Picturing inequities for health impact assessment : linked electronic records, mortality and regional disparities in Portugal

© 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis GroupHealth impact assessment (HIA) focuses on minimizing inequities when studying the effects of a policy on the population’s health. Nevertheless, it is seldom simultaneously quantified, multivariate, and visually graphically comprehensible for non-statisticians. This paper aims to address that gap, assessing a policy promoting the quality of Electronic Health Records, linking hospital and primary health care data (Blood Pressure, Cholesterol, Triglycerides, Waist Circumference, Body Mass Index) to mortality outcomes and regional inequities. Acute Myocardial Infarction patients admitted in the hospital are then followed regularly in Portuguese NHS Primary Care. Regional disparities regarding recorded information are observed and different association patterns with mortality identified, ranked, and visualized through adjusted ORs for sex, age, and indicators of severity of hospital admission, complemented with multivariate correspondence analysis. A pathway to handling equity within quantitative HIA shows that complexity in data and methods may generate simplicity and clarity through visual graphical aids. Tackling Big Data with Data Science in HIA may even be at the center of future health reforms, assessing impacts of health promotion and chronic disease policies.This work was partially supported by the CUTEHeart Project – Comparative Use of Technologies for Coronary Heart Disease, funded by FCT, QREN, COMPETE [grant number HMSP-ICT/0013/2011] (http://cuteheart.med.up.pt).info:eu-repo/semantics/publishedVersio

Using motivational interviewing and technology to increase confidence in nutritional counseling among dental hygienists: a thesis

Purpose: Research shows definite connections between food choices and caries, periodontal disease, and oral cancer. Dental hygienists have the unique opportunity to educate patients on how nutrition can improve oral health. Dental hygiene students are introduced to these concepts but struggle to gain confidence to share this knowledge with patients. This study looked at an educational module on motivational interviewing (MI) and an electronic assessment tool to build student confidence with nutritional counseling. Methods: Students participated in an educational module to review MI and introduce the electronic nutritional risk assessment and counseling tool. Prior to the module, participants completed a pretest about attitudes and confidence levels regarding MI and nutritional counseling. After three weeks of clinical practice, participants completed a posttest including the same questions, a report on the frequency of nutritional counseling sessions, and open-ended questions. Data was compared for quantitative changes and qualitative themes from participant responses. Results: Twenty-two students (n = 22) participated in both pretest and posttest. There were statistically significant changes in participants’ frequency of nutritional counseling sessions (p = 0.049) as well as in their confidence (p = 0.007) and comfort (p = 0.020) discussing nutrition with patients. Participants struggled to become more confident in MI as demonstrated with no significant change in their feelings surrounding MI (p = 0.150). Students reporting increased nutritional counseling sessions showed improvement in their confidence with nutritional counseling. Conclusion: Introducing MI with an electronic assessment tool to aid dental hygiene students can improve confidence with nutritional counseling

Two years of unintended consequences: introducing an electronic health record system in a hospice in Scotland

Aims and objectivesThe aim of the study was to explore the impact of implementing an electronic health record system on staff at a Scottish hospice.BackgroundElectronic health records are broadly considered preferable to paper based systems. However, changing from one system to the other is difficult. This study analysed the impact of this change in a Scottish hospice.DesignNaturalistic prospective repeated measures mixed methods approach.MethodData on the usability of the system, staff engagement and staff experience were obtained at four time points spanning 30 months from inception. Quantitative data were obtained from surveys, qualitative from Concurrent Analysis of free text comments and focus group. Participants were all 150 employees of a single hospice in Scotland.ResultsBoth system usability and staff engagement scores decreased for the first two years before recovering at 30 months. Staff experience data pointed to two main challenges:1.Technical issues, with subthemes of accessibility and usability.2.Cultural issues, with sub themes of time, teamwork, care provision and perception of change.ConclusionIt took 30 months for system usability and staff engagement scores to rise, after falling significantly for the first two years. The unintended outcomes of implementation included challenges to the way the patient story was both recorded and communicated. Nevertheless this process of change was found to be consistent with the ‘J curve’ theory of organizational change, and as such is both predictable and manageable for other organizations.Relevance to practiceIt is known that implementing an electronic health record system is complex. This paper puts parameters on this complexity by defining both the nature of the complexity (‘J’ curve) and the time taken for the organisation to begin recovery from the challenges (two years). Understanding these parameters will help health organisations across the world plan more strategically

Understanding the Value of Notes in Electronic Health Records

The digitalization of health records has enabled the collection of large-scale valuable datasets on healthcare. However, it has led to complaints about the diminishing value of medical notes, and often contributes to the growing physician burnout. Since writing good notes can potentially improve the quality of healthcare, it is important that doctors get some machine assistance with writing notes and bridge that gap in quality. Therefore, we examine the value of medical notes compared to the structured information in electronic health records through a prediction framework. We hypothesize that 1) medical notes provide additional predictive power to structured information; 2) certain parts of medical notes are more valuable than others (for example, original vs. ``copy-pasted''). To evaluate our hypotheses, we use the task of in-hospital mortality prediction, using timeseries derived from structured information for the first 24 hours and first 48 hours of a patient's admission. We run an additional retrospective mortality prediction task where we use all of the data associated with the patient's admission. Our results show that although medical notes bring only marginal predictive value to structured information, using them together consistently improves the prediction. Surprisingly, we also find that the usage of more common English words in notes provide more value than the uncommon English words (which also includes Medical words). Our findings indicate that there is great room for further understanding and improving the value of medical notes

Intervalos de tiempo en el diagnóstico de cáncer en el contexto de Atención Primaria en un policlínico de Jesús María, 2010 – 2015

Determina los intervalos de tiempo en el diagnóstico de cáncer en el contexto de atención primaria en una Institución Prestadora de Servicios de Salud (IPRESS) ubicada en el distrito de Jesús María. Comprende los años 2010 y 2015. Describe las características de los pacientes, sintomatología, diagnóstico definitivo de malignidad, y la variación de los intervalos según el tipo de cáncer. Es un estudio descriptivo, longitudinal y no concurrente basado en la revisión de historias clínicas. Obtiene 720 casos relevantes al estudio. La mediana del intervalo de paciente, o tiempo desde primer síntoma hasta primera consulta, es de 98 días. La mediana del intervalo de médico, o tiempo desde primera consulta hasta primer examen para descartar malignidad, es de 0 días. La mediana del intervalo de atención primaria, o tiempo desde primera cita hasta referencia, es de 6 días. Concluye que los valores obtenidos son iguales o mayores que los reportados en la literatura. Es necesario implementar medidas que reduzcan el tiempo para diagnóstico de cáncer.Tesi

Investigating Psychosocial Factors: Supporting Clinical Decisions for Outpatient Diabetes Care.

Practitioners often make decisions to diverge from clinical targets specified in diabetes clinical practice guidelines (CPGs) based on each patient’s unique situation, although reasons for this are poorly understood. Additionally, while practitioners understand that psychosocial factors may influence self-care behavior and subsequently health outcomes, little is known as to how psychosocial factors influence clinical decisions, including those that deviate from guidelines. Therefore, through a sequential exploratory mixed methods study involving physician interviews (n=17) and a survey of physicians, nurses and diabetes educators (n=229) I investigated practitioners’ access to, and use of, psychosocial information as a basis for clinical decisions in outpatient diabetes care. This study revealed four major findings. First, that psychosocial information is not considered when patients have good glycemic control, but they do consider it when a patient: 1) has persistent, poor glycemic control, 2) is a new patient or has a new diabetes diagnosis, and 3) worsening of glycemic control. Second, access to psychosocial information is granted through dialogue in an ongoing, trusting relationship. Physicians use specific techniques to build trusting relationships, which include demonstrating caring and creating a safe environment characterized by patient autonomy and privacy. Third, awareness of psychosocial information may trigger decisions to personalize HbA1c targets, pursue less aggressive treatment plans or augment guideline-concordant treatment with actions to address barriers to care, such as referrals to prescription assistance. Fourth, EHR designs are not optimized for capturing and retrieving qualitative and situationally-dependent psychosocial information, which tends to come in a narrative form. Specifically, study findings offer new insight into circumstances in which practitioners’ decisions may deviate from CPGs, and their rationales for doing so. Practitioners connecting patients to supplemental resources represent efforts to reduce negative impacts of psychosocial factors on diabetes-related self-care. If successful, these actions could ultimately improve diabetes outcomes. Findings regarding the importance of a trusting clinician-patient relationship also suggest the importance of care continuity to psychosocial information use. Moreover, results indicate that effective use of psychosocial information requires unique socio-technical supports that include clinician-patient relationship-building efforts and digital tools that are optimized for the capture and retrieval of information in narrative form.PhDInformationUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/116735/1/csenteio_1.pd