Informatics systems to promote improved care for chronic illness: a literature review

Structuring clinical workflows for diabetes care: an overview of the OntoHealth approach

BACKGROUND

Electronic health records (EHRs) play an important role in the treatment of chronic diseases such as diabetes mellitus. Although the interoperability and selected functionality of EHRs are already addressed by a number of standards and best practices, such as IHE or HL7, the majority of these systems are still monolithic from a user-functionality perspective. The purpose of the OntoHealth project is to foster a functionally flexible, standards-based use of EHRs to support clinical routine task execution by means of workflow patterns and to shift the present EHR usage to a more comprehensive integration concerning complete clinical workflows.

OBJECTIVES

The goal of this paper is, first, to introduce the basic architecture of the proposed OntoHealth project and, second, to present selected functional needs and a functional categorization regarding workflow-based interactions with EHRs in the domain of diabetes.

METHODS

A systematic literature review regarding attributes of workflows in the domain of diabetes was conducted. Eligible references were gathered and analyzed using a qualitative content analysis. Subsequently, a functional workflow categorization was derived from diabetes-specific raw data together with existing general workflow patterns.

RESULTS

This paper presents the design of the architecture as well as a categorization model which makes it possible to describe the components or building blocks within clinical workflows. The results of our study lead us to identify basic building blocks, named as actions, decisions, and data elements, which allow the composition of clinical workflows within five identified contexts.

CONCLUSIONS

The categorization model allows for a description of the components or building blocks of clinical workflows from a functional view.

Patients' contribution to the development of a web-based plan for integrated care - a participatory design study

AIMS AND OBJECTIVES

The aim was to explore how a participatory design (PD) approach involving adult patients and parents of children with disabilities could contribute to the development of an electronic "Individual Care Plan" (e-ICP) in Norway. The system was intended to simplify multi-disciplinary cross-sector documentation and collaboration between care professionals and patients in care planning.

METHODS

The data in the study comprised semi-structured interviews with patients and parents, as well as field notes. Systematic text condensation (STC) in a stepwise analysis model was performed on the data.

RESULTS

Testing through three phases resulted in system improvements and additional functionality according to the participating patients' needs and requests. PD was initially applied, enabling a constructive dialogue between developers and patients. System training and collecting patient expectations was a preliminary task. Patients then brought testing experiences to the system developers, focusing first on access to information and document filing. Later, finalizing testing towards a tool for interaction with care professionals was a main concern.

CONCLUSION

Adult patients and parents participating in the study provided various insights and expectations that informed system improvements and resulted in new functionality. System development and testing in healthcare can successfully incorporate patient involvement.

Chronic kidney disease in an electronic health record problem list: quality of care, ESRD, and mortality

BACKGROUND

Whether chronic kidney disease (CKD) recognition in an electronic health record (EHR) problem list improves processes of care or clinical outcomes of end-stage renal disease (ESRD) and death is unclear.

METHODS

We identified patients who had at least 1 year of follow-up (2005-2009) in our EHR-based CKD registry (n = 25,742). CKD recognition was defined by having ICD-9 codes for CKD, diabetic kidney disease, or hypertensive kidney disease in the problem list. We calculated proportions of patients with and without CKD recognition and examined differences by demographics, clinical factors, and development of ESRD or mortality. We evaluated differences in the proportion of patients with CKD-specific laboratory results checked before and after recognition among cases and propensity-matched controls.

RESULTS

Only 11% (n = 2,735) had CKD recognition in the problem list and they were younger (68 vs. 71 years), a higher proportion were male (61 vs. 37%) and African-American (21 vs. 10%) compared to those unrecognized. CKD-specific laboratory results for patients with estimated glomerular filtration rate (eGFR) 30-59 including intact parathyroid hormone (23 vs. 6%), vitamin D (22 vs. 18%), phosphorus (29 vs. 7%), and a urine check for proteinuria (55 vs. 36%) were significantly more likely to be done among those with CKD recognition (all p < 0.05). Similar results were found for eGFR <30 except for proteinuria and in our propensity score-matched control analysis. There was no independent association of CKD recognition with ESRD or mortality.

CONCLUSIONS

CKD recognition in the EHR problem list was low, but translated into more CKD-specific processes of care; however ESRD or mortality were not affected.

A mobile health infrastructure to support underserved patients with chronic disease

BACKGROUND

Chronic diseases are the global leading cause of death, but the US health system is poorly designed to support patients with chronic disease. Underserved patients report high rates of cell phone use and interest in using mobile technology for health care. A mobile health infrastructure may help transform health care delivery for underserved patients with chronic disease.

PROBLEM

This study assessed the feasibility of integrating mobile health infrastructure with clinical information systems and the electronic medical record (EMR) to support patients with chronic disease through automated, bidirectional text messaging.

GOALS

Three priority areas of chronic disease management were targeted. Existing self-management support was expanded, and new support for laboratory test scheduling and medication management was created.

STRATEGY

Adult patients (n=135) with diabetes selected preferred content and scheduling for self-management message prompts. Outreach messages were sent to patients overdue for laboratory tests and medications. Manual review of pharmacy and laboratory outreach data was conducted for quality assurance. Focus groups were held to solicit patient perspectives.

RESULTS

Patients sent over 6500 response messages with response rates of 53.7% (blood sugar), 48.8% (step counts), and 31.9% (blood pressure). Laboratory data integration was achieved, but pharmacy data gaps required ongoing manual review. Focus group participants reported improved self-management and information awareness.

IMPLICATIONS

HIT was used to address dependency on visit-bound disease management in a novel, low-cost way. Use of a mobile health infrastructure was feasible. Text messaging solutions may mitigate barriers to access and enhance support for patients with chronic disease.

Does the use of consumer health information technology improve outcomes in the patient self-management of diabetes? A meta-analysis and narrative review of randomized controlled trials

PURPOSE

To assess whether the use of consumer health information technologies (CHITs) improves outcomes in the patient self-management of diabetes.

METHOD

The evidence from randomized controlled trials (RCTs) on the effects of CHITs on patient outcomes was analyzed using either meta-analysis or a narrative synthesis approach. A systematic search of seven electronic databases was conducted to identify relevant reports of RCTs for the analysis. In the meta-analyses, standardized mean differences in patient outcomes were calculated and random-effects models were applied in cases where the heterogeneity of the results was moderate or high, otherwise fixed-effects models were used.

RESULTS

Sixty-two studies, representing 67 RCTs, met the inclusion criteria. The results of the meta-analyses showed that the use of CHITs was associated with significant reductions in HbA1c, blood pressure, total cholesterol, and triglycerides levels when compared with the usual care. The findings from the narrative synthesis indicated that only a small proportion of the trials reported positive effects of CHITs on patient outcomes.

CONCLUSIONS

The use of CHITs in supporting diabetes self-management appears to have potential benefits for patients' self-management of diabetes. However, the effectiveness of the technologies in improving patient outcomes still awaits confirmation in future studies.

PC. Perspectives on Global Public Health Informatics

Public health professionals’ functions are rapidly expanding beyond their countries’ borders. Many academic centers are recognizing the importance of global health and are creating programs to train students to meet this growing demand. Global health centers and institutes also are being created to focus on the research and programmatic efforts needed to understand the burden of disease worldwide, as well as the financial, political, medical, policy, workforce, and infrastructure issues surrounding any solutions. Due to this emerging interest by the public health community, we need to understand where the intersection between global health and informatics occurs. For many years, the promise of what technology can do to alleviate suffering and support disease surveillance and other public health activities took precedence over understanding the environment in which the technology has to function. People and their participation in the implementation of the technological solution are critical for success. In resource-poor environments, the deployment of technological solutions faces other challenges for success. Lack of stable electrical power, availability of Internet connections, and a workforce that can support the information technology remain barriers to successful implementation. Yet, through experiences in the implementation of information technology as supported by international donors and the US President’s Emergency Plan for AIDS Relief, lessons are being learned to move forward towards the benefits that global health informatics can bring.

New electronic protocol for home enteral nutrition therapy

BACKGROUND

Informatics can help the development of home enteral nutrition therapy (HENT). By using an electronic protocol with an electronic database it is possible to organize, structure and manage, information.

AIM

To develop an electronic protocol for data collection on treatment of patients with home enteral nutrition.

METHOD

After a review in theoretical material about home enteral nutrition therapy, 1793 data collection items were selected and grouped into nine categories: patient identification, nutritional assessment, dietetics prescription, indications for enteral nutrition, access to enteral nutrition options, composition of enteral nutrition, administration system, complications, and readmission. Was used the Electronic Integrated Computerized Procotols System (SINPE©) to organize that knowledge and the database that attends this research was named Informatized Master Protocol of HENT. The last step was the creation of a specific protocol to collect data by using informations from this database.

RESULTS

After installing the program, the system recognizes the user by identifying a pre-defined security authorization and also provides a screen to select a master protocol which the user can access. Items that arrange the specific protocol are contained in the Master Protocol and the information for this protocol are displayed.

CONCLUSION

It was possible to create an electronic protocol for HENT patients care with safety data based on research in enteral nutrition support.

Connecting at-risk inpatient asthmatics to a community-based program to reduce home environmental risks: care system redesign using quality improvement methods

INTRODUCTION

Connecting patients admitted with asthma to community-based services could improve care and more efficiently allocate resources. We sought to develop and evaluate an intervention to mitigate in-home environmental hazards (eg, pests, mold) for such children.

METHODS

This was a controlled, quality improvement study on the inpatient units of an urban, academic children's hospital. Clinicians and public health officials co-developed processes to identify children with in-home risks and refer them for assessment and remediation. Processes assessed were the rate at which those identified as eligible were offered referrals, those referred received inspections, and primary care physicians (PCPs) were notified of risks and referrals. Consecutively occurring and seasonally matched intervention (n = 30) and historical control (n = 38) subcohorts were compared with respect to postdischarge mitigating actions (eg, discussions with landlords, PCPs), remaining risks, and morbidity (symptom-free days in previous 2 weeks and Child Asthma Control Test scores).

RESULTS

In the first year, the percentage of eligible children offered referrals increased to a sustained rate of ∼90%; ∼65% of referrals led to in-home inspections (n = 50); and hazards were abated in 30 homes. PCP notification increased from 50% to ∼80%. After discharge, referred parents were more likely to discuss concerns with landlords, the health department, attorneys, and PCPs than patients admitted preimplementation (all P < .05). Referred households were more likely to report reduced presence of ≥2 exposures (P < .05). No differences in asthma morbidity were observed.

CONCLUSIONS

We integrated environmental hazard mitigation into inpatient care. Community-engaged care delivery that reduces risks for poor asthma outcomes can be initiated within the hospital.

Electronic tools for health information exchange: an evidence-based analysis

BACKGROUND

As patients experience transitions in care, there is a need to share information between care providers in an accurate and timely manner. With the push towards electronic medical records and other electronic tools (eTools) (and away from paper-based health records) for health information exchange, there remains uncertainty around the impact of eTools as a form of communication.

OBJECTIVE

To examine the impact of eTools for health information exchange in the context of care coordination for individuals with chronic disease in the community.

DATA SOURCES

A literature search was performed on April 26, 2012, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published until April 26, 2012 (no start date limit was applied).

REVIEW METHODS

A systematic literature search was conducted, and meta-analysis conducted where appropriate. Outcomes of interest fell into 4 categories: health services utilization, disease-specific clinical outcomes, process-of-care indicators, and measures of efficiency. The quality of the evidence was assessed individually for each outcome. Expert panels were assembled for stakeholder engagement and contextualization.

RESULTS

Eleven articles were identified (4 randomized controlled trials and 7 observational studies). There was moderate quality evidence of a reduction in hospitalizations, hospital length of stay, and emergency department visits following the implementation of an electronically generated laboratory report with recommendations based on clinical guidelines. The evidence showed no difference in disease-specific outcomes; there was no evidence of a positive impact on process-of-care indicators or measures of efficiency.

LIMITATIONS

A limited body of research specifically examined eTools for health information exchange in the population and setting of interest. This evidence included a combination of study designs and was further limited by heterogeneity in individual technologies and settings in which they were implemented.

CONCLUSIONS

There is evidence that the right eTools in the right environment and context can significantly impact health services utilization. However, the findings from this evidence-based analysis raise doubts about the ability of eTools with care-coordination capabilities to independently improve the quality of outpatient care. While eTools may be able to support and sustain processes, inefficiencies embedded in the health care system may require more than automation alone to resolve.

PLAIN LANGUAGE SUMMARY

Patients with chronic diseases often work with many different health care providers. To ensure smooth transitions from one setting to the next, health care providers must share information and coordinate care effectively. Electronic medical records (eTools) are being used more and more to coordinate patient care, but it is not yet known whether they are more effective than paper-based health records. In this analysis, we reviewed the evidence for the use of eTools to exchange information and coordinate care for people with chronic diseases in the community. There was some evidence that eTools reduced the number of hospital and emergency department visits, as well as patients' length of stay in the hospital, but there was no evidence that eTools improved the overall quality of patient care.

Medical Home Features of VHA Primary Care Clinics and Avoidable Hospitalizations

BACKGROUND

As the Veterans Health Administration (VHA) reorganizes providers into the patient-centered medical home, questions remain whether this model of care can demonstrate improved patient outcomes and cost savings.

OBJECTIVE

We measured adoption of medical home features by VHA primary care clinics prior to widespread implementation of the patient-centered medical home and examined if they were associated with lower risk and costs of potentially avoidable hospitalizations.

DESIGN

Secondary patient data was linked to clinic administrative and survey data. Patient and clinic factors in the baseline year (FY2009) were used to predict patient outcomes in the follow-up year.

PARTICIPANTS

2,853,030 patients from 814 VHA primary care clinics

MAIN MEASURES

Patient outcomes were measured by hospitalizations for an ambulatory care sensitive condition (ACSC) and their costs and identified through diagnosis and procedure codes from inpatient records. Clinic adoption of medical home features was obtained from the American College of Physicians Medical Home Builder®.

KEY RESULTS

The overall mean home builder score in the study clinics was 88 (SD = 13) or 69%. In adjusted analyses an increase of 10 points in the medical home adoption score in a clinic decreased the odds of an ACSC hospitalization for patients by 3% (P = 0.032). By component, higher access and scheduling (P = 0.004) and care coordination and transitions (P = 0.020) component scores were related to lower risk of an ACSC hospitalization, and higher population management was related to higher risk (P = 0.023). Total medical home features was not related to ACSC hospitalization costs among patients with at least one (P = 0.074).

CONCLUSION

Greater adoption of medical home features by VHA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations with access and scheduling and care coordination/transitions in care as key factors.

Feasibility and impact of an evidence-based electronic decision support system for diabetes care in family medicine: protocol for a cluster randomized controlled trial

Background

In Belgium, the construction of the national electronic point-of-care information service, EBMPracticeNet, was initiated in 2011 to optimize quality of care by promoting evidence-based decision-making. The collaboration of the government, healthcare providers, Evidence-Based Medicine (EBM) partners, and vendors of Electronic Health Records (EHR) is unique to this project. All Belgian healthcare professionals get free access to an up-to-date database of validated Belgian and nearly 1,000 international guidelines, incorporated in a portal that also provides EBM information from sources other than guidelines, including computerized clinical decision support that is integrated in the EHRs.

The EBMeDS system is the electronic evidence-based decision support system of EBMPracticeNet. The EBMeDS system covers all clinical areas of diseases and could play a crucial role in response to the emerging challenge posed by chronic conditions. Diabetes was chosen as the analysis topic of interest. The objective of this study is to assess the effectiveness of EBMeDS use in improving diabetes care. This objective will be enhanced by a formal process evaluation to provide crucial information on the feasibility of using the system in daily Belgian family medicine.

Methods

The study is a cluster-randomized trial with before/after measurements conducted in Belgian family medicine. Physicians’ practices will be randomly assigned to the intervention or control group in a 1:1 ratio, to receive either the EBMeDS reminders or to follow the usual care process. Randomization will be performed by a statistical consultant with an electronic random list generator, anonymously for the researchers. The follow-up period of the study will be 12 months with interim analysis points at 3, 6 and 9 months. Primary outcome is the one-year pre- to post-implementation change in HbA1c. Patients will not be informed about the intervention. Data analysts will be kept blinded to the allocation.

Discussion

The knowledge obtained in this study will be useful for further integration in other Belgian software packages. Users’ perceptions and process evaluation will provide information for improving the feasibility of the system.

Trial registration

The trial is registered with the ClinicalTrials.gov registry: NCT01830569.

Can computerized clinical decision support systems improve diabetes management? A systematic review and meta-analysis

AIMS

To systematically review randomized trials that assessed the effects of computerized clinical decision support systems in ambulatory diabetes management compared with a non-computerized clinical decision support system control.

METHODS

We included all diabetes trials from a comprehensive computerized clinical decision support system overview completed in January 2010, and searched EMBASE, MEDLINE, INSPEC/COMPENDEX and Evidence-Based Medicine Reviews (EBMR) from January 2010 to April 2012. Reference lists of related reviews, included articles and Clinicaltrials.gov were also searched. Randomized controlled trials of patients with diabetes in ambulatory care settings comparing a computerized clinical decision support system intervention with a non-computerized clinical decision support system control, measuring either a process of care or a patient outcome, were included. Screening of studies, data extraction, risk of bias and quality of evidence assessments were carried out independently by two reviewers, and discrepancies were resolved through consensus or third-party arbitration. Authors were contacted for any missing data.

RESULTS

Fifteen trials were included (13 from the previous review and two from the current search). Only one study was at low risk of bias, while the others were of moderate to high risk of bias because of methodological limitations. HbA1c (3 months' follow-up), quality of life and hospitalization (12 months' follow-up) were pooled and all favoured the computerized clinical decision support systems over the control, although none were statistically significant. Triglycerides and practitioner performance tended to favour computerized clinical decision support systems although results were too heterogeneous to pool.

CONCLUSIONS

Computerized clinical decision support systems in diabetes management may marginally improve clinical outcomes, but confidence in the evidence is low because of risk of bias, inconsistency and imprecision.

Secure messaging and diabetes management: experiences and perspectives of patient portal users

BACKGROUND

Patient portal use has been associated with favorable outcomes, but we know less about how patients use and benefit from specific patient portal features.

OBJECTIVE

Using mixed-methods, we explored how adults with type 2 diabetes (T2DM) use and benefit from secure messaging (SM) within a patient portal.

METHODS

Adults with T2DM who had used a patient portal participated in a focus group and completed a survey (n=39) or completed a survey only (n=15). We performed thematic analysis of focus group transcripts to identify the benefits of and barriers to using SM within a portal. We also examined the association between use of various patient portal features and patients' glycemic control.

RESULTS

Participants were on average 57.1 years old; 65% were female; 76% were Caucasian/White, and 20% were African American/Black. Self-reported benefits of SM within a portal included enhanced patient satisfaction, enhanced efficiency and quality of face-to-face visits, and access to clinical care outside traditional face-to-face visits. Self-reported barriers to using SM within a portal included preconceived beliefs or rules about SM and prior negative experiences with SM. Participants' assumptions about providers' opinions about SM and providers' instructions about SM also influenced use. Greater self-reported use of SM to manage a medical appointment was significantly associated with patients' glycemic control (ρ=-0.29, p=0.04).

CONCLUSION

SM within a portal may facilitate access to care, enhance the quality of office visits, and be associated with patient satisfaction and clinical outcomes for patients with diabetes, but provider communication about SM is essential.

Impact of electronic health records on malpractice claims in a sample of physician offices in Colorado: a retrospective cohort study

BACKGROUND

Electronic health records (EHRs) might reduce medical liability claims and potentially justify premium credits from liability insurers, but the evidence is limited.

OBJECTIVES

To evaluate the association between EHR use and medical liability claims in a population of office-based physicians, including claims that could potentially be directly prevented by features available in EHRs ("EHR-sensitive" claims).

DESIGN

Retrospective cohort study of medical liability claims and analysis of claim abstracts.

PARTICIPANTS

The 26 % of Colorado office-based physicians insured through COPIC Insurance Company who responded to a survey on EHR use (894 respondents out of 3,502 invitees).

MAIN MEASURES

Claims incidence rate ratio (IRR); prevalence of "EHR-sensitive" claims.

KEY RESULTS

473 physicians (53 % of respondents) used an office-based EHR. After adjustment for sex, birth cohort, specialty, practice setting and use of an EHR in settings other than an office, IRR for all claims was not significantly different between EHR users and non-users (0.88, 95 % CI 0.52-1.46; p = 0.61), or for users after EHR implementation as compared to before (0.73, 95 % CI 0.41-1.29; p = 0.28). Of 1,569 claim abstracts reviewed, 3 % were judged "Plausibly EHR-sensitive," 82 % "Unlikely EHR-sensitive," and 15 % "Unable to determine." EHR-sensitive claims occurred in six out of 633 non-users and two out of 251 EHR users. Incidence rate ratios were 0.01 for both groups.

CONCLUSIONS

Colorado physicians using office-based EHRs did not have significantly different rates of liability claims than non-EHR users; nor were rates different for EHR users before and after EHR implementation. The lack of significant effect may be due to a low prevalence of EHR-sensitive claims. Further research on EHR use and medical liability across a larger population of physicians is warranted.

An information technology framework for strengthening telehealthcare service delivery

OBJECTIVE

Telehealthcare has been used to provide healthcare service, and information technology infrastructure appears to be essential while providing telehealthcare service. Insufficiencies have been identified, such as lack of integration, need of accommodation of diverse biometric sensors, and accessing diverse networks as different houses have varying facilities, which challenge the promotion of telehealthcare. This study designs an information technology framework to strengthen telehealthcare delivery.

MATERIALS AND METHODS

The proposed framework consists of a system architecture design and a network transmission design. The aim of the framework is to integrate data from existing information systems, to adopt medical informatics standards, to integrate diverse biometric sensors, and to provide different data transmission networks to support a patient's house network despite the facilities. The proposed framework has been evaluated with a case study of two telehealthcare programs, with and without the adoption of the framework.

RESULTS

The proposed framework facilitates the functionality of the program and enables steady patient enrollments. The overall patient participations are increased, and the patient outcomes appear positive. The attitudes toward the service and self-improvement also are positive.

CONCLUSIONS

The findings of this study add up to the construction of a telehealthcare system. Implementing the proposed framework further assists the functionality of the service and enhances the availability of the service and patient acceptances.

Implementing a knowledge application program for anxiety and depression in community-based primary mental health care: a multiple case study research protocol

BACKGROUND

Anxiety and depressive disorders are increasingly recognized as a health care policy priority. Reducing the treatment gap for common mental disorders requires strengthening the quality of primary mental health care. We developed a knowledge application program designed to improve the organization and delivery of care for anxiety and depression in community-based primary mental health care teams in Quebec, Canada. The principal objectives of the study are: to implement and evaluate this evidence-based knowledge application program; to examine the contextual factors associated with the selection of local quality improvement strategies; to explore barriers and facilitators associated with the implementation of local quality improvement plans; and to study the implementation of local quality monitoring strategies.

METHODS

The research design is a mixed-methods prospective multiple case study. The main analysis unit (cases) is composed of the six multidisciplinary community-based primary mental health care teams, and each of the cases has identified at least one primary care medical clinic interested in collaborating with the implementation project. The training modules of the program are based on the Chronic Care Model, and the implementation strategies were developed according to the Promoting Action on Research Implementation in Health Services conceptual framework.

DISCUSSION

The implementation of an evidence-based knowledge application program for anxiety and depression in primary care aims to improve the organization and delivery of mental health services. The uptake of evidence to improve the quality of care for common mental disorders in primary care is a complex process that requires careful consideration of the context in which innovations are introduced. The project will provide a close examination of the interplay between evidence, context and facilitation, and contribute to the understanding of factors associated with the process of implementation of interventions in routine care. The implementation of the knowledge application program with a population health perspective is consistent with the priorities set forth in the current mental health care reform in Quebec. Strengthening primary mental health care will lead to a more efficient health care system.

A randomized controlled trial of health information exchange between human immunodeficiency virus institutions

CONTEXT

In order for patients to benefit from a multidisciplinary treatment approach, diverse providers must communicate on patient care.

OBJECTIVE

We sought to examine the effect of information exchange across multidisciplinary human immunodeficiency virus (HIV) care providers on patient health outcomes.

DESIGN

Randomized controlled trial, randomized at the patient level.

SETTING

Six infectious disease clinics paired with 9 ancillary care settings (eg, HIV case management).

PARTICIPANTS

Two hundred fifty-four patients with HIV receiving care at the infectious disease clinics.

INTERVENTION

Health information was exchanged for 2 years per patient between medical and ancillary care providers using electronic health records and printouts inserted into charts. Medical care providers gave ancillary care providers HIV viral loads, CD4 values, current medications, and appointment attendance. Ancillary care providers gave medical providers the information on medication adherence and major changes (eg, loss of housing).

MAIN OUTCOME MEASURES

We abstracted from medical records HIV viral loads, CD4 counts, and antiretroviral medication prescriptions before and during the intervention. From 0-, 12-, and 24-month patient surveys, we assessed hospitalizations, emergency department use, and health-related quality of life measured by the Medical Outcomes Study Short Form-36 (SF-36).

RESULTS

No statistically significant differences between cases and controls were found across time for the following: proportion with suppressed viral load, changes in viral load or CD4 values, patients being prescribed antiretroviral medication, hospitalizations, emergency department visits, or any scale of the SF-36. Trends were mixed but leaned toward better health for control participants.

CONCLUSIONS

The exchange of this specific set of information between HIV medical and ancillary care providers was neutral on a variety of patient health outcomes.

Measuring value for money: a scoping review on economic evaluation of health information systems

Objective

To explore how key components of economic evaluations have been included in evaluations of health information systems (HIS), to determine the state of knowledge on value for money for HIS, and provide guidance for future evaluations.

Materials and methods

We searched databases, previously collected papers, and references for relevant papers published from January 2000 to June 2012. For selection, papers had to: be a primary study; involve a computerized system for health information processing, decision support, or management reporting; and include an economic evaluation. Data on study design and economic evaluation methods were extracted and analyzed.

Results

Forty-two papers were selected and 33 were deemed high quality (scores ≥8/10) for further analysis. These included 12 economic analyses, five input cost analyses, and 16 cost-related outcome analyses. For HIS types, there were seven primary care electronic medical records, six computerized provider order entry systems, five medication management systems, five immunization information systems, four institutional information systems, three disease management systems, two clinical documentation systems, and one health information exchange network. In terms of value for money, 23 papers reported positive findings, eight were inconclusive, and two were negative.

Conclusions

We found a wide range of economic evaluation papers that were based on different assumptions, methods, and metrics. There is some evidence of value for money in selected healthcare organizations and HIS types. However, caution is needed when generalizing these findings. Better reporting of economic evaluation studies is needed to compare findings and build on the existing evidence base we identified.

Health information technology capacity at federally qualified health centers: a mechanism for improving quality of care

BACKGROUND

The adoption of health information technology has been recommended as a viable mechanism for improving quality of care and patient health outcomes. However, the capacity of health information technology (i.e., availability and use of multiple and advanced functionalities), particularly in federally qualified health centers (FQHCs) on improving quality of care is not well understood. We examined associations between health information technology (HIT) capacity at FQHCs and quality of care, measured by the receipt of discharge summary, frequency of patients receiving reminders/notifications for preventive care/follow-up care, and timely appointment for specialty care.

METHODS

The analyses used 2009 data from the National Survey of Federally Qualified Health Centers. The study included 776 of the FQHCs that participated in the survey. We examined the extent of HIT use and tested the hypothesis that level of HIT capacity is associated with quality of care. Multivariable logistic regressions, reporting unadjusted and adjusted odds ratios, were used to examine whether 'FQHCs' HIT capacity' is associated with the outcome measures.

RESULTS

The results showed a positive association between health information technology capacity and quality of care. FQHCs with higher HIT capacity were significantly more likely to have improved quality of care, measured by the receipt of discharge summaries (OR=1.43; CI=1.01, 2.40), the use of a patient notification system for preventive and follow-up care (OR=1.74; CI=1.23, 2.45), and timely appointment for specialty care (OR=1.77; CI=1.24, 2.53).

CONCLUSIONS

Our findings highlight the promise of HIT in improving quality of care, particularly for vulnerable populations who seek care at FQHCs. The results also show that FQHCs may not be maximizing the benefits of HIT. Efforts to implement HIT must include strategies that facilitate the implementation of comprehensive and advanced functionalities, as well as promote meaningful use of these systems. Further examination of the role of health information systems in clinical decision-making and improvements in patient outcomes are needed to better understand the benefits of HIT in improving overall quality of care.

Health care worker perspectives inform optimization of patient panel-support tools: a qualitative study

Electronic decision-support systems appear to enhance care, but improving both tools and work practices may optimize outcomes. Using qualitative methods, the authors' aim was to evaluate perspectives about using the Patient Panel-Support Tool (PST) to better understand health care workers' attitudes toward, and adoption and use of, a decision-support tool. In-depth interviews were conducted to elicit participant perspectives about the PST-an electronic tool implemented in 2006 at Kaiser Permanente Northwest. The PST identifies "care gaps" and recommendations in screening, medication use, risk-factor control, and immunizations for primary care panel patients. Primary care physician (PCP) teams were already grouped (based on performance pre- and post-PST introduction) into lower, improving, and higher percent-of-care-needs met. Participants were PCPs (n=21), medical assistants (n=11), and quality and other health care managers (n=20); total n=52. Results revealed that the most commonly cited benefit of the PST was increased in-depth knowledge of patient panels, and empowerment of staff to do quality improvement. Barriers to PST use included insufficient time, competing demands, suboptimal staffing, tool navigation, documentation, and data issues. Facilitators were strong team staff roles, leadership/training for tool implementation, and dedicated time for tool use. Higher performing PCPs and their assistants more often described a detailed team approach to using the PST. In conclusion, PCP teams and managers provided important perspectives that could help optimize use of panel-support tools to improve future outcomes. Improvements are needed in tool function and navigation; training; staff accountability and role clarification; and panel management time.

Mobile phone-based pattern recognition and data analysis for patients with type 1 diabetes

BACKGROUND

Persons with type 1 diabetes who use electronic self-help tools, most commonly blood glucose meters, record a large amount of data about their personal condition. Mobile phones are powerful and ubiquitous computers that have a potential for data analysis, and the purpose of this study is to explore how self-gathered data can help users improve their blood glucose management.

SUBJECTS AND METHODS

Thirty patients with insulin-regulated type 1 diabetes were equipped with a mobile phone application for 3-6 months, recording blood glucose, insulin, dietary information, physical activity, and disease symptoms. The data were analyzed in terms of usage of the different modules and which data processing and visualization tools could be constructed to support the use of these data.

RESULTS

Eighteen patients (denoted "adopters") recorded complete data for over 80 consecutive days, up to 247 days. Among those who withdrew or did not use the application extensively, the most common reasons given were outdated or difficult-to-use phone. Data analysis using period finding and scale-space trends was found to yield significant patterns for most adopters. Pattern recognition methods to predict low or high blood glucose were found to be performing poorly.

CONCLUSIONS

Minimally intrusive mobile applications enable users with type 1 diabetes to record data that can provide data-driven feedback to the user, potentially providing relevant insight into their disease.

"Think different": a qualitative assessment of commercial innovation for diabetes information technology programs

BACKGROUND

This study reviews the state of diabetes information technology (IT) initiatives and presents a set of recommendations for improvement based on interviews with commercial IT innovators.

MATERIALS AND METHODS

Semistructured interviews were conducted with 10 technology developers, representing 12 of the most successful IT companies in the world. Average interview time was approximately 45 min. Interviews were audio-recorded, transcribed, and entered into ATLAS.ti for qualitative data analysis. Themes were identified through a process of selective and open coding by three researchers.

RESULTS

We identified two practices, common among successful IT companies, that have allowed them to avoid or surmount the challenges that confront healthcare professionals involved in diabetes IT development: (1) employing a diverse research team of software developers and engineers, statisticians, consumers, and business people and (2) conducting rigorous research and analytics on technology use and user preferences.

CONCLUSIONS

Because of the nature of their respective fields, healthcare professionals and commercial innovators face different constraints. With these in mind we present three recommendations, informed by practices shared by successful commercial developers, for those involved in developing diabetes IT programming: (1) include software engineers on the implementation team throughout the intervention, (2) conduct more extensive baseline testing of users and monitor the usage data derived from the technology itself, and (3) pursue Institutional Review Board-exempt research.

Evaluation of a real-time virtual intervention to empower persons living with HIV to use therapy self-management: study protocol for an online randomized controlled trial

BACKGROUND

Living with HIV makes considerable demands on a person in terms of self-management, especially as regards adherence to treatment and coping with adverse side-effects. The online HIV Treatment, Virtual Nursing Assistance and Education (Virus de I'immunodéficience Humaine-Traitement Assistance Virtuelle Infirmière et Enseignement; VIH-TAVIE™) intervention was developed to provide persons living with HIV (PLHIV) with personalized follow-up and real-time support in managing their medication intake on a daily basis. An online randomized controlled trial (RCT) will be conducted to evaluate the efficacy of this intervention primarily in optimizing adherence to combination anti-retroviral therapy (ART) among PLHIV.

METHODS/DESIGN

A convenience sample of 232 PLHIV will be split evenly and randomly between an experimental group that will use the web application, and a control group that will be handed a list of websites of interest. Participants must be aged 18 years or older, have been on ART for at least 6 months, and have internet access. The intervention is composed of four interactive computer sessions of 20 to 30 minutes hosted by a virtual nurse who engages the PLHIV in a skills-learning process aimed at improving self-management of medication intake. Adherence constitutes the principal outcome, and is defined as the intake of at least 95% of the prescribed tablets. The following intermediary measures will be assessed: self-efficacy and attitude towards antiretroviral medication, symptom-related discomfort, and emotional support. There will be three measurement times: baseline (T0), after 3 months (T3) and 6 months (T6) of baseline measurement. The principal analyses will focus on comparing the two groups in terms of treatment adherence at the end of follow-up at T6. An intention-to-treat (ITT) analysis will be carried out to evaluate the true value of the intervention in a real context.

DISCUSSION

Carrying out this online RCT poses various challenges in terms of recruitment, ethics, and data collection, including participant follow-up over an extended period. Collaboration between researchers from clinical disciplines (nursing, medicine), and experts in behavioral sciences information technology and media will be crucial to the development of innovative solutions to supplying and delivering health services.

TRIAL REGISTRATION

CE 11.184 / NCT 01510340.

Introducing an electronic Palliative Care Summary (ePCS) in Scotland: patient, carer and professional perspectives

BACKGROUND

An electronic Palliative Care Summary (ePCS) is currently being implemented throughout Scotland to provide out-of-hours (OOH) staff with up-to-date summaries of medical history, patient understanding and wishes, medications and decisions regarding treatment of patients requiring palliative care: automatic twice daily updates of information from GP records to a central electronic repository are available to OOH services.

AIMS

To identify key issues related to the introduction of ePCS from primary care and OOH staff, to identify facilitators and barriers to their use, to explore the experiences of patients and carers and to make recommendations for improvements.

METHODS

Twenty-two semi-structured interviews were carried out with a purposive sample of health professionals [practice nurses (3 interviews), GPs (12 interviews), a practice manager (1 interview) from practices using different computing software systems] and patients and/or carers (6 interviews for whom an ePCS had been completed). Interviews were digitally recorded, transcribed and analysed thematically.

RESULTS

Patients and carers were reassured that OOH staff were informed about their current circumstances. OOH staff considered the ePCS allowed them to be better informed in decision making and in carrying out home visits. GPs viewed the introduction of ePCSs to have benefits for in-hours structures of care including advance care planning. No interviewee expressed concern about confidentiality. Barriers raised related to the introduction of new technology including unfamiliarity with the process, limited time and information technology skills.

CONCLUSIONS

The ePCS has clear potential to improve patient care although several implementation issues and technical problems require to be addressed first to enable this. GPs and community nurses should identify more patients with malignant and non-malignant illnesses for completion of the ePCS.

Web-Based Specialist Support for Spinal Cord Injury Person's Care: Lessons Learned

Persons with disability from spinal cord injury (SCI) are subject to high risk of pathological events and need a regular followup even after discharge from the rehabilitation hospital. To help in followup, we developed a web portal for providing online specialist as well as GP support to SCI persons. After a feasibility study with 13 subjects, the portal has been introduced in the regional healthcare network in order to make it compliant with current legal regulations on data protection, including smartcard authentication. Although a number of training courses have been made to introduce SCI persons to portal use (up to 50 users), the number of accesses remained very low. Reasons for that have been investigated by means of a questionnaire submitted to the initial feasibility study subjects and included the still easier use of telephone versus our web-based smartcard-authenticated portal, in particular, because online communications are still perceived as an unusual way of interacting with the doctor. To summarize, the overall project has been appreciated by the users, but when it is time to ask for help to, the specialist, it is still much easier to make a phone call.

Perceptions regarding the ease of use and usefulness of health information exchange systems among medical providers, case managers and non-clinical staff members working in HIV care and community settings

PURPOSE

The objective of this paper is to describe how members of HIV patients' care teams perceived the usefulness and ease of use of newly implemented, innovative health information exchange systems (HIEs) in diverse HIV treatment settings. Five settings with existing electronic medical records (EMRs) received special funding to test enhancements to their systems. Participating clinics and community-based organizations added HIEs permitting bi-directional exchange of information across multiple provider sites serving the same HIV patient population.

METHODS

We conducted in-depth qualitative interviews and quantitative web-based surveys with case managers, medical providers, and non-clinical staff members to assess the systems' perceived usefulness and ease of use shortly after the HIEs were implemented. Our approach to data analysis was iterative. We first conducted a thematic analysis of the qualitative data and discovered that there were key differences in perceptions and actual use of HIEs across occupational groups. We used these results to guide our analysis of the quantitative survey data, stratifying by occupational group.

RESULTS

We found differences in reports of how useful and how well-used HIEs were, by occupation. Medical providers were more likely to use HIEs if they provided easier access to clinical information than was present in existing EMRs. Case managers working inside medical clinics found HIEs to be less helpful because they already had access to the clinical data. In contrast, case managers working in community settings appreciated the new access to patient information that the HIEs provided. Non-clinical staff uniformly found the HIEs useful for a broad range of tasks including clinic administration, grant writing and generating reports for funders.

CONCLUSION

Our study offers insights into the use and potential benefits of HIE in the context of HIV care across occupational groups.

SIGSAC Software: A tool for the Management of Chronic Disease and Telecare

Chronic disease management is highly complex because multiple interventions are required to improve clinical outcomes. From the patient's perspective, his main problems are dealing with self-management without support and feeling isolated between clinical visits. A strategy for providing continuous self-management support is the use of communication technologies, such as the telephone. However, to be efficient and effective, an information system is required for telecare planning and follows up. The use of electronic clinical records facilitates the implementation of telecare, but those systems often do not allow to combine usual care (visits to the health clinics) with telecare. This paper presents the experience of developing an application called SIGSAC (Software de Información, Gestión y Seguimiento para el Autocuidado Crónico) for Chronic Disease Management and Telecare follow up.

A user centered design approach for patient interfaces to a diabetes IT platform

Improving patient self-management can have a greater impact than improving any clinical treatment (WHO). We propose here a systematic and comprehensive user centered design approach for delivering a technological platform for diabetes disease management. The system was developed under the METABO research project framework, involving patients from 3 different clinical centers in Parma, Modena and Madrid.

Typical electronic health record use in primary care practices and the quality of diabetes care

PURPOSE

Recent efforts to encourage meaningful use of electronic health records (EHRs) assume that widespread adoption will improve the quality of ambulatory care, especially for complex clinical conditions such as diabetes. Cross-sectional studies of typical uses of commercially available ambulatory EHRs provide conflicting evidence for an association between EHR use and improved care, and effects of longer-term EHR use in community-based primary care settings on the quality of care are not well understood.

METHODS

We analyzed data from 16 EHR-using and 26 non-EHR-using practices in 2 northeastern states participating in a group-randomized quality improvement trial. Measures of care were assessed for 798 patients with diabetes. We used hierarchical linear models to examine the relationship between EHR use and adherence to evidence-based diabetes care guidelines, and hierarchical logistic models to compare rates of improvement over 3 years.

RESULTS

EHR use was not associated with better adherence to care guidelines or a more rapid improvement in adherence. In fact, patients in practices that did not use an EHR were more likely than those in practices that used an EHR to meet all of 3 intermediate outcomes targets for hemoglobin A(1c), low-density lipoprotein cholesterol, and blood pressure at the 2-year follow-up (odds ratio = 1.67; 95% CI, 1.12-2.51). Although the quality of care improved across all practices, rates of improvement did not differ between the 2 groups.

CONCLUSIONS

Consistent use of an EHR over 3 years does not ensure successful use for improving the quality of diabetes care. Ongoing efforts to encourage adoption and meaningful use of EHRs in primary care should focus on ensuring that use succeeds in improving care. These efforts will need to include provision of assistance to longer-term EHR users.

Effect of a web-based chronic disease management system on asthma control and health-related quality of life: study protocol for a randomized controlled trial

Background

Asthma is a prevalent and costly disease resulting in reduced quality of life for a large proportion of individuals. Effective patient self-management is critical for improving health outcomes. However, key aspects of self-management such as self-monitoring of behaviours and symptoms, coupled with regular feedback from the health care team, are rarely addressed or integrated into ongoing care. Health information technology (HIT) provides unique opportunities to facilitate this by providing a means for two way communication and exchange of information between the patient and care team, and access to their health information, presented in personalized ways that can alert them when there is a need for action. The objective of this study is to evaluate the acceptability and efficacy of using a web-based self-management system, My Asthma Portal (MAP), linked to a case-management system on asthma control, and asthma health-related quality of life.

Methods

The trial is a parallel multi-centered 2-arm pilot randomized controlled trial. Participants are randomly assigned to one of two conditions: a) MAP and usual care; or b) usual care alone. Individuals will be included if they are between 18 and 70, have a confirmed asthma diagnosis, and their asthma is classified as not well controlled by their physician. Asthma control will be evaluated by calculating the amount of fast acting beta agonists recorded as dispensed in the provincial drug database, and asthma quality of life using the Mini Asthma Related Quality of Life Questionnaire. Power calculations indicated a needed total sample size of 80 subjects. Data are collected at baseline, 3, 6, and 9 months post randomization. Recruitment started in March 2010 and the inclusion of patients in the trial in June 2010.

Discussion

Self-management support from the care team is critical for improving chronic disease outcomes. Given the high volume of patients and time constraints during clinical visits, primary care physicians have limited time to teach and reinforce use of proven self-management strategies. HIT has the potential to provide clinicians and a large number of patients with tools to support health behaviour change.

Trial Registration

Current Controlled Trials ISRCTN34326236.

Tracking the delivery of prevention-oriented care among primary care providers who have adopted electronic health records

The Primary Care Information Project is a New York City initiative aimed at improving population health through the improved delivery of preventive care. It has assisted with the adoption of a fully functional electronic health record (EHR) in over 300 primary care practices. Practices with EHRs automatically transmit summary data that can be used to track population health indicators for recommended preventive care. Early analysis, focusing on small practices with fewer than 10 providers serving Medicaid and uninsured populations, showed increases in the delivery of recommended services of 0.1-2.4% per month (p ≤ 0.05). However, measurement of preventive care across this population is limited by some inconsistency of data transmission. This study shows that EHRs can be used to track the delivery of recommended preventive care across small primary care practices serving lower income communities in which few data are generally available for assessing population health.

Bridging the digital divide in health care: the role of health information technology in addressing racial and ethnic disparities

BACKGROUND

Racial and ethnic disparities in health care have been consistently documented in the diagnosis, treatment, and outcomes of many common clinical conditions. There has been an acceleration of health information technology (HIT) implementation in the United States, with health care reform legislation including multiple provisions for collecting and using health information to improve and monitor quality and efficiency in health care. Despite an uneven and generally low level of implementation, research has demonstrated that HIT has the potential to improve quality of care and patient safety. If carefully designed and implemented, HIT also has the potential to eliminate disparities.

HIT AND DISPARITIES

Several root causes for disparities are amenable to interventions using HIT, particularly innovations in electronic health records, as well as strategies for chronic disease management. Recommendations regardinghealth care system, provider, and patient factors can help health care organizations address disparities as they adopt, expand, and tailor their HIT systems. In terms of health care system factors, organizations should (1) automate and standardize the collection of race/ethnicity and language data, (2) prioritize the use of the data for identifying disparities and tailoring improvement efforts, (3) focus HIT efforts to address fragmented care delivery for racial/ethnic minorities and limited-English-proficiency patients, (4) develop focused computerized clinical decision support systems for clinical areas with significant disparities, and (5) include input from racial/ethnic minorities and those with limited English proficiency in developing patient HIT tools to address the digital divide.

CONCLUSIONS

As investments are made in HIT, consideration must be given to the impact that these innovations have on the quality and cost of health care for all patients, including those who experience disparities.

Usability evaluation of a personal health record

The electronic personal health record (PHR) has been championed as a mediator of patient-centered care, yet its usability and utility to patients, key predictors of success, have received little attention. Human-centered design (HCD) offers validated methods for studying systems effects on users and their cognitive tasks. In HCD, user-centered activities allow potential users to shape the design of the end product and enhance its usability. We sought to evaluate the usability and functionality of HealthView, the PHR of the Duke University Health System, using HCD methods. Study participants were asked to think aloud as they carried out tasks in HealthView. They then completed surveys and interviews eliciting their reactions to the web portal. Findings were analyzed to generate redesign recommendations, which will be incorporated in a future release of HealthView.

From simply inaccurate to complex and inaccurate: complexity in standards-based quality measures

Quality measurement has been slow to make a major impact in health care. Initial measures were too simple to affect outcomes of importance. Incentive programs such as Meaningful Use encourage better measures, but in process may become more complex. We evaluated the measures selected for Meaningful Use in two ways: we counted unique concept identifiers, taxonomies, and aggregated concepts as measures of complexity; and we surveyed informatics professionals to assess difficulty. There were 20,316 unique concept identifiers, 35 taxonomies, and 317 aggregated concepts across the 45 measures. Half the respondents reported measures at least moderately difficult. The number of identifiers was associated with fewer implementations (r=-.37); rating-of-difficulty was associated with more taxonomies (r=.24). The impact on accuracy may be substantial when moving to measures intended to be more relevant to clinical outcomes but requiring the use of more taxonomies, unused structured concept identifiers, or concepts only in free text fields.

Race and medication adherence and glycemic control: findings from an operational health information exchange

The Central Indiana Beacon Community leads efforts for improving adherence to oral hypoglycemic agents (OHA) to achieve improvements in glycemic control for patients with type 2 diabetes. In this study, we explored how OHA adherence affected hemoglobin A1C (HbA1c) level in different racial groups. OHA adherence was measured by 6-month proportion of days covered (PDC). Of 3,976 eligible subjects, 12,874 pairs of 6-month PDC and HbA1c levels were formed between 2002 and 2008. The average HbA1c levels were 7.4% for African-Americans and 6.5% for Whites. The average 6-month PDCs were 40% for African-Americans and 50% for Whites. In mixed effect generalized linear regression analyses, OHA adherence was inversely correlated with HbA1c level for both African-Americans (-0.80, p<0.0001) and Whites (-0.53, p<0.0001). The coefficient was -0.26 (p<0.0001) for the interaction of 6-month PDC and African-Americans. Significant risk factors for OHA non-adherence were race, young age, non-commercial insurance, newly-treated status, and polypharmacy.

Advances and current state of the security and privacy in electronic health records: survey from a social perspective

E-Health systems are experiencing an impulse in these last years, when many medical agencies began to include digital solutions into their platforms. Electronic Health Records (EHRs) are one of the most important improvements, being in its most part a patient-oriented tool. To achieve a completely operational EHR platform, security and privacy problems have to be resolved, due to the importance of the data included within these records. But given all the different methods to address security and privacy, they still remain in most cases as an open issue. This paper studies existing and proposed solutions included in different scenarios, in order to offer an overview of the current state in EHR systems. Bibliographic material has been obtained mainly from MEDLINE and SCOPUS sources, and over 30 publications have been analyzed. Many EHR platforms are being developed, but most of them present weaknesses when they are opened to the public. These architectures gain significance when they cover all the requisites related to security and privacy.

Transfer of information on palliative home care during the out-of-hours period

BACKGROUND

Continuity of end-of-life care for patients receiving palliative care is an important challenge for out-of-hours services in general practice.

AIM

To investigate how frequent information is transferred on patients receiving palliative care from GPs to the out-of-hours services, to explore the perceptions of GP's on this information transfer and to study the relation between information transfer and the used GP information systems.

METHODS

This is a mixed-method design study. The frequency of information transfer to the out-of-hours services was investigated by analyzing a regional out-of-hours database. Barriers and promoting factors for this transfer of information were investigated by using semi-structured interviews among a purposive sample of GPs from the same region. The relation between information transfer and the GP information system was investigated by a postal questionnaire in a national random selection of GPs.

RESULTS

When a palliative patient contacted the out-of-hours service, for 20% of these patients, a transfer of information was available and only half of these transfers included an anticipating end-of-life plan. All interviewed GPs considered continuity of care for these patients as important. However, some doubted whether a transfer of information is relevant for the quality of care. There was no relation between the information transfer and the used GP information systems.

CONCLUSION

For only a minority of patients receiving palliative care, a transfer of information including an anticipating management plan was present. There is a large variation in the opinions of GPs on how to organize continuity of end-of-life care.

Implementation of customized health information technology in diabetes self management programs

PURPOSE

The project was a nurse-led implementation of a software application, designed to combine clinical and demographic records for a diabetes education program, which would result in secure, long-term record storage.

BACKGROUND/RATIONALE

Clinical information systems may be prohibitively expensive for small practices and require extensive training for implementation. A review of the literature suggests that the use of simple, practice-based registries offer an economical method of monitoring the outcomes of diabetic patients.

PROJECT DESCRIPTION

The database was designed using a common software application, Microsoft Access. The theory used to guide implementation and staff training was Rogers' Diffusion of Innovations theory (1995).

OUTCOMES

Outcomes after a 3-month period included incorporation of 100% of new clinical and demographic patient records into the database and positive changes in staff attitudes regarding software applications used in diabetes self-management training. These objectives were met while keeping project costs under budgeted amounts.

CONCLUSIONS

As a function of the clinical nurse specialist (CNS) researcher role, there is a need for CNSs to identify innovative and economical methods of data collection. The success of this nurse-led project reinforces suggestions in the literature for less costly methods of data maintenance in small practice settings. Ongoing utilization and enhancement have resulted in the creation of a robust database that could aid in the research of multiple clinical issues.

IMPLICATIONS

Clinical nurse specialists can use existing evidence to guide and improve both their own practice and outcomes for patients and organizations. Further research regarding specific factors that predict efficient transition of informatics applications, how these factors vary according to practice settings, and the role of the CNS in implementation of such applications is needed.

Patient preferences for a hospital-based rheumatology Interactive Health Communication Application and factors associated with these preferences

OBJECTIVES

To examine current disease-related Internet use and intentions to use various online support services on a hospital-based Interactive Health Communication Application (IHCA) of patients with rheumatic diseases. Furthermore, to examine which variables are associated with the intentions to use different services.

METHODS

Questionnaires were sent to a random sample of 484 patients of a large hospital's rheumatology clinic: response was 47% (n = 227). Questions included socio-demographics, health characteristics, health literacy, patients' current disease-related Internet use and their intentions to use eight different support services: (i) information about disease and treatment; (ii) information about care and support; (iii) peer communication; (iv) e-consultation; (v) autonomous symptom monitoring; (vi) symptom monitoring with telemonitoring; (vii) self-management support; and (viii) access to their electronic medical records.

RESULTS

Although most patients with Internet access had used it in relation to their disease (82%), Internet use was mainly limited to searching information. Many patients (45-68%), however, intended to use seven out of eight possible online services if offered on a hospital-based rheumatology IHCA. An exception was peer communication; only 11% intended to use this service. Of all the services, access to the electronic medical record was mostly preferred, followed by information provision. Demographics, health characteristics and health literacy did not show clear significant relationships with the reported intentions.

CONCLUSION

Results show that patients with rheumatic diseases are interested in online support from the hospital and that they intend to use an IHCA, if it is available. Clear associating variables with reported intentions to use the different services were not found.

Innovations in the Utilization of Health Information Technology in Psychiatric Services

There is ever-increasing activity in applying information technology to various areas of healthcare, including mental health. Examples of innovations include applications in screening, treatment, clinical decision support, communication and coordination, telemedicine, Internet-based education and services, public health research, training and education, and bioinformatics. Issues and challenges include protection of privacy, managing narrative free text, assessing the reliability of information found online, and mitigating impact on clinical workflow. While many of the innovations described will not be fully realized until national information systems reach a larger scale, many are having a positive impact on mental healthcare today.

A nursing virtual intervention: real-time support for managing antiretroviral therapy

Based on a philosophy of empowerment, we developed the HIV Treatment, Virtual Nursing Assistance and Education intervention to equip persons living with HIV for managing their daily antiretroviral therapies. In this article, we describe the project and the process of developing it, which was carried out in three phases: (1) development of the intervention's clinical content, (2) generation of a multimedia presentation, and (3) implementation of our Web application via computer interface. The HIV Treatment, Virtual Nursing Assistance and Education consists of four interactive sessions at the computer, animated by a virtual nurse that takes the individual through the learning process about the capabilities necessary for taking the treatment. This information and strategies provided by the virtual nurse are specifically adapted to the participant, according to the responses he/she supplies. The virtual intervention approach, still experimental, is intended to be complementary with the actual clinical follow-up and has been developed in the context of reorganizing services and of the scarcity of resources. While we anticipate direct positive outcomes among the HIV clientele, it is also highly probable that this virtual support application will have ramifications among different clienteles who must also contend with the daily challenges of their health conditions.