Tailored Patient Information: Some Issues and Questions

Tailored patient information (TPI) systems are computer programs which produce personalised heath-information material for patients. TPI systems are of growing interest to the natural-language generation (NLG) community; many TPI systems have also been developed in the medical community, usually with mail-merge technology. No matter what technology is used, experience shows that it is not easy to field a TPI system, even if it is shown to be effective in clinical trials. In this paper we discuss some of the difficulties in fielding TPI systems. This is based on our experiences with 2 TPI systems, one for generating asthma-information booklets and one for generating smoking-cessation letters.Comment: This is a paper about technology-transfer. It does not have much technical conten

Widespread Adoption of Information Technology in Primary Care Physician Offices in Denmark: A Case Study

Describes the use of electronic medical records, standardized clinical communications, and patient identification numbers by Denmark's primary care physicians; a nonprofit organization's role in implementation and certification; and elements of success

A study of general practitioners' perspectives on electronic medical records systems in NHS Scotland

<b>Background</b> Primary care doctors in NHSScotland have been using electronic medical records within their practices routinely for many years. The Scottish Health Executive eHealth strategy (2008-2011) has recently brought radical changes to the primary care computing landscape in Scotland: an information system (GPASS) which was provided free-of-charge by NHSScotland to a majority of GP practices has now been replaced by systems provided by two approved commercial providers. The transition to new electronic medical records had to be completed nationally across all health-boards by March 2012. <p></p><b> Methods</b> We carried out 25 in-depth semi-structured interviews with primary care doctors to elucidate GPs' perspectives on their practice information systems and collect more general information on management processes in the patient surgical pathway in NHSScotland. We undertook a thematic analysis of interviewees' responses, using Normalisation Process Theory as the underpinning conceptual framework. <p></p> <b>Results</b> The majority of GPs' interviewed considered that electronic medical records are an integral and essential element of their work during the consultation, playing a key role in facilitating integrated and continuity of care for patients and making clinical information more accessible. However, GPs expressed a number of reservations about various system functionalities - for example: in relation to usability, system navigation and information visualisation. <b>Conclusion </b>Our study highlights that while electronic information systems are perceived as having important benefits, there remains substantial scope to improve GPs' interaction and overall satisfaction with these systems. Iterative user-centred improvements combined with additional training in the use of technology would promote an increased understanding, familiarity and command of the range of functionalities of electronic medical records among primary care doctors

Investigating the prevalence and causes of prescribing errors in general practice : the PRACtICe Study

Report prepared by the University of Nottingham, University of Reading and University of Hertfordshir

Interpretative perspectives on the acceptance of an optional information system

Understanding the factors that contribute to the acceptance and use of information systems is a central concern in the field of information systems. Especially in cases where users are relatively free to use an information system (a so called optional information system) it is important for implementers to understand which factors determine acceptance in order to develop an effective design and implementation plan. In order to identify factors that determine acceptance, this report describes and analyses the implementation of a therapy expert system for general practitioners (GPs) in the Netherlands. The Netherlands Ministry of Health decided to implement this system with the objective to promote cost effectiveness, consistency and quality of therapies and drug prescriptions of general practitioners. This paper uses an interpretive perspective to analyze the limited acceptance of the system. While the promotion campaign focused on the system, GPs based their decision on wider contextual factors. The case demonstrates pitfalls, which come up during the implementation of such a system, and shows which factors may play a role in the decision of possible users to accept or reject such an optional information system. Different issues arise from this case. One is that users seem to differ from non-users and that perceptions about the system itself but also about non-system features affect the decision to accept. The paper uses the evidence of the case by suggesting to extend the technology acceptance model (TAM) with relevant contextual factors. It concludes by outlining its implications for implementers of optional information systems in general.

Summary care record early adopter programme: an independent evaluation by University College London.

Benefits The main potential benefit of the SCR is considered to be in emergency and unscheduled care settings, especially for people who are unconscious, confused, unsure of their medical details, or unable to communicate effectively in English. Other benefits may include improved efficiency of care and avoidance of hospital admission, but it is too early for potential benefits to be verified or quantified. Progress As of end April 2008, the SCR of 153,188 patients in the first two Early Adopter sites (Bolton and Bury) had been created. A total of 614,052 patients in four Early Adopter sites had been sent a letter informing them of the programme and their choices for opting out of having a SCR. Staff attitudes and usage The evaluation found that many NHS staff in Early Adopter sites (which had been selected partly for their keenness to innovate in ICT) were enthusiastic about the SCR and keen to see it up and running, but a significant minority of GPs had chosen not to participate in the programme and others had deferred participation until data quality improvement work was completed. Whilst 80 per cent of patients interviewed were either positive about the idea of having a SCR or ?did not mind?, others were strongly opposed ?on principle?. Staff who had attempted to use the SCR when caring for patients felt that the current version was technically immature (describing it as ?clunky? and ?complicated?), and were looking forward to a more definitive version of the technology. A comparable technology (the Emergency Care Summary) introduced in Scotland two years ago is now working well, and over a million records have been accessed in emergency and out-of-hours care. Patient attitudes and awareness Having a SCR is optional (people may opt out if they wish, though fewer than one per cent of people in Early Adopter sites have done so) and technical security is said to be high via a system of password protection and strict access controls. Nevertheless, the evaluation showed that recent stories about data loss by government and NHS organisations had raised concerns amongst both staff and patients that human fallibility could potentially jeopardise the operational security of the system. Despite an extensive information programme to inform the public in Early Adopter sites about the SCR, many patients interviewed by the UCL team were not aware of the programme at all. This raises important questions about the ethics of an ?implied consent? model for creating the SCR. The evaluation recommended that the developers of the SCR should consider a model in which the patient is asked for ?consent to view? whenever a member of staff wishes to access their record. Not a single patient interviewed in the evaluation was confident that the SCR would be 100 per cent secure, but they were philosophical about the risks of security breaches. Typically, people said that the potential benefit of a doctor having access to key medical details in an emergency outweighed the small but real risk of data loss due to human or technical error. Even patients whose medical record contained potentially sensitive data such as mental health problems, HIV or drug use were often (though not always) keen to have a SCR and generally trusted NHS staff to treat sensitive data appropriately. However, they and many other NHS patients wanted to be able to control which staff members were allowed to access their record at the point of care. Some doctors, nurses and receptionists, it seems, are trusted to view a person?s SCR, whereas others are not, and this is a decision which patients would like to make in real time

Providing secure remote access to legacy applications

While the widespread adoption of Internet and Intranet technology has been one of the exciting developments of recent years, many hospitals are finding that their data and legacy applications do not naturally fit into the new methods of dissemination. Existing applications often rely on isolation or trusted networks for their access control or security, whereas untrusted wide area networks pay little attention to the authenticity, integrity or confidentiality of the data they transport. Many hospitals do not have the resources to develop new ''network-ready'' versions of existing centralised applications. In this paper, we examine the issues that must be considered when providing network access to an existing health care application, and we describe how we have implemented the proposed solution in one healthcare application namely the diabetic register at Hope Hospital. We describe the architecture that allows remote access to the legacy application, providing it with encrypted communications and strongly authenticated access control but without requiring any modifications to the underlying application. As well as comparing alternative ways of implementing such a system, we also consider issues relating to usability and manageability, such as password management

Integration and Continuity of Primary Care: Polyclinics and Alternatives, a Patient-Centred Analysis of How Organisation Constrains Care Coordination

Background An ageing population, increasingly specialised of clinical services and diverse healthcare provider ownership make the coordination and continuity of complex care increasingly problematic. The way in which the provision of complex healthcare is coordinated produces – or fails to – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational, relational). Care coordination is accomplished by a combination of activities by: patients themselves; provider organisations; care networks coordinating the separate provider organisations; and overall health system governance. This research examines how far organisational integration might promote care coordination at the clinical level. Objectives To examine: 1. What differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical coordination of care. 2. What difference provider ownership (corporate, partnership, public) makes. 3. How much scope either structure allows for managerial discretion and ‘performance’. 4. Differences between networked and hierarchical governance regarding the continuity and integration of primary care. 5. The implications of the above for managerial practice in primary care. Methods Multiple-methods design combining: 1. Assembly of an analytic framework by non-systematic review. 2. Framework analysis of patients’ experiences of the continuities of care. 3. Systematic comparison of organisational case studies made in the same study sites. 4. A cross-country comparison of care coordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics. 5. Analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute in-patient care. Results Starting from data about patients' experiences of the coordination or under-coordination of care we identified: 1. Five care coordination mechanisms present in both the integrated organisations and the care networks. 2. Four main obstacles to care coordination within the integrated organisations, of which two were also present in the care networks. 3. Seven main obstacles to care coordination that were specific to the care networks. 4. Nine care coordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than were care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care coordination because of its impact on GP workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care coordination, and therefore continuities of care, than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings

An Exploration of the Role of Substance Misuse Nurses in Scotland

Executive Summary Background With the increase of drug misuse over the past two decades, the role of the Substance Misuse Nurse has increased dramatically. Research on the role of nurses working in this field is minimal and there is little known about what they do, what they think about their clients and their role, and how they approach treatment. A pilot study on substance misuse nurses in Grampian indicated that nurses may be key gatekeepers to specialist services and some nurses appeared to have an important role in clinical decision making. However, clinical decision making and other key aspects of nurse practice may vary across services in different geographical areas. This research was designed to gain a better understanding of the role of the substance misuse nurse in Scotland. Aims and Objectives The aim of this research was to describe and analyse the role of substance misuse nurses working with drug misusers in Scotland. The objectives were: • to identify the population of specialist nurses working directly in the management of illicit drug users in Scotland and gain baseline data on their demography, caseload, services provided and level of interaction with other health professionals; • to compare their attitudes to drug misusers with those of other health professionals; • to explore their beliefs about the effectiveness of different treatment options; • to examine their role in the initial client assessment and subsequent management; • to describe their interaction with the client; • to explore their relationship with other professionals. Methods Mixed quantitative and qualitative methods were used. The population of Substance Misuse Nurses and midwives working specifically with drug misusers across Scotland were identified and posted a comprehensive questionnaire. The questionnaire covered issues including qualifications, training, attitudes and beliefs about treatment and aspects of practice such as caseloads, services provided and relationships with other health and social professionals. Face-to-face interviews were conducted with a sub-sample of nurses including a range of gender, experience, and NHS areas. Interviews covered nurses’ assessment and decision making regarding treatment and relationships with other professionals. Observations of specialist nurse and client consultations allowed for some insight into the general structure of the consultation, the setting where the consultation took place and the roles of nurse and client in assessment and treatment planning. Characteristics of SMS nurses and services • A scoping exercise indentified 272 nurses. Of these 244 were sent a questionnaire (the remainder having left or being on sick leave). Of these, 79% responded. • Seventy percent (70%) were Grade G or above indicating a senior level workforce. • Most nurses were employed in substance misuse services (48%) or, similarly, drug and alcohol services (30%). • Formal training (university certificate/diploma) in substance misuse had been undertaken by 40% of nurses, induction training (i.e. at the start of employment) by 62% of nurses. • The median caseload was 38 clients. • The majority of consultations took place in clinical consultation rooms but this was not observed to influence the consultation. • Nurses reported that the average length of a consultation was 38 minutes. All of the observed consultations were scheduled for 30 minutes but half over-ran. Motivation, attitudes and beliefs • The challenging nature of working with drug misusers was a positive motivating factor for nurses working in this field. • Seventy-seven percent (77%) of nurses considered working with drug misusers to be rewarding, although 79% also considered that this population were not easy to deal with. Opinion was split about whether drug misusers could be manipulative in consultations. Initial assessment of clients • Waiting times for assessment were generally an issue of concern to nurses. • A detailed assessment was almost always conducted at the first consultation. • An SMR24 was almost always completed at the first consultation. • Interviews and observation of nurse-client consultations found that the approach to assessment seemed consistent across geographical areas. • Assessment included: brief physical examination, urine sampling, detailed exploration of drug use, exploration of physical problems, discussion of social and family support, housing and employment status and history of involvement in the criminal justice system. • Consultations were often brought to a close by discussing treatment expectations. • Initial assessment could take place over more than one appointment and several appointments could be required before a treatment plan was implemented. Making treatment decisions • Clients were actively encouraged to participate in treatment decisions. • Although 84% of nurses reported they were expected to follow a treatment protocol only 44% said they always did (for any treatment). • Eighty-six percent (86%) of nurses had seen the National Clinical Guidelines (DoH, 1999), and those who were interviewed felt that these provided a good framework for treatment, although they were perhaps lacking in detail. • Nurses reported that they often consulted widely with other health professionals but, most frequently, with the client, before making a treatment decision. • A third of nurses reported writing prescriptions for a doctor to sign. • Seventy percent (70%) of respondents felt nurses should be able write prescriptions but only if they were experienced nurses with appropriate training. Comparing beliefs of nurses with those of GPs and pharmacists Nurses were asked some questions which had been asked of GPs and pharmacists in previous national surveys conducted in 2000. This allowed for comparisons to be made: • When making treatment decisions nurses were less influenced than GPs by the attitude and behaviour of drug misusers. • When making treatment decisions nurses were more influenced than GPs by societal factors such as reducing the transmission of infectious disease. • Nurses were less likely than GPs to favour detoxification as a treatment approach, although 83% of nurses agreed that a community based detoxification programme was an effective tool for the treatment of drug misuse. • Nurses were more confident than GPs about their ability to successfully manage polydrug users. • Nurses and GPs were split in their beliefs about the effectiveness of dihydrocodeine. • Nurses believed more strongly than pharmacists that maintenance prescribing could stop the use of illicit drugs. • Fewer nurses than pharmacists believed that controlled drug dispensing should take place in central clinics rather than community pharmacies. Multidisciplinary working • Over half of nurses considered their relationship with pharmacists, GPs, health visitors/community nurses, hospital doctors and social workers to be good. • Opportunities to discuss services with local policy makers were considered insufficient. • Relationships with GPs seemed positive because nurses felt GPs valued their specialist knowledge. • Nurses had frequent contact with pharmacists and respected the difficulties of a pharmacist’s work. • Relationships with social services were variable. Some nurses felt undervalued by their social work colleagues, or felt there was a lack of joint planning for individual client care. • Nurses were clear about what circumstances should lead to a break in confidentiality between services and of how to go about this. • Integrated drug services were seen as potentially beneficial but there were specific concerns about the implications for clients of sharing information with other agencies and practical concerns about the size of joint assessment tools. Health and Safety at work • Sixty-four percent (64%) of nurses reported that they had been physically or verbally abused by clients, and half of those who had been subject to abuse felt current safety provision in their service was insufficient. Nurses in most areas said that the safety of staff was considered to be a high service priority, but there was evidence from interviews this was still lacking in some areas. • Greater use of personal alarms and alarms in consultation rooms, use of mobile phones, and specialised training were suggested as ways of improving safety. • Nurses said that the majority of their consultations take place in clinics/consultation rooms rather than clients’ homes. • The feeling was commonly expressed among interviewees that their work could be stressful, and this was seen as due to paperwork, excessive caseloads and working in isolation. Discussion of Findings This study provides baseline information which can be used to inform individual nurses, services, policy makers and researchers. Some individual nurses reading this report might find an element that is simply describing what they already know. This is inevitable but it is hoped individual nurses will still find interest in the views and practice of others within their profession. The value of this report is that it has quantified these findings on a national basis, providing robust data for workforce planning and needs assessment. It has not been possible to compare findings, and thus the practice of substance misuse nurses in Scotland, with other areas or countries because there is no comparable published work. It is also not possible to give guidelines or examples of ‘good practice’ as this would have involved data collection from clients and other professionals which was outwith this study’s remit. This study has found a reassuring consistence of practice across Scotland. Although many substance misuse nurses work in some degree of isolation there is an apparently high level of discussion and consultation with other service colleagues which provides support. The role of the nurse in the initial assessment and treatment plan is critical. Nevertheless, decisions regarding treatment plans were made largely between nurses and clients, with nurses making use of service protocols/guidelines. Some might question whether a nurse is the most appropriate person to undertake these tasks. Ability to conduct physical examination, some knowledge of pharmacology, mental health and psychology as well as an ability to explore the wider social context is required. On reflection a nurse, with mental health qualifications seems to have the most appropriate skills for this. There is a willingness by nurses to take on the role of prescribing albeit in a limited capacity, and only by very experienced nurses with appropriate training. Currently, a minority of nurses reported writing prescriptions to be signed by doctors, which is possible for doctors with handwriting exemptions. This raises issues about clinical governance. In signing the prescription a GP is still taking responsibility even though s/he may know little about the patient’s current condition. An important strand of a substance misuse nurse’s practice is ongoing support or counselling for clients. This raises issues about models of counselling followed and nurses’ competencies in doing this. The nature or model of counselling used by nurses was not explicitly covered in this research and further exploration of counselling would be an area for future research. Relationships with other professionals, were generally reported to be good. Nurses generally believed GPs valued their role. Comparison of attitudes of substance misuse nurses with earlier surveys of pharmacists and GPs indicates they are more positive in general and about treatment outcomes in particular. Nurses viewed the challenging aspect of working with drug misusers more positively than pharmacists and GPs. Nurses were less positive about their ability to influence policy. Currently substance misuse nurses have little input at policy level. At a local level, through Drug and Alcohol Action Teams (DAATs) this could improve the feeling of ownership towards service developments related to the Joint Future agenda. Service managers are currently the key link between nurses and DAATs. Perhaps a service nurse with more client contact should also attend to provide client feedback. At a national level greater nursing input into policy could give this specialist group a greater feeling of professional cohesion as well as keeping policy makers informed. Concerns about health and safety at work need to be considered at a national professional level as well as locally. Whether these issues should be addressed through the involvement of an organisation such as the Association of Nurses in Substance Abuse (ANSA) or an appointed individual is for discussion. Recommendations • All substance misuse nurses should receive induction training prior to commencing their post. Greater time should be protected to allow participation in training. • There should be further exploration of what models of counselling, if any, are followed to assess whether current training is adequate. • Appointment scheduling may need review as there was evidence that consultation time was routinely underestimated. Frequency of missed appointments needs to be considered at the same time. • Staffing of substance misuse nurses should be expanded in order to reduce: excessive caseloads; lengthy waiting lists; insufficient cover for holidays, training and absences; and occupational stress. • Nurses could be involved in GP training to share their experience of managing difficult cases such as poly-drug users and widen GPs perspective of the social benefits of drug misuse treatment. • Nurses should be kept aware of developments on integrated care for drug misusers. This would allow them to understand the principles behind integrated care and be aware of how their service fits into the overall plan. • Extending the role of senior substance misuse nurses to include the prescribing of controlled drugs should be considered. • A clearer job title should be given to nurses working in substance misuse so that they may be easily identified and representable at both DAAT and Scottish Executive level, e.g. Specialist Nurse in Substance Misuse. • Efforts should be made to improve substance misuse nurses’ opportunities to influence policy. • All substance misuse nurses should be provided with appropriate on going training, procedures and practices to allow them to carry out their work safely