Use of comparative performance indicators in rehabilitation.

BACKGROUND: The development of performance indicators that enable benchmarking between organizations is an important mechanism for accountability, organizational learning, and performance improvement. In the province of Quebec (Canada), 21 rehabilitation organizations developed a common set of performance indicators through interorganizational collaboration. PURPOSE: The aims of this study were to describe the rehabilitation organizations' use of a common set of performance indicators and to identify the factors influencing such use. APPROACH: A qualitative survey was performed. Individual semistructured interviews were conducted with executives (n = 18) working at 16 rehabilitation organizations using a common set of performance indicators. A thematic analysis of the factors of use was performed according to the Consolidated Framework for Implementation Research. The use of performance indicators was categorized as purposeful, political, or passive. FINDINGS: Our results showed that all organizations used the common set of performance indicators. Four factors were identified as important to all the rehabilitation organizations to explain their interest in comparative performance indicators: the need to develop their own performance indicators, the compatibility of performance information with organizational needs, complexity/simplicity of performance information, and the support offered by their common association. Sixty-three percent of rehabilitation organizations made purposeful or political use of performance indicators. Three main factors contributed to typify those organizations from the others: the perceived quality of the performance indicators, the leadership of decision makers, and the resources available. PRACTICE IMPLICATIONS: Our results showed that use of performance indicators can support the initiation of projects for improving the quality of care. Key recommendations are proposed to decision makers that may enhance performance indicators' use.

A Time Trade-off-derived Value Set of the EQ-5D-5L for Canada.

BACKGROUND: The 5-level version of the EQ-5D (EQ-5D-5L) was recently developed. A number of preference-based scoring systems are being developed for several countries around the world. OBJECTIVE: To develop a value set for the EQ-5D-5L based on societal preferences in Canada. METHODS: We used age, sex, and education quota sampling from the general population from 4 cities across Canada. Composite time trade-off (cTTO) and traditional time trade-off (tTTO) were used as the main elicitation technique. A total of 86 EQ-5D-5L health states grouped into 10 blocks were valued using cTTO, whereas a subset of 18 severe states was also valued using tTTO. Participants meeting predefined inconsistency criteria were excluded from the analyses. For the value set development, we used tTTO and positive cTTO values, while censoring negative and zero cTTO values at zero. Models with the main effects presented using linear terms combined with various additional terms were estimated. The preferred model was selected based primarily on logically ordered coefficients, and secondly model fit. RESULTS: Of the 1209 participants who completed the interview, 136 met criteria that excluded them from the primary analyses. The demographics and socioeconomic status of the remaining 1073 participants were similar to the Canadian general population. The preferred model has 5 linear terms for the main effects, a term for level 4 or 5 for each dimension, and a term for the squared total number of level 4 or 5 beyond the first. For this preferred model, the health utilities ranged from -0.148 for the worst (55555) to 0.949 for the best (11111) EQ-5D-5L states. CONCLUSIONS: This is the first TTO-based value set of the EQ-5D-5L for Canada. It can be used to support the health utility estimation in economic evaluations for reimbursement decision making in Canada.

Determinants of time trade-off valuations for EQ-5D-5L health states: data from the Canadian EQ-5D-5L valuation study.

BACKGROUND: Previous studies suggest that population subgroups have different perceptions of health, as well as different preferences for hypothetical health states. OBJECTIVE: To identify determinants of health states preferences elicited using time trade-off (TTO) for the 5-level EQ-5D questionnaire (EQ-5D-5L) in Canada. METHODS: Data were from the Canadian EQ-5D-5L Valuation Study, which took place in Edmonton, Hamilton, Montreal, and Vancouver. Each respondent valued 10 of 86 hypothetical health states during an in-person interview using a computer-based TTO exercise. The TTO scores were the dependent variable and explanatory variables including age, sex, marital status, education, employment, annual household income, ethnicity, country of birth, dwelling, study site, health literacy, number of chronic conditions, previous experience with illness, and self-rated health. RESULTS: Average [standard deviation (SD)] age of respondents (N = 1209) was 48 (17) years, and 45 % were male. In multivariable linear regression models with random effects, adjusted for severity of health states and inconsistencies in valuations, older age [unstandardized regression coefficient (ß) = -0.077], male sex (ß = 0.042), being married (ß = 0.069), and urban dwelling (ß = -0.055) were significantly associated with health states scores. Additionally, participants from Edmonton (ß = -0.124) and Vancouver (ß = -0.156), but not those from Hamilton, had significantly lower TTO scores than those from Montreal. CONCLUSIONS: Socio-demographic characteristics were the main determinants of preferences for EQ-5D-5L health states in this study. Interestingly, preferences were significantly lower in western Canadian cities compared to eastern ones, bringing into question whether a single preference algorithm is suitable for use in all parts of Canada.

How different are composite and traditional TTO valuations of severe EQ-5D-5L states?

OBJECTIVE: Different variants of time trade-off (TTO) have been employed to elicit health state preferences and to create value sets for preference-based instruments. We compared composite TTO (cTTO) with traditional TTO (tTTO) in valuing severe EQ-5D-5L health states. METHODS: cTTO uses tTTO to elicit values for health states better than dead and the lead-time TTO for states worse than dead. Eighteen severe states were valued using both cTTO and tTTO. Participants meeting predefined inconsistency criteria were excluded from the analyses. Histograms were used to examine the distributions of cTTO and tTTO values. Mean difference between the cTTO and tTTO values was calculated. Bland-Altman plots were used to examine the agreement between the cTTO and tTTO values for each health state. We used a logistic mixed effects model with random intercepts to identify variables that were associated with the directional change between the two TTO values. RESULTS: A total of 1024 participants were included in the analysis with the mean age (SD) being 47.1 (17.4) years and 54.9 % female. For cTTO, 25 % of the values clustered at zero and there were few values between 0 and -0.5. In contrast, tTTO had fewer values at zero and more falling between -0.5 and 0. The distribution of positive values was similar between cTTO and tTTO. For worse than dead health states, the cTTO values tended to be higher than the tTTO values. In the logistic mixed effects model, those who did not agree that it was easy to understand the cTTO questions more likely changed from positive values in cTTO to zero or negative values in tTTO or change from zero cTTO values to negative values in tTTO compared with those who agreed (odds ratio 1.314, p = 0.037). CONCLUSION: cTTO is an appealing technique in eliciting health state preferences, but further evidence is needed for its performance in valuing EQ-5D health states on a wide spectrum of health state severity.

To What Extent Can the Use of a Mobility Assistance Dog Reduce Upper Limb Efforts When Manual Wheelchair Users Ascend a Ramp?

Biomechanical evidence is needed to determine to what extent the use of a mobility assistance dog (AD(Mob)) may minimize mechanical loads and muscular demands at the upper limbs among manual wheelchair users. This study quantified and compared upper limb efforts when propelling up a ramp with and without an AD(Mob) among manual wheelchair users. Ten manual wheelchair users with a spinal cord injury who own an AD(Mob) ascended a ramp with and without their AD(Mob). The movements of the wheelchair and upper limbs were captured and the forces applied at the pushrims were recorded to compute shoulder mechanical loading. Muscular demand of the pectoralis major, anterior deltoid, biceps, and the triceps was normalized against the maximum electromyographic values. The traction provided by the AD(Mob) significantly reduced the total force applied at the pushrim and its tangential component while the mechanical effectiveness remained similar. The traction provided by the AD(Mob) also resulted in a significant reduction in shoulder flexion, internal rotation, and adduction moments. The muscular demands of the anterior deltoid, pectoralis major, biceps, and triceps were significantly reduced by the traction provided by the AD(Mob). The use of AD(Mob) represents a promising mobility assistive technology alternative to minimize upper limb mechanical loads and muscular demands and optimize performance during wheelchair ramp ascent.

Expected Health Benefits as the Ultimate Outcome of Information Available on Stroke Engine, a Knowledge Translation Stroke Rehabilitation Website: Web-Based Survey.

BACKGROUND: Electronic knowledge resources are readily available and typically target different audiences, including health professionals and the public, that is, those with lived experience and their relatives. The knowledge-to-action framework, in combination with the information assessment method (IAM), considering both the value-of-information construct and the conceptual model of acquisition-cognition-application, can be used to support the evaluation process of such resources. As an example, Stroke Engine is an evidence-based knowledge translation resource in stroke rehabilitation (assessments and interventions) for health professionals and students as well as individuals who have sustained a stroke and their relatives. According to Google Analytics, the website is perused >10,000 times per week. OBJECTIVE: With the overall aim to improve the content available on Stroke Engine, we documented Stroke Engine users' perceptions of situational relevance, cognitive impact, intention to use, and expected patient and health benefits regarding the information consulted. METHODS: A web-based survey anchored in the IAM was made available via an invitation tab. The IAM is a validated questionnaire that is designed to assess the value of information. Sociodemographic characteristics were also collected, and a space for free-text comments was provided. Descriptive statistics were used, and thematic analysis was used for the free-text comments. RESULTS: The sample consisted of 6634 respondents. Health professionals (3663/6634, 55.22%) and students (2784/6634, 41.97%) represented 97.18% (6447/6634) of the total responses. The remaining 2.82% (187/6634) of the responses were from individuals who had sustained a stroke (87/6634, 1.31%) and their relatives (100/6634, 1.51%). Regarding situational relevance, assessments (including selecting, obtaining, and interpreting results from a test) was the main topic searched by health professionals (1838/3364, 54.64%) and students (1228/2437, 50.39%), whereas general information on stroke rehabilitation was the top-ranked topic for nearly two-thirds of the individuals with stroke (45/76, 59%) and their relatives (57/91, 63%). Cognitive impact was characterized by learning something new. Intention to use was high (4572/6379, 71.67%) among the respondents and varied in context (eg, refine a topic, research, class assignments, teaching, and education). Respondents commented on ways to improve content. Expected patient and health benefits such as improvement in health and well-being was the top-ranked category for all 4 subgroups, followed by the avoidance of unnecessary or inappropriate treatment for health professionals (183/623, 29.4%) and a feeling of being reassured for individuals with stroke (26/75, 35%) and their relatives (28/97, 29%). CONCLUSIONS: Valuable feedback on Stroke Engine was obtained in terms of its accessibility, relevance for informational needs and retrieval, accuracy, and applicability; however, of utmost importance is the potential implementation of its evidence-based content in clinical practice and the perceived expected impact on patients, their relatives, and their health professionals. The feedback received allowed for corrections and the identification of key topics for further development.

Clinicians' expectations of Web 2.0 as a mechanism for knowledge transfer of stroke best practices.

BACKGROUND: Health professionals are increasingly encouraged to adopt an evidence-based practice to ensure greater efficiency of their services. To promote this practice, several strategies exist: distribution of educational materials, local consensus processes, educational outreach visits, local opinion leaders, and reminders. Despite these strategies, gaps continue to be observed between practice and scientific evidence. Therefore, it is important to implement innovative knowledge transfer strategies that will change health professionals' practices. Through its interactive capacities, Web 2.0 applications are worth exploring. As an example, virtual communities of practice have already begun to influence professional practice. OBJECTIVE: This study was initially developed to help design a Web 2.0 platform for health professionals working with stroke patients. The aim was to gain a better understanding of professionals' perceptions of Web 2.0 before the development of the platform. METHODS: A qualitative study following a phenomenological approach was chosen. We conducted individual semi-structured interviews with clinicians and managers. Interview transcripts were subjected to a content analysis. RESULTS: Twenty-four female clinicians and managers in Quebec, Canada, aged 28-66 participated. Most participants identified knowledge transfer as the most useful outcome of a Web 2.0 platform. Respondents also expressed their need for a user-friendly platform. Accessibility to a computer and the Internet, features of the Web 2.0 platform, user support, technology skills, and previous technological experience were found to influence perceived ease of use and usefulness. Our results show that the perceived lack of time of health professionals has an influence on perceived behavioral intention to use it despite favorable perception of the usefulness of the Web 2.0 platform. CONCLUSIONS: In conclusion, female health professionals in Quebec believe that Web 2.0 may be a useful mechanism for knowledge transfer. However, lack of time and lack of technological skills may limit their use of a future Web 2.0 platform. Further studies are required with other populations and in other regions to confirm these findings.

Assessing the accuracy of an inter-institutional automated patient-specific health problem list.

BACKGROUND: Health problem lists are a key component of electronic health records and are instrumental in the development of decision-support systems that encourage best practices and optimal patient safety. Most health problem lists require initial clinical information to be entered manually and few integrate information across care providers and institutions. This study assesses the accuracy of a novel approach to create an inter-institutional automated health problem list in a computerized medical record (MOXXI) that integrates three sources of information for an individual patient: diagnostic codes from medical services claims from all treating physicians, therapeutic indications from electronic prescriptions, and single-indication drugs. METHODS: Data for this study were obtained from 121 general practitioners and all medical services provided for 22,248 of their patients. At the opening of a patient's file, all health problems detected through medical service utilization or single-indication drug use were flagged to the physician in the MOXXI system. Each new arising health problem were presented as 'potential' and physicians were prompted to specify if the health problem was valid (Y) or not (N) or if they preferred to reassess its validity at a later time. RESULTS: A total of 263,527 health problems, representing 891 unique problems, were identified for the group of 22,248 patients. Medical services claims contributed to the majority of problems identified (77%), followed by therapeutic indications from electronic prescriptions (14%), and single-indication drugs (9%). Physicians actively chose to assess 41.7% (n = 106,950) of health problems. Overall, 73% of the problems assessed were considered valid; 42% originated from medical service diagnostic codes, 11% from single indication drugs, and 47% from prescription indications. Twelve percent of problems identified through other treating physicians were considered valid compared to 28% identified through study physician claims. CONCLUSION: Automation of an inter-institutional problem list added over half of all validated problems to the health problem list of which 12% were generated by conditions treated by other physicians. Automating the integration of existing information sources provides timely access to accurate and relevant health problem information. It may also accelerate the uptake and use of electronic medical record systems.

Advancing the chronic care road map: a contemporary overview.

In an effort to assess and advance the community-based model of chronic care, we reviewed a contemporary spectrum of Canadian chronic disease management and prevention (CDMP) programs with a participatory audience of administrators, academics, professional and non-professional providers and patients. While many questions remain unanswered, several common characteristics of CDMP success were apparent. These included community-based partnerships with aligned goals; inter-professional and non-professional care, including patient self-management; measured and shared information on practices and outcomes; and visible leadership. Principal improvement opportunities identified were the enhanced engagement of all stakeholders; further efficacy evidence for team care; facile information systems, with clear rationales for data selection, access, communication and security; and increased education of, and resource support for, patients and caregivers. Two immediate actions were suggested. One was a broad and continuing communication plan highlighting CDMP issues and opportunities. The other was a standardized survey of team structures, interventions, measurements and communications in ongoing CDMP programs, with a causal analysis of their relation to outcomes. In the longer term, the key needs requiring action were more inter-professional education of health human resources and more practical information systems available to all stakeholders. Things can be better.

Portrait of driving practice following a mild stroke: a secondary analysis of a chart audit.

Background: The majority of individuals who have had a mild stroke are discharged home from acute care. Yet, the proportion who are assessed for driving ability and given related recommendations is unknown.Objective: To describe acute care practice related to driving among individuals whose discharge location is home.Methods: A secondary analysis of data from a chart audit was realized in the Province of Quebec, Canada. Data were retrieved from the charts by trained extractors. Evaluation practice was described according to whether the driving assessment was specific or nonspecific to driving (cognitive, perceptual and visual functions). Descriptive statistics were used.Results: The sample consisted of 419 charts of individuals with a mean age of 70.5 ± 13.3 years old. Mean length of hospital stay was 10.3 ± 13.3 days. Specific driving assessment was documented among 26/419 (6.2%) charts while for seven of these, the assessment was considered full. Meanwhile, 92/419 (22.0%) were considered as problematic for driving a vehicle. Nonspecific driving assessment was documented among 70/419 (16.7%), 43/419 (10.3%) and 33/419 (7.9%) of charts for cognitive, perceptual and visual functions, respectively. Charts were characterized by several missing data relating to driving.Conclusion: The proportion of charts documenting driving restriction post-stroke in acute care was very low. Assuming that all driving discussions and referrals were captured in the charts (which may not be the case), our results would indicate an important gap in acute care practice as compared to best practices relating to driving post-stroke.

Connecting with clinicians: opportunities to strengthen rehabilitation research.

PURPOSE: This article examines the distinctive opportunities and challenges involved in connecting with clinicians to strengthen rehabilitation research. METHOD: The relevant literature on various factors that link researchers and clinicians is summarized and discussed. RESULTS: Links between researchers and clinicians are demonstrated by evidence-based practice, common conceptual background and the development of research capacity. Sustainable partnerships can evolve throughout the research process by using various enduring strategies such as experts' committee as well as novel approaches like communities of practice. CONCLUSION: This paper reflects the conviction that reducing the gap between research and clinical practice will be facilitated by implementing partnerships originating from both researchers and clinicians.

Feasibility, Safety and Efficacy of a Virtual Reality Exergame System to Supplement Upper Extremity Rehabilitation Post-Stroke: A Pilot Randomized Clinical Trial and Proof of Principle.

(1) Background: Increasing the amount of therapy time has been shown to improve motor function in stroke survivors. However, it is often not possible to increase the amount of therapy time provided in the current one-on-one therapy models. Rehabilitation-based virtual reality exergame systems, such as Jintronix, can be offered to stroke survivors as an adjunct to traditional therapy. The goal of this study was to examine the safety and feasibility of providing additional therapy using an exergame system and assess its preliminary clinical efficacy. (2) Methods: Stroke survivors receiving outpatient rehabilitation services participated in this pilot randomized control trial in which the intervention group received 4 weeks of exergaming sessions in addition to traditional therapy sessions. (3) Results: Nine subjects in the intervention and nine subjects in the control group completed the study. The intervention group had at least two extra sessions per week, with an average duration of 44 min per session and no serious adverse events (falls, dizziness, or pain). The efficacy measures showed statistically meaningful improvements in the activities of daily living measures (i.e., MAL-QOM (motor activity log-quality of movement) and both mobility and physical domains of the SIS (stroke impact scale) with mean difference of 1.0%, 5.5%, and 6.7% between the intervention and control group, respectively) at post-intervention. (4) Conclusion: Using virtual reality exergaming technology as an adjunct to traditional therapy is feasible and safe in post-stroke rehabilitation and may be beneficial to upper extremity functional recovery.

A randomized trial of the effectiveness of on-demand versus computer-triggered drug decision support in primary care.

OBJECTIVES: Prescribing alerts generated by computerized drug decision support (CDDS) may prevent drug-related morbidity. However, the vast majority of alerts are ignored because of clinical irrelevance. The ability to customize commercial alert systems should improve physician acceptance because the physician can select the circumstances and types of drug alerts that are viewed. We tested the effectiveness of two approaches to medication alert customization to reduce prevalence of prescribing problems: on-physician-demand versus computer-triggered decision support. Physicians in each study condition were able to preset levels that triggered alerts. DESIGN: This was a cluster trial with 28 primary care physicians randomized to either automated or on-demand CDDS in the MOXXI drug management system for 3,449 of their patients seen over the next 6 months. MEASUREMENTS: The CDDS generated alerts for prescribing problems that could be customized by severity level. Prescribing problems included dosing errors, drug-drug, age, allergy, and disease interactions. Physicians randomized to on-demand activated the drug review when they considered it clinically relevant, whereas physicians randomized to computer-triggered decision support viewed all alerts for electronic prescriptions in accordance with the severity level they selected for both prevalent and incident problems. Data from administrative claims and MOXXI were used to measure the difference in the prevalence of prescribing problems at the end of follow-up. RESULTS: During follow-up, 50% of the physicians receiving computer-triggered alerts modified the alert threshold (n = 7), and 21% of the physicians in the alert-on-demand group modified the alert level (n = 3). In the on-demand group 4,445 prescribing problems were identified, 41 (0.9%) were seen by requested drug review, and in 31 problems (75.6%) the prescription was revised. In comparison, 668 (10.3%) of the 6,505 prescribing problems in the computer-triggered group were seen, and 81 (12.1%) were revised. The majority of alerts were ignored because the benefit was judged greater than the risk, the interaction was known, or the interaction was considered clinically not important (computer-triggered: 75.8% of 585 ignored alerts; on-demand: 90% of 10 ignored alerts). At the end of follow-up, there was a significant reduction in therapeutic duplication problems in the computer-triggered group (odds ratio 0.55; p = 0.02) but no difference in the overall prevalence of prescribing problems. CONCLUSION: Customization of computer-triggered alert systems is more useful in detecting and resolving prescribing problems than on-demand review, but neither approach was effective in reducing prescribing problems. New strategies are needed to maximize the use of drug decision support systems to reduce drug-related morbidity.

Using eHealth Technologies: Interests, Preferences, and Concerns of Older Adults.

BACKGROUND: The Internet and eHealth technologies represent new opportunities for managing health. Age, sex, socioeconomic status, and current technology use are some of the known factors that influence individuals' uptake of eHealth; however, relatively little is known about facilitators and barriers to eHealth uptake specific to older adults, particularly as they relate to their experiences in accessing health care. OBJECTIVE: The aim of our study was to explore the interests, preferences, and concerns of older adults in using the Internet and eHealth technologies for managing their health in relation to their experiences with the current health care system. METHODS: Two focus groups (n=15) were conducted with adults aged 50+ years. Pragmatic thematic analysis using an inductive approach was conducted to identify the interests, preferences, and concerns of using the Internet and eHealth technologies. RESULTS: Five themes emerged that include (1) Difficulty in identifying credible and relevant sources of information on the Web; (2) Ownership, access, and responsibility for medical information; (3) Peer communication and support; (4) Opportunities to enhance health care interactions; and (5) Privacy concerns. These findings support the potential value older adults perceive in eHealth technologies, particularly in their ability to provide access to personal health information and facilitate communication between providers and peers living with similar conditions. However, in order to foster acceptance, these technologies will need to provide personal and general health information that is secure, readily accessible, and easily understood. CONCLUSIONS: Older adults have diverse needs and preferences that, in part, are driven by their experiences and frustrations with the health care system. Results can help inform the design and implementation of technologies to address gaps in care and access to health information for older adults with chronic conditions who may benefit the most from this approach.

Informing the development of an Internet-based chronic pain self-management program.

BACKGROUND: Self-management can optimize health outcomes for individuals with chronic pain (CP), an increasing fiscal and social burden in Canada. However, self-management is rarely integrated into the regular care (team activities and medical treatment) patients receive. Health information technology offers an opportunity to provide regular monitoring and exchange of information between patient and care team. OBJECTIVE: To identify information needs and gaps in chronic pain management as well as technology features to inform the development of an Internet-based self-management program. METHODS: Two methods were used. First was a structured literature review: electronic databases were searched up to 2015 with combinations of MeSH terms and text-words such as chronic pain, self-management, self-efficacy, technology, Internet-based, patient portal, and e-health. A narrative synthesis of the characteristics and content of Internet-based pain management programs emerging from the literature review and how they relate to gaps in chronic pain management were completed. Second, four audiotaped focus group sessions were conducted with individuals with chronic pain and caregivers (n=9) and health professionals (n=7) recruited from three multidisciplinary tertiary and rehabilitation centres. A thematic analysis of the focus group transcripts was conducted. RESULTS: Thirty-nine primary articles related to 20 patient-oriented Internet-based programs were selected. Gaps in CP management included lack of knowledge, limited access to health care, suboptimal care, and lack of self-management support. Overall, 14 themes related to information needs and gaps in care were identified by both health professionals and patients, three were exclusive to patients and five to health professionals. Common themes from the focus groups included patient education on chronic pain care, attitude-belief-culture, financial and legal issues, end-of-program crash, and motivational content. CONCLUSIONS: Internet-based programs contain automated, communication and decision support features that can address information and care gaps reported by patients and clinicians. However, focus groups identified functionalities not reported in the literature, non-medical and condition- and context-specific information, integration of personal health records, and the role of the different health professionals in chronic pain management were not identified. These gaps need to be considered in the future development of Internet-based programs. While the association between the mechanisms of Internet-based programs' features and outcomes is not clearly established, the results of this study indicate that interactivity, personalization and tailored messages, combined with therapist contact will maximize the effectiveness of an Internet-based chronic pain program in enhancing self-management.

The development and evaluation of an integrated electronic prescribing and drug management system for primary care.

OBJECTIVE: To develop and evaluate the acceptability and use of an integrated electronic prescribing and drug management system (MOXXI) for primary care physicians. DESIGN: A 20-month follow-up study of MOXXI (Medical Office of the XXIst Century) implementation in 28 primary care physicians and 13,515 consenting patients. MEASUREMENT: MOXXI was developed to enhance patient safety by integrating patient demographics, retrieving active drugs from pharmacy systems, generating an automated problem list, and providing electronic prescription, stop order, automated prescribing problem alerts, and compliance monitoring functions. Evaluation of technical performance, acceptability, and use was conducted using audit trails, questionnaires, standardized tasks, and information from comprehensive health insurance databases. RESULTS: Perceived improvements in continuity of care and professional autonomy were associated with physicians' expected use of MOXXI. Physician speed in using MOXXI improved substantially in the first three months; however, only the represcribing function was faster using MOXXI than by handwritten prescription. Physicians wrote electronic prescriptions in 36.9 per 100 visits and reviewed the patient's drug profile in 12.6 per 100 visits. Physicians rated printed prescriptions, the current drug list, and the represcribing function as the most beneficial aspects of the system. Physicians were more likely to use the drug profile for patients who used more medication, made more emergency department visits, had more prescribing physicians, and lower continuity of care. CONCLUSION: Primary care physicians believed an integrated electronic prescribing and drug management system would improve continuity of care, and they were more likely to use the system for patients with more complex, fragmented care.

Long-term caregiving after stroke: the impact on caregivers' quality of life.

This study examined the health-related quality of life (HRQL) and overall quality of life (QOL) of family caregivers of stroke survivors to determine changes over time and to identify QOL predictors. Caregivers were interviewed after 1.5 and 2 years of caregiving. The scores on the mental subscales were significantly lower than on the age- and sex-matched population norms. The most important predictors of QOL were the stroke survivor's behavioral disturbances and reintegration into normal patterns of living. Caregivers who reported fewer stroke-survivor behavioral disturbances and well-adjusted reintegration also reported a higher personal QOL. These results highlight the impact of a stroke on the caregiver's HRQL and QOL, even after 2 years, and the importance of interventions for caregivers.

Maximizing post-stroke upper limb rehabilitation using a novel telerehabilitation interactive virtual reality system in the patient's home: study protocol of a randomized clinical trial.

BACKGROUND: Telerehabilitation (TR), or the provision of rehabilitation services from a distance using telecommunication tools such as the Internet, can contribute to ensure that patients receive the best care at the right time. This study aims to assess the effect of an interactive virtual reality (VR) system that allows ongoing rehabilitation of the upper extremity (UE) following a stroke, while the person is in their own home, with offline monitoring and feedback from a therapist at a distance. METHODS/DESIGN: A single-blind (evaluator is blind to group assignment) two-arm randomized controlled trial is proposed, with participants who have had a stroke and are no longer receiving rehabilitation services randomly allocated to: (1) 4-week written home exercise program, i.e. usual care discharge home program or (2) a 4-week home-based TR exercise program using VR in addition to usual care i.e. treatment group. Motor recovery of the UE will be assessed using the Fugl-Meyer Assessment-UE and the Box and Block tests. To determine the efficacy of the system in terms of functional recovery, the Motor Activity Log, a self-reported measure of UE use will be used. Impact on quality of life will be determined using the Stroke Impact Scale-16. Lastly, a preliminary cost-effectiveness analysis will be conducted using costs and outcomes for all groups. DISCUSSION: Findings will contribute to evidence regarding the use of TR and VR to provide stroke rehabilitation services from a distance. This approach can enhance continuity of care once patients are discharged from rehabilitation, in order to maximize their recovery beyond the current available services.

The impact of electronic health records on time efficiency of physicians and nurses: a systematic review.

A systematic review of the literature was performed to examine the impact of electronic health records (EHRs) on documentation time of physicians and nurses and to identify factors that may explain efficiency differences across studies. In total, 23 papers met our inclusion criteria; five were randomized controlled trials, six were posttest control studies, and 12 were one-group pretest-posttest designs. Most studies (58%) collected data using a time and motion methodology in comparison to work sampling (33%) and self-report/survey methods (8%). A weighted average approach was used to combine results from the studies. The use of bedside terminals and central station desktops saved nurses, respectively, 24.5% and 23.5% of their overall time spent documenting during a shift. Using bedside or point-of-care systems increased documentation time of physicians by 17.5%. In comparison, the use of central station desktops for computerized provider order entry (CPOE) was found to be inefficient, increasing the work time from 98.1% to 328.6% of physician's time per working shift (weighted average of CPOE-oriented studies, 238.4%). Studies that conducted their evaluation process relatively soon after implementation of the EHR tended to demonstrate a reduction in documentation time in comparison to the increases observed with those that had a longer time period between implementation and the evaluation process. This review highlighted that a goal of decreased documentation time in an EHR project is not likely to be realized. It also identified how the selection of bedside or central station desktop EHRs may influence documentation time for the two main user groups, physicians and nurses.

Service Dogs for People with Spinal Cord Injury: Outcomes Regarding Functional Mobility and Important Occupations.

No research using standardized tests based on direct observations along with longitudinal studies have shown the effects of service dogs on persons with mobility impairment. Our research objectives were to document the consequences of the use of the service dog on wheelchair propelling, grasping objects, shoulder pain, occupational performance, reintegration into normal living and psychosocial impacts for people with spinal cord injury (SCI). A cross sectional study was conducted with 45 males and 21 females with SCI (average age = 41.2). They were assessed in their homes and their communities, two to five years after they received their service dogs. Observations were based on four testing methods. An ongoing longitudinal study is reported, based on 9 months (n = 8 to 16) of data from four standardised questionnaires. Results demonstrate that services dogs are an efficient assistive technology for persons with SCI.