A qualitative study on the Virtual Emergency Department care experiences of equity-deserving populations.

Patients from equity-deserving populations, such as those who are from racialized communities, the 2SLGBTQI+ community, who are refugees or immigrants, and/or who have a disability, may experience a unique set of challenges accessing virtual models of care. The objective of this qualitative study was to describe the experiences of patients from equity-deserving communities and their family members who received care from a Virtual Emergency Department (ED) in Toronto, Canada. Forty-three participants (36 patients and 7 family caregivers) with different and intersecting identities who used the Virtual ED participated in the study. Semi-structured interviews were conducted to explore reasons for accessing the Virtual ED, barriers to access, and how the Virtual ED met their care needs and expectations, including ways their experience could have been improved. Thematic analysis was used to identify themes from the data. Patients from equity-deserving populations described negative past experiences with ED in-person care, which included recounts of discrimination or culturally insensitive care while waiting to see the ED physician or nurse. Conversely, participants found the Virtual ED to be a socially and culturally safe space since they could now by-pass the waiting room experience. However, virtual care could not replace in-person care for certain issues (e.g., physical exam), and there was a need for greater promotion of the service to specific communities that might benefit from having access to the Virtual ED. Targeted outreach to help raise awareness of the service to equity-deserving communities is an important future direction.

Electronic communication between family physicians and patients: Findings from a multisite survey of academic family physicians in Ontario.

OBJECTIVE: To assess the proportion of academic family physicians using e-mail with patients and to explore related attitudes, barriers, and facilitators. DESIGN: A 47-item questionnaire was created after a literature review, discussions with study team members, pretesting, and pilot testing. The questionnaire was disseminated electronically from June to August 2017. SETTING: Ontario. PARTICIPANTS: All family physicians affiliated with the Department of Family and Community Medicine at the University of Toronto. MAIN OUTCOME MEASURES: Physician practices using e-mail (including barriers to and facilitators of e-mail use with patients), use of e-mail with other health care providers, use of communication technologies other than e-mail, and demographic and practice information. RESULTS: A total of 1553 surveys were disseminated and 865 responses received (56% response rate). Overall, 610 respondents met inclusion criteria. Of these respondents, 43% (265 of 610) personally sent e-mails to patients in a typical week. An additional 21% (126 of 610) reported that they did not personally e-mail patients, but their clinic staff did. Patient convenience and a decrease in the need for telephone communication were the most commonly noted reasons for e-mail use. Facilitators of e-mail use included integration with the electronic medical record, enhanced e-mail access control, security features, and financial compensation. Barriers to e-mail use included privacy and security concerns, concerns about inappropriate e-mail use by patients, and the creation of unrealistic expectations about physician availability. CONCLUSION: E-mail use between academic family physicians and patients was found to be much higher than shown in previous studies of Canadian physicians. This finding might have been owing to unique aspects of academic medicine, remuneration via capitation, or other factors. Efforts to increase physician use of e-mail with patients should address concerns related to privacy and security, electronic medical record integration, and financial compensation.

Towards Educational Electronic Health Records (EHRs): A Design Process for Integrating EHRs, Simulation, and Video Tutorials.

Electronic health records (EHRs) are becoming ubiquitous in healthcare practice. However, their use in medical education has been slower to catch on and a new category of EHRs is beginning to emerge known as eduEHRs. These systems allow learners to explore and experiment with EHRs in the context of medical education. However, current eduEHRs have limitations, such as a lack of dynamic interaction built-in that would mimic real-world use of these tools. To overcome this, the integration of eduEHRs with software and tools such as video simulations and tutorials has considerable promise. In this paper we describe a new design process for integrating EHRs, simulations, and video tutorials.

A Pilot Study of Computer-Based Simulation Training for Enhancing Family Medicine Residents' Competence in Computerized Settings.

We previously developed a prototype computer-based simulation to teach residents how to integrate better EMR use in the patient-physician interaction. To evaluate the prototype, we conducted usability tests with three non-clinician students, followed by a pilot study with 16 family medicine residents. The pilot study included pre- and post-test surveys of competencies and attitudes related to using the EMR in the consultation and the acceptability of the simulation, as well as 'think aloud' observations. After using the simulation prototypes, the mean scores for competencies and attitudes improved from 14.88/20 to 15.63/20 and from 22.25/30 to 23.13/30, respectively; however, only the difference for competencies was significant (paired t-test; t=-2.535, p=0.023). Mean scores for perceived usefulness and ease of use of the simulation were good (3.81 and 4.10 on a 5-point scale, respectively). Issues identified in usability testing include confusing interaction with some features, preferences for a more interactive representation of the EMR, and more options for shared decision making. In conclusion, computer-based simulation may be an effective and acceptable tool for teaching residents how to better use EMRs in clinical encounters.

User Manuals for a Primary Care Electronic Medical Record System: A Mixed Methods Study of User- and Vendor-Generated Documents.

RESEARCH PROBLEM: Tutorials and user manuals are important forms of impersonal support for using software applications including electronic medical records (EMRs). Differences between user- and vendor documentation may indicate support needs, which are not sufficiently addressed by the official documentation, and reveal new elements that may inform the design of tutorials and user manuals. RESEARCH QUESTION: What are the differences between user-generated tutorials and manuals for an EMR and the official user manual from the software vendor? LITERATURE REVIEW: Effective design of tutorials and user manuals requires careful packaging of information, balance between declarative and procedural texts, an action and task-oriented approach, support for error recognition and recovery, and effective use of visual elements. No previous research compared these elements between formal and informal documents. METHODOLOGY: We conducted an mixed methods study. Seven tutorials and two manuals for an EMR were collected from three family health teams and compared with the official user manual from the software vendor. Documents were qualitatively analyzed using a framework analysis approach in relation to the principles of technical documentation described above. Subsets of the data were quantitatively analyzed using cross-tabulation to compare the types of error information and visual cues in screen captures between user- and vendor-generated manuals. RESULTS AND DISCUSSION: The user-developed tutorials and manuals differed from the vendor-developed manual in that they contained mostly procedural and not declarative information; were customized to the specific workflow, user roles, and patient characteristics; contained more error information related to work processes than to software usage; and used explicit visual cues on screen captures to help users identify window elements. These findings imply that to support EMR implementation, tutorials and manuals need to be customized and adapted to specific organizational contexts and workflows. The main limitation of the study is its generalizability. Future research should address this limitation and may explore alternative approaches to software documentation, such as modular manuals or participatory design.

Peril of the pox. Are primary care providers aware of varicella vaccination guidelines?

PURPOSE: To determine whether physicians providing primary care in Ontario were aware of guidelines published by Health Canada's National Advisory Committee on Immunization (NACI), their opinions about the varicella vaccine, and factors that influence use of the vaccine. METHODS: A questionnaire examining awareness, knowledge, and perceived barriers to using varicella vaccine was developed and mailed to a random sample of 500 family physicians and 400 pediatricians practising in Ontario. RESULTS: To the 900 questionnaires mailed, 284 family physicians (56.9%) and 232 pediatricians (59.2%) responded. Fifty-six percent of family physicians and 95.4% of pediatricians providing primary care were aware of the Health Canada guidelines. Physicians who were aware of the Health Canada guidelines were more knowledgeable about the vaccine and were more likely to recommend it. Both groups of physicians identified cost (not covered by the government), problems with storage and handling, and concerns about long-term immunity as barriers to use of the vaccine. CONCLUSION: While awareness of the guidelines was associated with better knowledge of and following recommendations for the vaccine, Health Canada guidelines were not widely distributed to all primary care providers. One way to encourage incorporation of varicella vaccine guidelines into practice would be to improve dissemination of the guidelines to all primary care providers.