Voices in the wilderness: Co-location meeting the needs of children in protective care.

OBJECTIVE: To explore how access to a family medicine clinic co-locating with the Children's Aid Society (CAS) of Hamilton in Ontario helped meet the unique needs of children in care. DESIGN: Qualitative research using semistructured face-to-face and telephone interviews. SETTING: The CAS of Hamilton. PARTICIPANTS: Nineteen foster parents. METHODS: Stakeholders were invited to participate with flyers posted in the clinic, notices that were mailed to foster parents, personal invitations that were distributed during clinic visits, and an internal memo that was distributed to the CAS staff. Informed consent and assent where appropriate was obtained before an interview was started. Interviews were audiorecorded when and where feasible, transcribed, and subsequently underwent inductive, thematic analysis. Common themes evolved by consensus. MAIN FINDINGS: Foster parents valued the family medicine clinic co-locating with the CAS. The co-location helped children in care to know that there were others in similar circumstances. Foster parents learned from and shared parenting skills with one another, which resulted in developing confidence in the care they provided. The clinic became a neutral place for children in care, foster parents, and birth parents. The clinic team gathered the children's complete health records and was responsible for sharing this information when appropriate. CONCLUSION: Access to a family medicine clinic designed specifically for children in care that co-located with the CAS enhanced not only the planning, management, and evaluation of care, but also provided a consistency that was not found in other parts of the children's lives; this helped generate trusting relationships over time. The co-location provided a strong spoke in the circle of care.

Global health in Canadian medical education: current practices and opportunities.

PURPOSE: Globalization is altering health and health care. At the same time, prospective and current medical students are increasingly requesting global health training and creating opportunities when these are not provided by medical schools. To understand the type and amount of global health activities provided in Canadian medical schools, the authors undertook a survey of global health educational opportunities available at all 17 medical schools during the 2005-2006 academic year. METHOD: Using a structured questionnaire, information was collected from deans' offices, institutional representatives, faculty, students, and medical school Web sites. RESULTS: All 17 medical schools participated. Canadian medical schools vary widely in their approach to global health education, ranging from neither required nor elective courses in global health to well-developed, two-year electives that include didactic and overseas training. There is no consensus on the educational content covered, the year in which global health issues are taught, whether materials should be elective or required, or how much training is needed. Of the 16 Canadian medical schools that allow students to participate in international electives, 44% allow these electives to occur without clear faculty oversight or input. CONCLUSIONS: Despite both the strong, growing demand from medical students and the changing societal forces that call for better global health training, Canadian medical school curricula are not well positioned to address these needs. Improving global health opportunities in Canadian medical school curricula will likely require national leadership from governing academic bodies.

An effort to improve electronic health record medication list accuracy between visits: patients' and physicians' response.

OBJECTIVE: To evaluate the efficacy of a secure web-based patient portal called Patient Gateway (PG) in producing more accurate medication lists in the electronic health record (EHR), and whether sending primary care physicians (PCPs) a clinical message updating them on the information their patients provided caused physicians to update the EHR medication list. METHODS: We compared the medication list accuracy of 84 patients using PG with that of 79 who were not. Patient-reported medication discrepancies were noted in the EHR in a clinical note by research staff and a message was sent to the participants' PCPs notifying them of the updated information. RESULTS: Participants were taking 665 medications according to the EHR, and reported 273 additional medications. A lower percentage of PG users' drug regimens (54% versus 61%, p=0.07) were reported to be correct than those of PG non-users, although PG users took significantly more medications than their non-user counterparts (5.0 versus 3.1 medications, p=0.0001). Providing patient-reported information in a clinical note and sending a clinical message to the primary care doctor did not result in PCPs updating their patients' EHR medication lists. CONCLUSIONS: Medication lists in EHRs were frequently inaccurate and most frequently overlooked over-the-counter (OTC) and non-prescription drugs. Patients using a secure portal had just as many discrepancies between medication lists and self-report as those who did not, and notifying physicians of discrepancies via e-mail had no effect.

Electronic health records in specialty care: a time-motion study.

BACKGROUND: Electronic health records (EHRs) have great potential to improve safety, quality, and efficiency in medicine. However, adoption has been slow, and a key concern has been that clinicians will require more time to complete their work using EHRs. Most previous studies addressing this issue have been done in primary care. OBJECTIVE: To assess the impact of using an EHR on specialists' time. DESIGN Prospective, before-after trial of the impact of an EHR on attending physician time in four specialty clinics at an integrated delivery system: cardiology, dermatology, endocrine, and pain. MEASUREMENTS: We used a time-motion method to measure physician time spent in one of 85 designated activities. RESULTS: Attending physicians were monitored before and after the switch from paper records to a web-based ambulatory EHR. Across all specialties, 15 physicians were observed treating 157 patients while still using paper-based records, and 15 physicians were observed treating 146 patients after adoption. Following EHR implementation, the average adjusted total time spent per patient across all specialties increased slightly but not significantly (Delta = 0.94 min., p = 0.83) from 28.8 (SE = 3.6) to 29.8 (SE = 3.6) min. CONCLUSION: These data suggest that implementation of an EHR had little effect on overall visit time in specialty clinics.

A cost-benefit analysis of electronic medical records in primary care.

Electronic medical record systems improve the quality of patient care and decrease medical errors, but their financial effects have not been as well documented. The purpose of this study was to estimate the net financial benefit or cost of implementing electronic medical record systems in primary care. We performed a cost-benefit study to analyze the financial effects of electronic medical record systems in ambulatory primary care settings from the perspective of the health care organization. Data were obtained from studies at our institution and from the published literature. The reference strategy for comparisons was the traditional paper-based medical record. The primary outcome measure was the net financial benefit or cost per primary care physician for a 5-year period. The estimated net benefit from using an electronic medical record for a 5-year period was 86,400 US dollars per provider. Benefits accrue primarily from savings in drug expenditures, improved utilization of radiology tests, better capture of charges, and decreased billing errors. In one-way sensitivity analyses, the model was most sensitive to the proportion of patients whose care was capitated; the net benefit varied from a low of 8400 US dollars to a high of 140,100 US dollars . A five-way sensitivity analysis with the most pessimistic and optimistic assumptions showed results ranging from a 2300 US dollars net cost to a 330,900 US dollars net benefit. Implementation of an electronic medical record system in primary care can result in a positive financial return on investment to the health care organization. The magnitude of the return is sensitive to several key factors.

Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality.

While evidence-based medicine has increasingly broad-based support in health care, it remains difficult to get physicians to actually practice it. Across most domains in medicine, practice has lagged behind knowledge by at least several years. The authors believe that the key tools for closing this gap will be information systems that provide decision support to users at the time they make decisions, which should result in improved quality of care. Furthermore, providers make many errors, and clinical decision support can be useful for finding and preventing such errors. Over the last eight years the authors have implemented and studied the impact of decision support across a broad array of domains and have found a number of common elements important to success. The goal of this report is to discuss these lessons learned in the interest of informing the efforts of others working to make the practice of evidence-based medicine a reality.

The Internet as a vehicle to communicate health information during a public health emergency: a survey analysis involving the anthrax scare of 2001.

BACKGROUND: The recent public health risks arising from bioterrorist threats and outbreaks of infectious diseases like SARS (Severe Acute Respiratory Syndrome) highlight the challenges of effectively communicating accurate health information to an alarmed public. OBJECTIVE: To evaluate use of the Internet in accessing information related to the anthrax scare in the United States in late 2001, and to strategize about the most effective use of this technology as a communication vehicle during times of public health crises. METHODS: A paper-based survey to assess how individuals obtained health information relating to bioterrorism and anthrax during late 2001. We surveyed 500 randomly selected patients from two ambulatory primary care clinics affiliated with the Brigham and Women's Hospital in Boston, Massachusetts. RESULTS: The response rate was 42%. While traditional media provided the primary source of information on anthrax and bioterrorism, 21% (95% CI, 15%-27%) of respondents reported searching the Internet for this information during late 2001. Respondents reported trusting information from physicians the most, and information from health websites slightly more than information from any traditional media source. Over half of those searching the Internet reported changing their behavior as a result of information found online. CONCLUSIONS: Many people already look to the Internet for information during a public health crisis, and information found online can positively influence behavioral responses to such crises. However, the potential of the Internet to convey accurate health information and advice has not yet been realized. In order to enhance the effectiveness of public-health communication, physician practices could use this technology to pro-actively e-mail their patients validated information. Still, unless Internet access becomes more broadly available, its benefits will not accrue to disadvantaged populations.

Opportunities to enhance patient and physician e-mail contact.

The purpose of our study was to evaluate how e-mail is currently used between physicians and patients in an integrated delivery system, and to identify developments that might promote increased use of this form of communication. A paper-based survey questionnaire was administered to 94 primary care physicians. We evaluated the role e-mail currently plays in a physician's typical work day, physician views on the impact of e-mail on phone use and the barriers to increasing the use of e-mail with patients. 76% of physicians surveyed responded. All respondents currently use e-mail. Close to 75% of physicians use e-mail with their patients, but the vast majority do so with only 1-5% of those patients. 50% of physicians believe that up to 25% of their patients would send e-mail to them if given the option, with an additional 37% believing that between 25% and 50% of patients would value this option. The main reported barriers to physician-patient e-mail related to workload, security and payment. Our survey findings indicate that with adequate pre-screening, triage, and reimbursement mechanisms physicians would be open to substantially increasing e-mail communication with patients.

Primary care physician attitudes towards using a secure web-based portal designed to facilitate electronic communication with patients.

BACKGROUND: Patient demand for email contact with physician practices is high. If physicians met this demand, improvements in communication, quality of care and patient satisfaction could result. However, physicians have typically been hesitant to communicate electronically with patients, largely due to concerns relating to workload, security and lack of compensation. GOAL: To assess physician attitudes towards electronic communication with patients six months after the implementation of an application called Patient Gateway. Patient Gateway allows patients to access an extract of their medical record and facilitates online communication with medical practices. METHODS: A paper-based survey was administered to the 43 primary care physicians in one integrated delivery system, with a 56% (24/43) response rate. RESULTS: Overall, physicians felt that Patient Gateway's impact on their practices was positive, especially in the areas of refill and referral request management and appointment scheduling. However, physicians are still hesitant to increase general electronic communication with patients; none opted to use Patient Gateway's general messaging function with patients, and those who had previously used outside systems to exchange emails with some patients continued to communicate with only a small proportion of their patient panel in this way. However, 38% of physicians already communicate with their own physicians via email, and another 19% would like to do so. CONCLUSIONS: Physicians' fears about being overwhelmed with messages were not realised. While physicians were generally enthusiastic about the application, none used it directly to communicate with patients. Over three-quarters of respondents indicated that they would be more enthusiastic about electronic communication with patients if this time were compensated.

Impact of an Electronic Health Record on oncologists' clinic time.

The use of Electronic Health Records (EHRs) has been widely advocated to transform health-care delivery by improving quality, safety, and efficiency. Compared to a paper-based system, EHRs offer better access to clinical data and facilitate order entry and decision support. However, the benefits provided by EHRs do not eliminate the need to assess how such systems alter clinician time utilization. A major barrier to EHR use has been the concern that the EHR will take longer to use than paper-based systems. Few studies have addressed this issue in specialty clinic settings. We performed a time-motion study to evaluate how oncologists' time utilization differed before and after EHR implementation.

Primary care physician time utilization before and after implementation of an electronic health record: a time-motion study.

Despite benefits associated with the use of electronic health records (EHRs), one major barrier to adoption is the concern that EHRs may take longer for physicians to use than paper-based systems. To address this issue, we performed a time-motion study in five primary care clinics. Twenty physicians were observed and specific activities were timed during a clinic session before and after EHR implementation. Surveys evaluated physicians' perceptions regarding the EHR. Post-implementation, the adjusted mean overall time spent per patient during clinic sessions decreased by 0.5 min (p=0.86; 95% confidence interval [-5.05, 6.04]) from a pre-intervention adjusted average of 27.55 min (SE=2.1) to a post-intervention adjusted average of 27.05 min (SE=1.6). A majority of survey respondents believed EHR use results in quality improvement, yet only 29% reported that EHR documentation takes the same amount of time or less compared to the paper-based system. While the EHR did not require more time for physicians during a clinic session, further studies should assess the EHR's potential impact on non-clinic time.

Communicating health information to an alarmed public facing a threat such as a bioterrorist attack.

Considerable literature exists on the communication of risk to the public through channels such as television, radio, and newspapers. However, little has been written on the communication of risk through less traditional communication forms, such as the Internet. The purpose of this study was to investigate the role of the Internet as an additional source of health information to that provided by the traditional news media in managing the public's response to an emerging health risk such as a bioterrorist attack. Despite some of the Internet's advantages over traditional media, including the depth and speed in which information can be conveyed to different audiences, the Internet was underutilized during fall 2001, when it became important to convey information on the risks of anthrax. A number of developments are required if the health care system is to capitalize on the Internet's potential as a risk communication device. These developments include research into public Internet searching behavior and further development in the role of search engines and government agencies in organizing quality health information.

Physicians' perceptions toward electronic communication with patients.

Despite the widespread use of email, electronic communication between physicians and patients is not part of the standard physician-patient relationship in the United States. Increased use of email may improve physician-patient communication, which is associated with improved patient satisfaction and health status. Evaluating email communication in this context is vital to minimizing potential risks and maximizing benefit to physicians and patients. We evaluated email use between physicians and patients, and physicians perceptions of the value and issues surrounding this form of communication in order to identify issues that would facilitate and improve electronic communication.