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Implementation of Shared Medical Appointments to Address Cardiovascular Disease Risk in Patients With Metabolic Syndrome

A Project Submitted in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF NURSING PRACTICE in NursingMetabolic syndrome is a condition in which the components – central adiposity, insulin resistance, atherogenic dyslipidemia, and elevated blood pressure - confer increased cardiovascular morbidity and mortality. A pilot clinical practice improvement project was developed and implemented using shared medical appointments to address cardiovascular disease risk in adult patients at a rural health care clinic on the southern Kenai Peninsula, Alaska who met the diagnostic criteria for metabolic syndrome. Statistically significant improvement in self-reported minutes of exercise was demonstrated for the nominal group of participants. Participants were at least as satisfied or more satisfied with shared medical appointments compared to traditional medical appointments. Limitations aside, the Doctor of Nursing Practice (DNP) project demonstrated the feasibility of using shared medical appointments to address cardiovascular disease risk in this patient population. There is need for additional research into the “physiology,” or curricular and other structural and procedural elements of shared medical appointments for patients with metabolic syndrome that would afford decreased cardiovascular disease risk. The Doctor of Nursing Practice (DNP) project goals were in accordance with the overarching aims of the National Quality Strategy that build on the Institute for Healthcare Improvement’s Triple Aim – cost-effective, patient-centered, quality care that improves health.Title Page / Abstract / Table of Contents / List of Figures / List of Tables / List of Appendices / Nomenclature / Overview of the Problem / Review of the Literature / Organization Framework / Project Design / Implementation Process / Outcomes and Evaluation / Implications for Nursing Practice / Summary and Conclusion / References / Appendice

Methodological approaches to study context in intervention implementation studies: an evidence gap map

Within implementation science studies, contextual analysis is increasingly recognized as foundational to interventions' successful and sustainable implementation. However, inconsistencies between methodological approaches currently limit progress in studying context and guidance to standardize the use of those approaches is scant. Therefore, this study's objective was to systematically review and map current methodological approaches to contextual analysis in intervention implementation studies. The results would help us both to systematize the process of contextual analysis and identify gaps in the current evidence.; We conducted an evidence gap map (EGM) based on literature data via a stepwise approach. First, using an empirically developed search string, we randomly sampled 20% of all intervention implementation studies available from PubMed per year (2015-2020). Second, we assessed included studies that conducted a contextual analysis. Data extraction and evaluation followed the Basel Approach for CoNtextual ANAlysis (BANANA), using a color-coded rating scheme. Also based on BANANA and on the Context and Implementation of Complex Interventions (CICI) framework-an implementation framework that pays ample attention to context- we created visual maps of various approaches to contextual analysis.; Of 15, 286 identified intervention implementation studies and study protocols, 3017 were screened for inclusion. Of those, 110 warranted close examination, revealing 22% that reported on contextual analysis. Only one study explicitly applied a framework for contextual analysis. Data were most commonly collected via surveys (n = 15) and individual interviews (n = 13). Ten studies reported mixed-methods analyses. Twenty-two assessed meso-level contextual and setting factors, with socio-cultural aspects most commonly studied. Eighteen described the use of contextual information for subsequent project phases (e.g., intervention development/adaption, selecting implementation strategies). Nine reported contextual factors' influences on implementation and/or effectiveness outcomes.; This study describes current approaches to contextual analysis in implementation science and provides a novel framework for evaluating and mapping it. By synthesizing our findings graphically in figures, we provide an initial evidence base framework that can incorporate new findings as necessary. We strongly recommend further development of methodological approaches both to conduct contextual analysis and to systematize the reporting of it. These actions will increase the quality and consistency of implementation science research

Clinical foundations and information architecture for the implementation of a federated health record service

Clinical care increasingly requires healthcare professionals to access patient record information that may be distributed across multiple sites, held in a variety of paper and electronic formats, and represented as mixtures of narrative, structured, coded and multi-media entries. A longitudinal person-centred electronic health record (EHR) is a much-anticipated solution to this problem, but its realisation is proving to be a long and complex journey. This Thesis explores the history and evolution of clinical information systems, and establishes a set of clinical and ethico-legal requirements for a generic EHR server. A federation approach (FHR) to harmonising distributed heterogeneous electronic clinical databases is advocated as the basis for meeting these requirements. A set of information models and middleware services, needed to implement a Federated Health Record server, are then described, thereby supporting access by clinical applications to a distributed set of feeder systems holding patient record information. The overall information architecture thus defined provides a generic means of combining such feeder system data to create a virtual electronic health record. Active collaboration in a wide range of clinical contexts, across the whole of Europe, has been central to the evolution of the approach taken. A federated health record server based on this architecture has been implemented by the author and colleagues and deployed in a live clinical environment in the Department of Cardiovascular Medicine at the Whittington Hospital in North London. This implementation experience has fed back into the conceptual development of the approach and has provided "proof-of-concept" verification of its completeness and practical utility. This research has benefited from collaboration with a wide range of healthcare sites, informatics organisations and industry across Europe though several EU Health Telematics projects: GEHR, Synapses, EHCR-SupA, SynEx, Medicate and 6WINIT. The information models published here have been placed in the public domain and have substantially contributed to two generations of CEN health informatics standards, including CEN TC/251 ENV 13606

E-health and e-welfare of Finland - Check point 2015

The new e-health and e-welfare strategy in Finland aims to support the renewal of the social welfare and health care services and the active role of citizens in maintaining their own well-being. The means include the development of knowledge management and increasing the provision of online services. The overall structural changes taking place in Finnish health and social care will also influence information and communication technologies (ICT). The report provides information about the change in the services and the service system brought on by ICT over time. The report illustrates the status in 2014 as compared with the strategic outcomes and objectives set on ICT to support performance and renewal of social welfare and health care. The results are condensed from four surveys for a comprehensive view: availability and use of ICT in health care as well as in social care, usability of the systems for physicians, and citizens´ use and anticipations. These are accompanied by a review of Finnish health care system and ICT development. For the international reader, the report provides an overview of progressive nationwide activities towards better e-services in Finland

Quality framework for semantic interoperability in health informatics: definition and implementation

Aligned with the increased adoption of Electronic Health Record (EHR) systems, it is recognized that semantic interoperability provides benefits for promoting patient safety and continuity of care. This thesis proposes a framework of quality metrics and recommendations for developing semantic interoperability resources specially focused on clinical information models, which are defined as formal specifications of structure and semantics for representing EHR information for a specific domain or use case. This research started with an exploratory stage that performed a systematic literature review with an international survey about the clinical information modelling best practice and barriers. The results obtained were used to define a set of quality models that were validated through Delphi study methodologies and end user survey, and also compared with related quality standards in those areas that standardization bodies had a related work programme. According to the obtained research results, the defined framework is based in the following models: Development process quality model: evaluates the alignment with the best practice in clinical information modelling and defines metrics for evaluating the tools applied as part of this process. Product quality model: evaluates the semantic interoperability capabilities of clinical information models based on the defined meta-data, data elements and terminology bindings. Quality in use model: evaluates the suitability of adopting semantic interoperability resources by end users in their local projects and organisations. Finally, the quality in use model was implemented within the European Interoperability Asset register developed by the EXPAND project with the aim of applying this quality model in a broader scope to contain any relevant material for guiding the definition, development and implementation of interoperable eHealth systems in our continent. Several European projects already expressed interest in using the register, which will now be sustained by the European Institute for Innovation through Health Data

The Measurement of Output and Productivity in the Health Care Sector in Canada: An Overview

To achieve efficient allocation of resources in the health care sector, accurate measures of health care output and productivity are essential. According to official estimates of productivity produced by Statistics Canada, labour productivity in the business sector of the health care (excluding hospitals) and social assistance industry declined 0.28 per cent per year between 1994 and 2003. Estimates of productivity produced by the CSLS, based on official Statistics Canada employment and real GDP figures, show that labour productivity in the health care and social assistance industry declined by 0.69 per cent per year between 1987 and 2006. It is widely recognized that official output and productivity figures may seriously underestimate the true contribution of the health care sector to real output, and more importantly to the economic well-being of Canadians. Alternative approaches show that price indices for health care output may be overestimated and, therefore, quality improvements may not be accurately captured by estimates of real health care output. More resources are needed to further investigate the alternative approaches discussed in this report and develop better output measures that adjust for outcomes directly related to health care spending.Health sector, Productivity, Measurement, Canada, Outcomes.