Impact of Patient Portal Use on Duplicate Laboratory Tests in Diabetes Management.

Background: Patients seek care across multiple health care settings. One coordination issue is the unnecessary duplication of laboratory across different health care settings. This analysis examined the association between patient portal use and duplication of laboratory testing among Veterans who are dual users of Veterans Affairs (VA) and non-VA providers. Materials and Methods: A national sample of Veterans who were newly authenticated users of the portal during fiscal year (FY) 2013 who used Blue Button at least once were compared with a random sample of Veterans who were not registered to use the portal. From these two groups, Veterans who were also Medicare-eligible users in FY2014 were identified. Duplicate testing was defined as receipt of more than five HbA1c (hemoglobin A1c) in 1 year. Results: Use of the Blue Button decreased the odds of duplicate HbA1c testing in VA and Medicare-covered facilities across three comparisons: (1) overall between users and nonusers: portal users were less likely to have duplicate testing; (2) pre-post comparison: there was a trend toward lower duplicate testing in both groups across time; and (3) pre-post comparisons accounting for use of the portal: the trend toward lower duplicate testing was greater in Blue Button users. Conclusion: Duplicate HbA1c testing was significantly lower in dual users of VA and Medicare services who used the Blue Button feature of their VA patient portal. Non-VA providers encounter barriers to access of complete information about Veterans who also use VA health care. Provider endorsement of consumer-mediated health information exchange could help further this model of sharing information.

Design and Evaluation of a Web-Based Symptom Monitoring Tool for Heart Failure.

Heart failure is a chronic condition where symptom recognition and between-visit communication with providers are critical. Patients are encouraged to track disease-specific data, such as weight and shortness of breath. Use of a Web-based tool that facilitates data display in graph form may help patients recognize exacerbations and more easily communicate out-of-range data to clinicians. The purposes of this study were to (1) design a Web-based tool to facilitate symptom monitoring and symptom recognition in patients with chronic heart failure and (2) conduct a usability evaluation of the Web site. Patient participants generally had a positive view of the Web site and indicated it would support recording their health status and communicating with their doctors. Clinician participants generally had a positive view of the Web site and indicated it would be a potentially useful adjunct to electronic health delivery systems. Participants expressed a need to incorporate decision support within the site and wanted to add other data, for example, blood pressure, and have the ability to adjust font size. A few expressed concerns about data privacy and security. Technologies require careful design and testing to ensure they are useful, usable, and safe for patients and do not add to the burden of busy providers.

Barriers and facilitators to managing multiple chronic conditions: a systematic literature review.

The prevalence of multiple chronic conditions (MCC) is increasing, creating challenges for patients, families, and the health care system. A systematic literature search was conducted to locate studies describing patient's perceptions of facilitators and barriers to management of MCC. Thirteen articles met study inclusion criteria. Patients reported nine categories of barriers including financial constraints, logistical challenges, physical limitations, lifestyle changes, emotional impact, inadequate family and social support, and the complexity of managing multiple conditions, medications, and communicating with health care providers. Four facilitators were found, including health system support, individualized care education and knowledge, informal support from family and social systems, and having personal mental and emotional strength. Existing research on management of MCC from the patient's perspective is limited. Interventions are needed to improve management practices with particular attention to the knowledge and skills required by this unique population.

It's always something: hospital nurses managing risk.

The purpose of this qualitative study was to describe the process by which hospital staff nurses keep patients safe within their hospital safety culture. Findings from this study culminated in a grounded theory of Managing Risk, the process by which nurses keep their patients safe from harm. Participants perceived that their patients were always at risk (it's always something), thus keeping patients safe was a continual, repetitive process of managing risk to prevent harm to patients. Stages of this process included risk assessment, risk recognition, prioritization, and protective interventions. Practicing nurses can use this theory to understand and articulate their critical role in keeping patients safe in hospitals. Further examination of this process is necessary for targeted assessment of a safety culture's impact on bedside nursing practice, thus providing a basis for specific interventions to improve patient safety.

Heart failure care management programs: a review of study interventions and meta-analysis of outcomes.

BACKGROUND: The objective of this systematic review and meta-analysis was to describe and quantify individual interventions used in multicomponent outpatient heart failure management programs. METHODS: MEDLINE, CINAHL, and the Cochrane Central Register of Controlled Trials between 1995 and 2008 were searched using 10 search terms. Randomized controlled trials evaluating outpatient programs that addressed comprehensive care to decrease readmissions for patients with heart failure were identified. Forty-three articles reporting on 35 studies that reported readmissions separately from other outcomes were included. Three investigators independently abstracted primary study characteristics and outcomes. RESULTS: In the 35 studies, participants included 8071 subjects who were typically older (mean [SD] age, 70.7 [6.5] years) and male (59%). Using our coding scheme, the number of individual interventions within a program ranged from 1 to 7 within individual studies; the most commonly used interventions were patient education, symptom monitoring by study staff, symptom monitoring by patients, and medication adherence strategies. Most programs had a teaching component with a mean (SD) of 6.4 (3.9) individual topics covered; frequent teaching topics were symptom recognition and management, medication review, and self-monitoring. Fewer than half of the 35 studies reviewed reported adequate data to be included in the meta-analysis. Some outcomes were infrequently reported, limiting statistical power to detect treatment effects. CONCLUSION: A number of studies evaluating multicomponent HF management programs have found positive effects on important patient outcomes. The contribution of the individual interventions included in the multicomponent program on patient outcomes remains unclear. Future studies of chronic disease interventions must include descriptions of recommended key program components to identify critical program components.

Passive sensor technology interface to assess elder activity in independent living.

BACKGROUND: The effectiveness of clinical information systems to improve nursing and patient outcomes depends on human factors, including system usability, organizational workflow, and user satisfaction. OBJECTIVE: The aim of this study was to examine to what extent residents, family members, and clinicians find a sensor data interface used to monitor elder activity levels usable and useful in an independent living setting. METHODS: Three independent expert reviewers conducted an initial heuristic evaluation. Subsequently, 20 end users (5 residents, 5 family members, 5 registered nurses, and 5 physicians) participated in the evaluation. During the evaluation, each participant was asked to complete three scenarios taken from three residents. Morae recorder software was used to capture data during the user interactions. RESULTS: The heuristic evaluation resulted in 26 recommendations for interface improvement; these were classified under the headings content, aesthetic appeal, navigation, and architecture, which were derived from heuristic results. Total time for elderly residents to complete scenarios was much greater than for other users. Family members spent more time than clinicians but less time than residents did to complete scenarios. Elder residents and family members had difficulty interpreting clinical data and graphs, experienced information overload, and did not understand terminology. All users found the sensor data interface useful for identifying changing resident activities. DISCUSSION: Older adult users have special needs that should be addressed when designing clinical interfaces for them, especially information as important as health information. Evaluating human factors during user interactions with clinical information systems should be a requirement before implementation.

Improving nurse care coordination with technology.

Technology offers potential solutions to the pending crisis of healthcare for older adults, while healthcare workers are in short supply. Technology can enable remote monitoring of individuals and early detection of potential problems, so that early interventions can help older adults remain as healthy and independent as possible. Research is under way with passive monitoring technology in senior housing that is finding patterns in the data that can enhance nurse care coordination through early illness detection. With early detection, interventions can be more effective and reduce hospitalization and other healthcare expenses. Case studies are presented, and implications are discussed.

Developing a comprehensive electronic health record to enhance nursing care coordination, use of technology, and research.

As in acute care, use of health information technology in long-term care holds promise for increased efficiency, better accuracy, reduced costs, and improved outcomes. A comprehensive electronic health record (EHR), which encompasses all health care measures that clinicians want to use-both standard health care assessments and those acquired through emerging technology-is the key to improved, efficient clinical decision making. New technologies using sensors to passively monitor older adults at home are being developed and are commercially available. However, integrating the clinical information systems with passive monitoring data so that clinical decision making is enhanced and patient records are complete is challenging. Researchers at the University of Missouri (MU) are developing a comprehensive EHR to: (a) enhance nursing care coordination at TigerPlace, independent senior housing that helps residents age in place; (b) integrate clinical data and data from new technology; and (c) advance technology and clinical research.

User perceptions of in-home medication dispensing devices.

The purpose of this study was to characterize patient and clinician perceptions of programmable medication devices (dispensers and timers) being marketed to consumers to improve medication adherence. Using principles of usability testing, 33 volunteer staff and clinic patients rated seven devices. Raters scored devices on cueing and alarms, storage and dispensing, machine characteristics, potential to improve adherence, and cost. Medication dispensers ranked highest overall. However, even if the Department of Veterans Affairs paid for them, patient participants would be unlikely to use them. No significant differences were found across the devices in the perceived likelihood that the device would improve medication adherence. In this article, we provide a set of criteria for patients who might choose such a device and clinicians who may recommend these kinds of devices. More work is needed in the design and deployment of these devices if they are to be part of a successful medication adherence plan.

Nurse burnout and patient safety outcomes: nurse safety perception versus reporting behavior.

This article examines the relationship between nurse burnout and patient safety indicators, including both safety perceptions and reporting behavior. Based on the Conservation of Resources model of stress and burnout, it is predicted that burnout will negatively affect both patient safety perceptions and perceived likelihood of reporting events. Nurses from a Veteran's Administration hospital completed the Maslach Burnout Inventory and safety outcomes subset of measures from the Agency for Healthcare Research and Quality Patient Safety Culture measure. After controlling for work-related demographics, multiple regression analysis supported the prediction that burnout was associated with the perception of lower patient safety. Burnout was not associated with event-reporting behavior but was negatively associated with reporting of mistakes that did not lead to adverse events. The findings extend previous research on the relationship between burnout and patient outcomes and offer avenues for future research on how nurse motivation resources are invested in light of their stressful work environment.

Veterans' use of Department of Veterans Affairs care and perceptions of outsourcing inpatient care.

The objective of the study was to examine veterans' perceptions of problems and benefits of outsourcing inpatient care from Veterans Affairs (VA) hospitals to private sector hospitals. Primary data were collected from a cross-section of 42 veterans who were VA users and nonusers using focus groups. Focus group discussion examined reasons patients use VA care, differences between VA and civilian care, positive and negative impacts of outsourcing, and special needs of veterans. Analyses revealed five domains related both to use of VA services and perceptions of outsourcing: costs, access, quality of care, contract (i.e., a covenant between veterans and the U.S. government), veteran milieu, and special needs. Participants identified a variety of potential positive and negative impacts. In general, veterans perceived more advantages than disadvantages to outsourcing VA care but still expressed significant concerns related to outsourcing. These issues should be considered in the development of future policy toward outsourcing VA care to the private sector.

A 10-Rights framework for patient care quality and safety.

Recent reports in the lay and professional press document the failings of our patient care systems and have led to a multitude of suggestions for patient care quality and safety improvement initiatives. Given the complexity and range of services being offered, hospitals are launching numerous improvement initiatives in nearly all clinical care and support areas. This article describes a quality improvement framework, the "10 Rights," designed to help leaders better understand, organize, and prioritize patient care quality and safety issues and approaches. In addition to describing the framework, each Right is linked to 3 current national efforts at enhancing patient care quality and safety: the Joint Commission on Accreditation of Healthcare Organizations' National Patient Safety Goals, the National Quality Forum 30 Safe Practices, and the Centers for Medicare and Medicaid Services Hospital Quality Measures.