Rapid assessment of clinical information systems in the healthcare setting: an efficient method for time-pressed evaluation

OBJECTIVE

Recent legislation in the United States provides strong incentives for implementation of electronic health records (EHRs). The ensuing transformation in U.S. health care will increase demand for new methods to evaluate clinical informatics interventions. Timeline constraints and a rapidly changing environment will make traditional evaluation techniques burdensome. This paper describes an anthropological approach that provides a fast and flexible way to evaluate clinical information systems.

METHODS

Adapting mixed-method evaluation approaches from anthropology, we describe a rapid assessment process (RAP) for assessing clinical informatics interventions in health care that we developed and used during seven site visits to diverse community hospitals and primary care settings in the U.S.

SETTING

Our multidisciplinary team used RAP to evaluate factors that either encouraged people to use clinical decision support (CDS) systems or interfered with use of these systems in settings ranging from large urban hospitals to single-practitioner, private family practices in small towns.

RESULTS

Critical elements of the method include: 1) developing a fieldwork guide; 2) carefully selecting observation sites and participants; 3) thoroughly preparing for site visits; 4) partnering with local collaborators; 5) collecting robust data by using multiple researchers and methods; and 6) analyzing and reporting data in a structured manner helpful to the organizations being evaluated.

CONCLUSIONS

RAP, iteratively developed over the course of visits to seven clinical sites across the U.S., has succeeded in allowing a multidisciplinary team of informatics researchers to plan, gather and analyze data, and report results in a maximally efficient manner.

Health, Climate Change and Sustainability: A systematic Review and Thematic Analysis of the Literature

BACKGROUND

Evidence of climate change and its impact continues to be accumulated, and it is argued that the consequences of climate change are likely to result in an increased demand on health services. It has been claimed that climate change presents new challenges for health services and that strategies should be adopted to address these challenges.

AIM

The aim of this systematic review was to map published literature on health, climate change and sustainability by categorising papers according to their focus on effects, strategy and actions, and to provide a thematic analysis of their content.

METHODS

Systematic searches were conducted via a range of healthcare related databases i.e. Pubmed, Medline, CINAHL, AMED, ASSIA, IBSS and ISI Web of Knowledge. Searches focussed upon papers published in English between 1998 and 2008. Retrieved papers were studied by the authors in order to inform the thematic analysis of their content.

RESULTS

A total of 114 publications were retrieved, of which 36 met the inclusion criteria for the systematic review. These 36 publications were categorised and are discussed according to their focus on: effects/impacts, strategy/policy, action/examples.

CONCLUSIONS

A number of papers report the potential health effects of climate change while others report policies and strategies to tackle these effects. However there is an urgent need to identify and report on the implementation of strategies to mitigate and adapt to these challenges and to publish real examples of actions. Actions that are taken need to be evidence/policy based, and implementations monitored, evaluated and published.

The use of descriptive words and metaphor in patient and carer experience of palliative day care: secondary analysis of a qualitative study

Background:

An independent evaluation of changes to the delivery of Palliative Day Services was carried out during 2006-2007 using interviews with service users. The analysis found that the words and metaphors employed by users of services emphasized their emotional response to the changes, and helped to explain their depth of feeling about their experiences, warranting further investigation.

Aim:

To conduct a secondary analysis on interview data collected for the Day Services Evaluation Study in order to understand how patients and their carers use descriptive words and metaphor when talking about their experiences of palliative day services.

Methods:

Interview transcripts from 40 patients and 8 carers were subjected to secondary thematic analysis. These were read individually and coded where metaphor or descriptive words had been used to emphasize the effect of the illness and the experiences of the Day Services.

Findings:

Examples of the metaphorical expressions and words used described the service as a ‘secure rock in a changing world’; transition was felt as ‘sadness’, a ‘betrayal’, with feelings that the changes were ‘bitter and twisted;’ and left ‘a black hole’. Post transition the mood had changed to acceptance ‘When life throws lemons at you, you make lemonade’.

Conclusions:

The metaphors and descriptive words used act as what we describe as ‘emotional intensifiers’ which provide a measure of the impact of the effect of illness, the effect of the day services on users and carers and the intensity of feeling during the time of transition.

The case for increased alcohol taxation in Australia

This paper is concerned with the arguments and evidence that support the use of alcohol taxation as a primary health care intervention. Taxation is treated as a policy option that may be subject to cost-benefit analysis. While overseas evidence is used, the article draws primarily upon the authors' earlier estimates of the cost of alcohol consumption and the effects of taxation in Australia. In addition, the paper considers the main arguments used against alcohol taxation for health policy. It is concluded that the arguments cannot be substantiated and that there is a strong case for increased alcohol taxes.

Are glycopeptides still appropriate and convenient for empiric use?

The glycopeptides vancomycin and teicoplanin are widely used, and indeed recommended for, the treatment of severe or resistant Gram-positive infections. Therapeutic drug monitoring is widely used for vancomycin but less commonly for teicoplanin, and remains controversial. We report the cost savings of a formulary decision to replace teicoplanin with daptomycin for the empiric treatment of complicated skin and soft tissue infections (CSSTIs), staphylococcal bacteraemia and hospital-acquired Gram-positive sepsis. In the Intensive Therapy Unit (ITU) we optimised treatment of serious Gram-positive infections by substituting teicoplanin with vancomycin administered by continuous infusion. Costs were calculated using British National Formulary (BNF) prices and costs for therapeutic drug monitoring. Daptomycin (350 mg/d) use was associated with a cost saving per 7 days of treatment of 86 pounds and vancomycin with 51 pounds (4 g/d) to 276 pounds (2 g/d) compared to the 600 mg teicoplanin dose. Our own formulary re-positioning of glyco/lipopeptides, i.e. the preferential use of vancomycin in the ITU and substitution of teicoplanin with daptomycin, is cost-effective and provides better therapeutic alternatives. Continuous vancomycin infusion in the ITU setting guarantees optimal dosing for severely ill patients. Daptomycin use on surgical and medical wards, apart from being marginally cheaper than teicoplanin, guarantees optimal dosing without the need for drug monitoring.

Addressing assessment in libyan medical education

Assessment is a powerful driver of student learning: it gives a message to learners about what they should be learning, what the learning organisation believes to be important, and how they should go about learning. Assessment tools allow measurement of student achievement and thereby give teachers insight into their students' learning, and enable teachers to make systematic judgements about progress and achievement. It is vital then that assessment tools drive students to learn the right things as well as measure student learning appropriately. Any attempts to reform curricula and teaching methods must consider the role of assessment in the learning process.

Libyan doctors and medical students have been calling for changes to teaching and assessment methods at undergraduate and postgraduate levels. A team from the Academic Centre for Medical Education at University College, London have been running workshops in conjunction with the Libyan Board of Medical Specialties since 2006 to discuss strategic aims of assessment in medical education in Libya for the 21st century and to deliver an assessment skills course to Libyan educators. This article outlines the course and the outcomes of preliminary discussions between academics from the UK, participants in the assessment courses and representatives from the Libyan Board of Medical Specialties. As a result of these discussions it was agreed by all that Libyan Medical School assessment methods need updating and, despite significant challenges, changes in assessment must be made as soon as possible. There is a real need for support in both addressing these changes and for practical training for assessors in contemporary assessment methods.