using semistructured, face-to-face interviews, a review of company documents, and site observation notes. Through thematic analysis, four themes emerged: (a) cost of prescription quality check and errors reduction strategy, (b) increased profitability strategy through error cost mitigation, (c) positive utilization of organization resources strategy, and (d) technology system implementation strategy to reduce prescription errors. A key recommendation is for independent pharmacy managers to involve pharmacy staff in developing the pharmacy system to promote user acceptance, which will assist in reducing prescription errors and raising profit. The implications for positive social change include the potential to mitigate the cost of prescription errors, prevent hospitalization and fatalities caused by medication errors, enhance patients’ quality of life, and boost the economy and employment opportunities in their communities

The Electronic Health Record's Impact on Labor and Delivery Nurses' Cognitive Work

The Electronic Health Record’s Impact on Labor and Delivery Nurses’ Cognitive WorkAbstractBackground and objective: Despite recognition that electronic health record (EHR) use has introduced cognitive challenges for clinicians, few studies have evaluated its impact on the cognitive dimension of nurses’ work. Labor and delivery nurses may encounter unique challenges when using the electronic health record since they also interact with an electronic fetal monitoring system. This study sought to explore labor and delivery nurses’ perceptions of the EHR’s impact on their cognitive work with the goal of identifying patient safety implications. Methods and setting: This was a grounded theory study using dimensional and situational analysis. Data were interviews and observations with 21 labor nurses at two community hospitals in the Western United States. Results: The ways that nurses configured care when using the EHR varied across participants and sites and depended on how easily they integrated it into their practice. Individual, group, and situational factors facilitated or constrained integration. This took place in a dynamic, high-acuity, specialty clinical environment while using EHRs that were not designed for pregnant women. Nurses used clinical decision support and other cognitive support features that rarely worked as intended due to the lack of EHR customization to account for pregnancy physiology and unique risk factors in the perinatal patient. Nurses viewed the quality of their relationships with patients and their families as an integral part of caring for laboring women and felt that interaction with the EHR sometimes threatened this dimension of their work. Conclusions: When nurses were unable to integrate the EHR into care it resulted in numerous consequences that have important safety implications. Available cognitive support features lacked the specialty-specific support needed to care for laboring women and instead required nurses to track information in other ways that added to their cognitive burden and work routines. As a result, nurses and patients were not benefitting from the intended decision support and patient safety protections offered by appropriate risk assessment screens or critical alerts. These findings have important implications for the configuration and design of EHRs in perinatal settings