Analysis of the impact of the Birmingham OwnHealth program on secondary care utilization and cost: a retrospective cohort study.

BACKGROUND: This study aimed to assess the impact of the Birmingham OwnHealth(®) program (a partnership among the National Health Service [NHS] Birmingham East and North, formerly Birmingham East and North PCT, as the commissioner, Pfizer Health Solutions [Tadworth, United Kingdom] as the primary contractor, and NHS Direct as a subcontractor) on the number of unscheduled secondary care spells and the cost of care for patients with long-term conditions. This article reports a retrospective cohort study conducted at the NHS Birmingham East and North. SUBJECTS AND METHODS: Adults with at least 1 of 10 defined long-term conditions were eligible for inclusion. Patients in the OwnHealth program were compared with those in a matched comparison group from a population who were eligible but did not enroll in the program. The main outcome measures were the difference in the number of secondary care spells (defined as the experience between hospital admission and discharge) between the OwnHealth group and the comparison group and the difference in the cost of care (calculated from the cost of activities during secondary care spells). RESULTS: The mean number of secondary care spells per person per year in the OwnHealth group was 0.61 (standard deviation [SD] 1.35) compared with 0.84 (SD 1.49) in the comparison group (p<0.0005). This constituted a 27% reduction in secondary care spells per person per year. The mean cost of secondary care spells per person per year in the OwnHealth group was $1,305 (SD $3,138) compared with $1,678 (SD $3,485) in the comparison group (p<0.0005). DISCUSSION: This difference in costs constituted a 27% reduction in utilization and 22% reduction in cost of secondary care with the OwnHealth program. CONCLUSIONS: Telehealth intervention can reduce the cost of secondary care of some patients with long-term conditions.

Challenges in data quality assurance for electronic health records.

Data quality is an integral part of EHR systems. Quality assurance for these systems not only identifies the current defects in the data but also aims for minimizing the risk of their future occurrence. Previous studies for secondary use of data in research projects presented several dimensions for such defects and proposed few methods for identifying them. Although those methods were successful in small scale research studies, their application to large scale day-to-day flow of information in EHR systems involves many challenges. In this paper, we highlighted those challenges for each method and each dimension and proposed a framework for using existing technologies to address those challenges.

The introduction and evaluation of mobile devices to improve access to patient records: a catalyst for innovation and collaboration at BCCA.

Prompt and efficient access to patient records is vital in providing optimal patient care. The Cancer Agency Information System (CAIS) is the primary patient record repository for the British Columbia Cancer Agency (BCCA) but is only accessible on traditional computer workstations. The BCCA clinics have significant space limitations resulting in multiple health care professionals sharing each workstation. Furthermore, workstations are not available in examination rooms. A novel and cost efficient solution is necessary to improve clinician access to CAIS. This prompted the BCCA and IMITS to embark on an innovative provincial collaboration to introduce and evaluate the impact of a mobile device to improve access to CAIS. The project consisted of 2 phases with over 50 participants from multiple clinical disciplines across BCCA sites. Phase I evaluated the adoptability, effectiveness and costs associated with providing access to CAIS using a generic viewer (Citrix). Phase II incorporated the feedback and findings from Phase I to make available a customized mobile device-specific application. Phase II also addressed privacy and security requirements.

Identifying Breast Cancer Recurrence in Administrative Data: Algorithm Development and Validation.

Breast cancer recurrence is an important outcome for patients and healthcare systems, but it is not routinely reported in cancer registries. We developed an algorithm to identify patients who experienced recurrence or a second case of primary breast cancer (combined as a "second breast cancer event") using administrative data from the population of Ontario, Canada. A retrospective cohort study design was used including patients diagnosed with stage 0-III breast cancer in the Ontario Cancer Registry between 1 January 2009 and 31 December 2012 and alive six months post-diagnosis. We applied the algorithm to healthcare utilization data from six months post-diagnosis until death or 31 December 2013, whichever came first. We validated the algorithm's diagnostic accuracy against a manual patient record review (n = 2245 patients). The algorithm had a sensitivity of 85%, a specificity of 94%, a positive predictive value of 67%, a negative predictive value of 98%, an accuracy of 93%, a kappa value of 71%, and a prevalence-adjusted bias-adjusted kappa value of 85%. The second breast cancer event rate was 16.5% according to the algorithm and 13.0% according to manual review. Our algorithm's performance was comparable to previously published algorithms and is sufficient for healthcare system monitoring. Administrative data from a population can, therefore, be interpreted using new methods to identify new outcome measures.

A requirements engineering approach for improving the quality of diabetes education websites.

Diabetes Mellitus is a major chronic disease with multi-organ involvement and high-cost complications. Although it has been proved that structured education can control the risk of developing these complications, there is big room for improvement in the educational services for these patients. e-learning can be a good solution to fill this gap. Most of the current e-learning solutions for diabetes were designed by computer experts and healthcare professionals but the patients, as end-users of these systems, haven't been deeply involved in the design process. Considering the expectations of the patients, this article investigates a requirement engineering process comparing the level of importance given to different attributes of the e-learning by patients and healthcare professionals. The results of this comparison can be used for improving the currently developed online diabetes education systems.

Usability evaluation of a pilot implementation of the electronic clinical transfusion management system IT specification for blood tracking.

Safe working practices and patient safety are of critical importance in the administration of blood transfusion. While the use of information technology has been proposed to ensure the safety of this process, the usability of such systems has not previously been studied. We present the results of a usability evaluation of an electronic clinical transfusion management system being piloted by the National Health Service in England. A number of major usability problems were recorded, largely relating to unnecessary action, limiting user control and recovery from user error. Such problems can, however, be resolved by relatively minor changes to system functionality and design.

Evaluation of alert-based monitoring in a computerised blood transfusion management system.

Blood transfusion is a critical and multi-step process that can be lifesaving. At the same time, any mistakes can be life threatening. An electronic blood transfusion system has been designed to ensure the correctness and safety of the blood transfusion process. The standards for the system include notification mechanisms to inform system managers of any errors in the process. Analysis of system alerts has been used to evaluate the performance of the system. The majority of alerts were classified as 'moderate' in terms of risk (i.e. operational rather than affecting clinical safety) and tended to result from user error. The process of alert acknowledgement and resolution by the system administrator acted as a bottleneck whenever the alerts increased above 100 items per month. Although there was no statistically significant correlation between the number of alerts and the number of transfusions or number of the new users of the system, relatively similar patterns were observable in their charts. A major benefit is that the alerts automatically provided information that would not be captured in a manual transfusion process.

Formatively evaluating the importance of different aspects of an electronic blood transfusion system from the end users' point of view: a questionnaire study.

Blood transfusion is a process in which potential errors may result in serious adverse events to patients. To help improve the safety and efficiency of the blood transfusion process an electronic clinical transfusion management system is being piloted by NHS Connecting for Health. Evaluation of the implementation is being carried out in parallel. One component of the evaluation project aims to assess the importance placed in the various potential benefits of this new system by patients and healthcare workers. A questionnaire was generated and completed by healthcare workers and patients. Results indicate respondents viewing all factors as at least "important". "System" factors were deemed most important. Overall, clinical workers expressed the lowest importance to new process factors. Ultimately these results will be measured against final satisfaction with the system to assess 'fit' between perceived importance and satisfaction to guide areas for attention and resource allocation.

Potential Return on Investment (RoI) on web-based diabetes education in UK.

The incidence of diabetes mellitus is growing in the UK. As most diabetes care is performed by the patients themselves, structured education is one way to encourage their responsible participation in delivering effective care. Continuous e-learning by Internet has proven to be a useful method of diabetes education. "Return on Investment" (RoI) can be used as an indicator of the cost-benefit of web-based education. RoI is the ratio of money gained or lost on an investment relative to the amount of money invested. This report uses system dynamics modeling to predict the flow of patients in the educational system and the cost of their care. The analysis compared traditional and web-based education. Separate models were developed for each educational method and simulated until 2020 in one year intervals. The population of diabetic patients was adjusted at each cycle according to anticipated incidence and mortality rates. The population of educated diabetic patients was based on the educational capacity and literacy limits of each method. A report by the National Health Service (NHS) was used to calculate the cost of care by considering the cost difference between uneducated and educated patients. By 2020 with an annual rate of inflation of 3%, the annual cost of care is projected to increase to pound 3.67 billion for the traditional model as compared to pound 3.39 billion for the web-based model. RoI is estimated to be a ratio of 32.33. Investment in web-based diabetes education is not only a health benefit but also a reduction in care cost.

Artificial Intelligence-Based Triage for Patients with Acute Abdominal Pain in Emergency Department; a Diagnostic Accuracy Study.

INTRODUCTION: Artificial intelligence (AI) is the development of computer systems which are capable of doing human intelligence tasks such as decision making and problem solving. AI-based tools have been used for predicting various factors in medicine including risk stratification, diagnosis and choice of treatment. AI can also be of considerable help in emergency departments, especially patients' triage. OBJECTIVE: This study was undertaken to evaluate the application of AI in patients presenting with acute abdominal pain to estimate emergency severity index version 4 (ESI-4) score without the estimate of the required resources. METHODS: A mixed-model approach was used for predicting the ESI-4 score. Seventy percent of the patient cases were used for training the models and the remaining 30% for testing the accuracy of the models. During the training phase, patients were randomly selected and were given to systems for analysis. The output, which was the level of triage, was compared with the gold standard (emergency medicine physician). During the test phase of the study, another group of randomly selected patients were evaluated by the systems and the results were then compared with the gold standard. RESULTS: Totally, 215 patients who were triaged by the emergency medicine specialist were enrolled in the study. Triage Levels 1 and 5 were omitted due to low number of cases. In triage Level 2, all systems showed fair level of prediction with Neural Network being the highest. In Level 3, all systems again showed fair level of prediction. However, in triage Level 4, decision tree was the only system with fair prediction. CONCLUSION: The application of AI in triage of patients with acute abdominal pain resulted in a model with acceptable level of accuracy. The model works with optimized number of input variables for quick assessment.

Oncology Nurses' Attitudes Toward the Edmonton Symptom Assessment System: Results From a Large Cancer Care Ontario Study.

PURPOSE/OBJECTIVES: To examine oncology nurses' attitudes toward and reported use of the Edmonton Symptom Assessment System (ESAS) and to determine whether the length of work experience and presence of oncology certification are associated with their attitudes and reported usage.
. DESIGN: Exploratory, mixed-methods study employing a questionnaire approach.
. SETTING: 14 regional cancer centers (RCCs) in Ontario, Canada.
. SAMPLE: Oncology nurses who took part in a larger province-wide study that surveyed 960 interdisciplinary providers in oncology care settings at all of Ontario's 14 RCCs.
. METHODS: Oncology nurses' attitudes and use of ESAS were measured using a 21-item investigator-developed questionnaire. Descriptive statistics and Kendall's tau-b or tau-c test were used for data analyses. Qualitative responses were analyzed using content analysis.
. MAIN RESEARCH VARIABLES: Attitudes toward and self-reported use of standardized symptom screening and ESAS.
. FINDINGS: More than half of the participants agreed that ESAS improves symptom screening, most said they would encourage their patients to complete ESAS, and most felt that managing symptoms is within their scope of practice and clinical responsibilities. Qualitative comments provided additional information elucidating the quantitative responses. Statistical analyses revealed that oncology nurses who have 10 years or less of work experience were more likely to agree that the use of standardized, valid instruments to screen for and assess symptoms should be considered best practice, ESAS improves symptom screening, and ESAS enables them to better manage patients' symptoms. No statistically significant difference was found between oncology-certified RNs and noncertified RNs on attitudes or reported use of ESAS.
. CONCLUSIONS: Implementing a population-based symptom screening approach is a major undertaking. The current study found that oncology nurses recognize the value of standardized screening, as demonstrated by their attitudes toward ESAS.
. IMPLICATIONS FOR NURSING: Oncology nurses are integral to providing high-quality person-centered care. Using standardized approaches that enable patients to self-report symptoms and understanding barriers and enablers to optimal use of patient-reported outcome tools can improve the quality of patient care.

Cancer Care Professionals' Attitudes Toward Systematic Standardized Symptom Assessment and the Edmonton Symptom Assessment System After Large-Scale Population-Based Implementation in Ontario, Canada.

CONTEXT: Cancer patients experience a high symptom burden throughout their illness. Despite this, patients' symptoms and needs are often not adequately screened for, assessed, and managed. OBJECTIVES: This study investigated the attitudes of cancer care professionals toward standardized systematic symptom assessment and the Edmonton Symptom Assessment System (ESAS) and their self-reported use of the instrument in daily practice in a large healthcare jurisdiction where this is routine. METHODS: A 21-item electronic survey, eliciting both closed and open-ended anonymous responses, was distributed to all 2806 cancer care professionals from four major provider groups: physicians, nurses, radiotherapists, and psychosocial oncology (PSO) staff at the 14 Regional Cancer Centres across Ontario, Canada. RESULTS: A total of 1065 questionnaires were returned (response rate: 38%); 960 were eligible for analysis. Most respondents (88%) considered symptom management to be within their scope of practice. Sixty-six percent of physicians considered the use of standardized tools to screen for symptoms as "best practice," compared to 81% and 93% of nurses and PSO staff, respectively. Sixty-seven percent of physicians and 85% of nurses found the ESAS to be a useful starting point to assess patients' symptoms. Seventy-nine percent of physicians looked at their patient's ESAS scores at visits either "always" or "often," compared to 29%, 66%, and 89% of radiotherapists, PSO staff, and nurses, respectively. Several areas for improvement of ESAS use and symptom screening were identified. CONCLUSION: Findings show significant albeit variable uptake across disciplines in the use of the ESAS since program initiation. Several barriers to using the ESAS in daily practice were identified. These need to be addressed.

Design and validation of a questionnaire to measure the attitudes of hospital staff concerning pandemic influenza.

BACKGROUND AND OBJECTIVE: When pandemics lead to a higher workload in the healthcare sector, the attitude of healthcare staff and, more importantly, the ability to predict the rate of absence due to sickness are crucial factors in emergency preparedness and resource allocation. The aim of this study was to design and validate a questionnaire to measure the attitude of hospital staff toward work attendance during an influenza pandemic. METHOD: An online questionnaire was designed and electronically distributed to the staff of a teaching medical institution in the United Kingdom. The questionnaire was designed de novo following discussions with colleagues at Imperial College and with reference to the literature on the severe acute respiratory syndrome (SARS) epidemic. The questionnaire included 15 independent fact variables and 33 dependent measure variables. A total of 367 responses were received in this survey. RESULTS: The data from the measurement variables were not normally distributed. Three different methods (standardized residuals, Mahalanobis distance and Cook's distance) were used to identify the outliers. In all, 19 respondents (5.17%) were identified as outliers and were excluded. The responses to this questionnaire had a wide range of missing data, from 1 to 74 cases in the measured variables. To improve the quality of the data, missing value analysis, using Expectation Maximization Algorithm (EMA) with a non-normal distribution model, was applied to the responses. The collected data were checked for homoscedasticity and multicollinearity of the variables. These tests suggested that some of the questions should be merged. In the last step, the reliability of the questionnaire was evaluated. This process showed that three questions reduced the reliability of the questionnaire. Removing those questions helped to achieve the desired level of reliability. CONCLUSION: With the changes proposed in this article, the questionnaire for measuring staff attitudes concerning pandemic influenza can be converted to a standardized and validated questionnaire to properly measure the expectations and attendance of healthcare staff in the event of pandemic flu.