The computerisation of community pharmacy

Computers have, over the past 10 to 15 years, become an integral part of many activities carried out by British community pharmacists. This thesis employs quantitative and qualitative research methods to explore the use of computers and other forms of information technology (IT) in a number of these activities. Mail questionnaires were used to estimate the level of IT use among British community pharmacists in 1989 and 1990. Comparison of the results suggests that the percentage of community pharmacists using computers and other forms of IT is increasing, and that the range of applications to which pharmacy computers are put is expanding. The use of an electronic, on-line information service, PINS, by community pharmacists was investigated using mail questionnaires. The majority of community pharmacists who subscribed to the service, and who responded to the questionnaire, claimed to use PINS less than they had expected to. In addition, most did not find it user-friendly. A computer program to aid pharmacists when responding to their patients' symptoms was investigated using interviews and direct observation. The aid was not found to help pharmacists in responding to patients' symptoms because of impracticalities involved in its operation. Use of the same computer program by members of the public without the involvement of a pharmacist was also studied. In this setting, the program was favourably accepted by the majority of those who used it. Provision of computer generated information leaflets from pharmacies was investigated using mail questionnaires and interviews. The leaflets were found to be popular with the majority of recipients interviewed. Since starting to give out the leaflets, 27 out of 55 pharmacists who responded to the questionnaire had experienced an increase in the numbers of prescriptions they dispensed. 46 had experienced an increase in the number of patient enquiries they received.

The influence of patient and doctor gender on diagnosing coronary heart disease

Using novel methods, this paper explores sources of uncertainty and gender bias in primary care doctors' diagnostic decision-making about coronary heart disease (CHD). Claims about gendered consultation styles and quality of care are re-examined, along with the adequacy of CHD models for women. Randomly selected doctors in the UK and the US (n=112, 56 per country, stratified by gender) were shown standardised videotaped vignettes of actors portraying patients with CHD. Patients' age, gender, ethnicity and social class were varied systematically. During interviews, doctors gave free-recall accounts of their decision-making, which were analysed to determine patient and doctor gender effects. We found differences in male and female doctors' responses to different types of patient information. Female doctors recall more patient cues overall, particularly about history presentation, and particularly amongst women. Male doctors appear less affected by patient gender but both male and especially female doctors take more account of male patients' age, and consider more age-related disease possibilities for men than women. Findings highlight the need for better integration of knowledge about female presentations within accepted CHD risk models, and do not support the contention that women receive better-quality care from female doctors.

Mobile case-based decision support for intelligent patient knowledge management

Hospitals everywhere are integrating health data using electronic health record (EHR) systems, and disparate and multimedia patient data can be input by different caregivers at different locations as encapsulated patient profiles. Healthcare institutions are also using the flexibility and speed of wireless computing to improve quality and reduce costs. We are developing a mobile application that allows doctors to efficiently record and access complete and accurate real-time patient information. The system integrates medical imagery with textual patient profiles as well as expert interactions by healthcare personnel using knowledge management and case-based reasoning techniques. The application can assist other caregivers in searching large repositories of previous patient cases. Patients' symptoms can be input to a portable device and the application can quickly retrieve similar profiles which can be used to support effective diagnoses and prognoses by comparing symptoms, treatments, diagnosis, test results and other patient information. © 2007 Sage Publications.

A patient's perspective:the impact of adverse drug reactions on patients and their views on reporting

What is known and objective: Adverse drug reactions to prescribed medication are relatively common events. However, the impact such reactions have on patients and their attitude to reporting such events have only been poorly explored. Previous studies relying on self-reporting patients indicate that altruism is an important factor. In the United Kingdom, patient reporting started in 2005; though, numbers of serious reports remain low. Method: A purposive sample of fifteen patients who had been admitted to an inner city hospital with an adverse drug reaction were interviewed using a semi-structured questionnaire. Patients were asked to relate in their own words their experience of an adverse drug reaction. Patient's reactions to the information leaflet, adherence to treatment and use of other sources of information on medication were assessed. Interviews were recorded, and a thematic analysis of patients'responses was performed. Results and discussion: Analysis of the patient interviews demonstrated the reality of being admitted to hospital is often a frightening process with a significant emotional cost. Anger, isolation, resentment and blame were common factors, particularly when medicines had been prescribed for acute conditions. For patients with chronic conditions, a more phlegmatic approach was seen especially with conditions with a strong support networks. Patients felt that communication and information should have been more readily available from the health care professional who prescribed the medication, although few had read the patient information leaflet. Only a minority of patients linked the medication they had taken to the adverse event, although some had received false reassurance that the drug was not related to their illness creating additional barriers. In contrast to previous studies, many patients felt that adverse drug reporting was not their concern, particularly as they obtained little direct benefit from it. The majority of patients were unaware of the Yellow Card Scheme in the UK for patient reporting. Even when explained, the scheme was felt too cold and impersonal and not a patient's 'job'. What is new and conclusion: Patients having a severe adverse drug reaction following an acute illness felt negative emotions towards their health care provider. Those with a chronic condition rationalized the event and coped better with its impact. Neither group felt that reporting the adverse reaction was their responsibility. Encouraging patients to report remains important but expecting patients to report solely for altruistic purposes may be unrealistic. © 2011 Blackwell Publishing Ltd.

"Making it all normal": the role of the Internet in problematic pregnancy

Women are actively encouraged to educate themselves about pregnancy from formal sources (e.g., information leaflets, antenatal classes, books). In addition, informal stories of pregnancy and birth are routinely told between women. However, increased prenatal testing means that more fetuses are diagnosed with abnormalities, shifting the information requirements during pregnancy. Traditional sources of information cannot cover all possible outcomes, and the Internet is beginning to fill this gap. In this article, we draw from interviews about experiences of antenatal screening and pregnancy to explore how the Internet provides a unique resource for problematic pregnancies. It allows access to information about rarer conditions beyond standard pregnancy texts, as well as personal narratives about conditions. Learning how others have coped or are coping in similar situations can help alleviate feelings of isolation, and also places women back in a familiar territory of shared pregnancy narratives.

Exploiting sensitivity of nonorthogonal joint diagonalisation as a security mechanism in steganography

We have recently proposed the framework of independent blind source separation as an advantageous approach to steganography. Amongst the several characteristics noted was a sensitivity to message reconstruction due to small perturbations in the sources. This characteristic is not common in most other approaches to steganography. In this paper we discuss how this sensitivity relates the joint diagonalisation inside the independent component approach, and reliance on exact knowledge of secret information, and how it can be used as an additional and inherent security mechanism against malicious attack to discovery of the hidden messages. The paper therefore provides an enhanced mechanism that can be used for e-document forensic analysis and can be applied to different dimensionality digital data media. In this paper we use a low dimensional example of biomedical time series as might occur in the electronic patient health record, where protection of the private patient information is paramount.

Watermarking biomedical time series data

This thesis addresses the problem of information hiding in low dimensional digital data focussing on issues of privacy and security in Electronic Patient Health Records (EPHRs). The thesis proposes a new security protocol based on data hiding techniques for EPHRs. This thesis contends that embedding of sensitive patient information inside the EPHR is the most appropriate solution currently available to resolve the issues of security in EPHRs. Watermarking techniques are applied to one-dimensional time series data such as the electroencephalogram (EEG) to show that they add a level of confidence (in terms of privacy and security) in an individual’s diverse bio-profile (the digital fingerprint of an individual’s medical history), ensure belief that the data being analysed does indeed belong to the correct person, and also that it is not being accessed by unauthorised personnel. Embedding information inside single channel biomedical time series data is more difficult than the standard application for images due to the reduced redundancy. A data hiding approach which has an in built capability to protect against illegal data snooping is developed. The capability of this secure method is enhanced by embedding not just a single message but multiple messages into an example one-dimensional EEG signal. Embedding multiple messages of similar characteristics, for example identities of clinicians accessing the medical record helps in creating a log of access while embedding multiple messages of dissimilar characteristics into an EPHR enhances confidence in the use of the EPHR. The novel method of embedding multiple messages of both similar and dissimilar characteristics into a single channel EEG demonstrated in this thesis shows how this embedding of data boosts the implementation and use of the EPHR securely.

Patient education in the treatment of asthma:a controlled evaluation of providing information for "new" asthmatics

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Patient/carers' recollection of medicines related information from an out-patient clinic appointment

AIM: To identify what medicines related information children/young people or their parents/carers are able to recall following an out-patient clinic appointment. METHOD: A convenience sample of patients' prescribed at least one new long-term (>6 weeks) medicine were recruited from a single UK paediatric hospital out-patient pharmacy. A face-to-face semi-structured questionnaire was administered to participants when they presented with their prescription. The questionnaire included the following themes: names of the medicines, therapeutic indication, dose regimen, duration of treatment and adverse effects.The results were analysed using Microsoft Excel 2013. RESULTS: One hundred participants consented and were included in the study. One hundred and forty-five medicines were prescribed in total. Participants were able to recall the names of 96 (66%) medicines and were aware of the therapeutic indication for 142 (97.9%) medicines. The dose regimen was accurately described for 120 (82.8%) medicines with the duration of treatment known for 132 (91%). Participants mentioned that they had been advised about side effects for 44 (30.3%) medicines. Specific counselling points recommended by the BNFc1, were either omitted or not recalled by participants for the following systemic treatments: cetirizine (1), chlorphenamine (1), desmopressin (2), hydroxyzine (2), itraconazole (1), piroxicam (2), methotrexate (1), stiripentol (1) and topiramate (1). CONCLUSION: Following an out-patient consultation, where a new medicine is prescribed, children and their parents/carers are usually able to recall the indication, dose regimen and duration of treatment. Few were able to recall, or were told about, possible adverse effects. This may include some important drug specific effects that require vigilance during treatment.Patients, along with families and carers, should be involved in the decision to prescribe a medicine.2 This includes a discussion about the benefits of the medicine on the patient's condition and possible adverse effects.2 Treatment side effects have been shown to be a factor in treatment non-adherence in paediatric long-term medical conditions.3 Practitioners should explain to patients, and their family members or carers where appropriate, how to identify and report medicines-related patient safety incidents.4 However, this study suggests that medical staff may not be comfortable discussing the adverse effects of medicines with patients or their parents/carers.Further research in to the shared decision making process in the paediatric out-patient clinic when a new long-term medicine is prescribed is required to further support medicines adherence and the patient safety agenda.

The link between the management of employees and patient mortality in acute hospitals

The relationship between human resource management practices and organizational performance (including quality of care in health-care organizations) is an important topic in the organizational sciences but little research has been conducted examining this relationship in hospital settings. Human resource (HR) directors from sixty-one acute hospitals in England (Hospital Trusts) completed questionnaires or interviews exploring HR practices and procedures. The interviews probed for information about the extensiveness and sophistication of appraisal for employees, the extent and sophistication of training for employees and the percentage of staff working in teams. Data on patient mortality were also gathered. The findings revealed strong associations between HR practices and patient mortality generally. The extent and sophistication of appraisal in the hospitals was particularly strongly related, but there were links too with the sophistication of training for staff, and also with the percentages of staff working in teams.

Issues of cause and control in patient accounts of Type 2 diabetes

Patients experience considerable difficulties in making and sustaining health-related lifestyle changes. Many Type 2 diabetes patients struggle to follow disease risk-management advice even when they receive extensive information and support. Drawing on a qualitative study of patients with Type 2 diabetes, the paper uses discourse analysis to examine their accounts about disease causation and disease management, and the implications for how they respond to their condition and health services advice. As it is a multifactorial disease, biomedical discourse around Type 2 diabetes is complex. Patients are encouraged to grasp the complicated message that both cause and medical outcomes related to their condition are partly, but not wholly, within their control. Discursive constructions identified from respondent accounts indicate how these two messages are deployed variously by respondents when accounting for disease causation and management. While these constructions (identified in respondent accounts as 'Up to me' and 'Down to them') are a valuable resource for patients, equally they may be deployed in a selective and detrimental way. We conclude that clear messages from health professionals about effective disease management may help patients to position themselves more effectively in relation to their condition. More importantly, they might serve to hinder the availability of inappropriate and potentially harmful patient positions where patients either relinquish responsibility for disease management or reject all input from health professionals. © The Author 2005. Published by Oxford University Press. All rights reserved.

Diagnosis of type 2 diabetes:A qualitative analysis of patients' emotional reactions and views about information provision

Research about diagnosis of chronic illness indicates this is an emotional time for patients. Information provision is especially salient for diabetes management. Yet current orthodoxy suggests that too much information at the time of diagnosis is unhelpful for patients. In this study, we used in-depth interviews with 40 newly diagnosed type 2 diabetic (T2DM) patients in Scotland, to explore their emotional reactions about diagnosis, and their views about information provision at the time of diagnosis. Data were analysed using a thematic approach. Our results showed three main 'routes' to diagnosis: 'suspected diabetes' route; 'illness' route; and 'routine' route. Those within the 'routine' route described the most varied emotional reactions to their diagnosis. We found that most patients, irrespective of their route to diagnosis, wanted more information about diabetes management at the time of diagnosis. We suggest that practitioners would benefit from being sensitive to the route patients follow to diagnosis, and prompt, simple but detailed advice about T2DM management would be helpful for newly diagnosed patients. © 2004 Elsevier Ireland Ltd. All rights reserved.

eHealth as a challenge to `expert' power: a focus group study of internet use for health information and management

Objective To investigate current use of the internet and eHealth amongst adults. Design Focus groups were conducted to explore participants' attitudes to and reasons for health internet use. Main outcome measures The focus group data were analysed and interpreted using thematic analysis. Results Three superordinate themes exploring eHealth behaviours were identified: decline in expert authority, pervasiveness of health information on the internet and empowerment. Results showed participants enjoyed the immediate benefits of eHealth information and felt empowered by increased knowledge, but they would be reluctant to lose face-to-face consultations with their GP. Conclusions Our findings illustrate changes in patient identity and a decline in expert authority with ramifications for the practitioner–patient relationship and subsequent implications for health management more generally.

Face context interferes with local part processing in a prosopagnosic patient

We investigated the role of local and global information on perceptual encoding of faces in patient HJA, who shows prosopagnosia and visual agnosia following occipito-temporal damage. HJA and an age-matched control were tested in a simultaneous matching task which focused on detection of local changes in faces: the inversion of central parts (eyes and mouth) relative to their context (as in the Thatcher illusion). Same-different judgements were made to normal, “thatcherised” and mixed type face pairs. Whole faces (Experiment 1), or face parts (Experiment 2), were presented in upright and inverted orientations. Compared to the control, HJA was severely impaired at matching whole faces, but he improved dramatically when face parts were presented in isolation. This suggests an inhibitory influence of face context on HJAs processing of local parts and a relatively intact ability to process part-based information from a face (when context cannot interfere). Face inversion did not affect HJAs performance. A control experiment (Experiment 3) with non-face stimuli (houses) suggested that the inhibitory influence of context on HJAs performance was restricted to faces. These results indicate that contextual information in a face can have an adverse influence on the processing of local part-based information in prosopagnosia.

Drug information in general practice pharmacy

The drug information sources currently available to general practice pharmacists have been identified. The use of and attitudes to these sources were assessed as well as the perceived information needs of practising pharmacists. The special requirements of women pharmacists and pharmacists working part-time were studied. The relationship of the medical representative as an information source for pharmacists was evaluated. Participation in continuing education programmes as a vital means of ensuring current information awareness and knowledge for the practising profession has been considered. Investigations were mainly pursued by questionnaire survey, while computer facilities were used for the processing and the analyses of data. The desirability of collated and evaluated information from one or more independent authoritative sources has been discussed. The increasing advisory role of the general practice pharmacist and the needs of the patient and potential customer have been discussed, with projections for the pharmacist's future health care contribution.