Global practice experience: A useful lens for understanding patient and staff perceptions of successful integration of health information technology in primary care

Making healthcare comprehensive and more efficient remains a complex challenge. Health Information Technology (HIT) is recognized as an important component of this transformation but few studies describe HIT adoption and it's effect on the bedside experience by physicians, staff and patients. This study applied descriptive statistics and correlation analysis to data from the Patient-Centered Medical Home National Demonstration Project (NDP) of the American Academy of Family Physicians. Thirty-six clinics were followed for 26 months by clinician/staff questionnaires and patient surveys. This study characterizes those clinics as well as staff and patient perspectives on HIT usefulness, the doctor-patient relationship, electronic medical record (EMR) implementation, and computer connections in the practice throughout the study. The Global Practice Experience factor, a composite score related to key components of primary care, was then correlated to clinician and patient perspectives. This study found wide adoption of HIT among NDP practices. Patient perspectives on HIT helpfulness on the doctor-patient showed a suggestive trend that approached statistical significance (p = 0.172). Clinicians and staff noted successful integration of EMR into clinic workflow and their perception of helpfulness to the doctor-patient relationship show a suggestive increase also approaching statistical significance (p=0.06). GPE was correlated with clinician/staff assessment of a helpful doctor-patient relationship midway through the study (R 0.460, p = 0.021) with the remaining time points nearing statistical significance. GPE was also correlated to both patient perspectives of EMR helpfulness in the doctor-patient relationship (R 0.601, p = 0.001) and computer connections (R 0.618, p = 0.0001) at the start of the study. ^

Chemotherapy patient perception regarding communication with the healthcare staff

Purpose: To qualitatively explore the communication between healthcare professionals and oncology patients based on the perception of patients undergoing chemotherapy.Method: Qualitative and exploratory design. Participants were 14 adult patients undergoing chemotherapy at different stages of the disease. A socio-demographic and clinical data form was utilized along with semi-structured interviews. The interviews were audio-recorded, transcribed and content analysis was performed. Two independent judges evaluated the interview content in regards to emerging categories and obtained a Kappa index of 0.834.Results: Three categories emerged from the data: 1) Technical communication without emotional support, in which the information provided is composed of strictly technical information regarding the diagnosis, treatment and/or prognosis; 2) Technical communication, in which the information provided is oriented towards the technical aspects of the patient’s physical condition, while also providing psychological support for the patients’ subjective needs; and 3) Insufficient technical communication, win which there are gaps in the information provided causing confusion and suffering to the patient.Conclusions: Communication with emotional support contributes to greater satisfaction of chemotherapy patients. Practical implications: the results provide elements for the training of healthcare professionals regarding the importance of the emotional support that can be offered to cancer patients during their treatment.

Avaliação da consulta médica realizada por ingressantes na residência de Pediatria

Diversos autores relatam que a consulta médica se associa a melhores resultados quando se adota como referencial o modelo centrado no paciente. OBJETIVO: Avaliar se os médicos ingressantes na residência de Pediatria realizam consultas ambulatoriais segundo pressupostos do modelo centrado no paciente. MÉTODO: Em 2007, no início de seu estágio de ambulatório, dez residentes foram selecionados aleatoriamente para serem filmados durante a realização de uma consulta. Adotando-se como referencial teórico pressupostos do modelo centrado no paciente, os dados foram analisados por meio de metodologia qualitativa, por meio da técnica exploratória, com três juízes independentes. RESULTADOS: A maioria dos residentes explora precocemente a primeira queixa referida pelos pais, assumindo-a como principal; não explora outras queixas; decide e faz orientações terapêuticas de modo não compartilhado; conversa pouco com as crianças; cria longos momentos de silêncio durante a consulta; não explica o exame físico e às vezes utiliza o prontuário como a principal fonte de informação. CONCLUSÃO: Os residentes realizam consultas sem a inclusão da perspectiva dos pais e, portanto, não atendem segundo pressupostos do modelo centrado no paciente.

O Ginecologista obstetra e a internet

OBJETIVOS: identificar a influência do uso da internet na prática e ambiente de trabalho médico e verificar como estas mudanças vêm acorrendo entre médicos ginecologistas e obstetras. MÉTODO: foram enviados 1.120 questionários para médicos ginecologistas e obstetras da cidade de São Paulo, dos quais retornaram 152, o correspondente a 13,6 por cento da amostra ou 6,1 por cento do total dos médicos cadastrados na SOGESP. A análise quantitativa do comportamento do médico quanto ao uso da internet foi realizada por meio de proporções, médias, cálculos de desvios-padrão e do teste de associação de qui-quadrado. Através da técnica de Cluster Analysis, foram determinados 4 grupos segundo o perfil dos profissionais relacionado ao uso desta ferramenta. RESULTADOS: não se observou relação de idade, sexo, locais de trabalho e desenvolvimento de apenas uma das especialidades Ginecologia ou Obstetrícia quanto à utilização da internet na prática médica. Observou-se uma tendência de uso mais freqüente entre médicos com doutorado. Quanto aos serviços médicos prestados por e-mail, receber e devolver exames foram as atividades mais realizadas pelos sujeitos da pesquisa. CONCLUSÃO: os ginecologistas obstetras pesquisados utilizam a internet na prática médica para própria atualização, para comunicação com pacientes ou para oferecer serviços às mesmas com diferentes assiduidades. Entretanto, este uso é ainda parcial, talvez relacionado ao receio de interferências negativas na relação com o paciente, além de preocupações quanto à implicações legais, éticas e principalmente econômicas relacionadas à prática profissional

Natureza, princípios e fundamentos das práticas e relações profissionais-doentes no contexto do Gabinete de Sub-visão do Instituto Dr. Gama Pinto

A institucionalização do direito à saúde, na constituição de 1976, como direito social e humano não parece ter conseguido, na prática dos profissionais de saúde, abalar a relação paternalista que coloca o doente numa situação de submissão face à dominância do poder/saber médico central ou periférico que o doente, nos termos de Parsons, deve acatar humildemente como “um bom doente”. É este papel de passividade e submissão do doente que nos propomos problematizar nos meandros dos direitos humanos/direitos sociais de cidadania como campo de construção social assente em práticas norteadas por direitos e deveres que, nos termos de Foucault, submetem os cidadãos a constrangimentos inerentes às relações de poder.

Assessment of nursing students and nurses' orientation towards patient-centeredness

Background - Being patient centered is a core value for nursing. Patient centered-care has been related to patient and health provider satisfaction, better health outcomes, higher quality of care and more efficient health care delivery. Objectives - The purpose was to assess the orientation adopted by nurses and students in patient care, using The Patient-Practitioner Orientation Scale, as well as to compare the results between resident nurses and students from different academic years. Settings - Public School of Nursing and a Central Hospital, in Lisbon (Portugal). Participants - Students in the first, second and fourth year of nursing school and nurses participated in the study. Methods - For data collection, we used The Patient-Practitioner Orientation Scale (European Portuguese version), an instrument designed to measure individual preferences toward the dimension of caring a sharing in health professional-patient relationship. Students and nurses also filled out two additional questions about their perception of competence in technical and communication skills. Additional demographic information was also collected, including gender, age, academic year and length of professional experience. Results - A total of 525 students (84.7% female) and 108 nurses (77.8% female) participated in this study. In general, caring sub-scores, measuring the preference of about attending to patient emotional aspects, were higher than sharing sub-scores, measuring beliefs about giving information and perceiving patient as a member of the health team. Students were significantly more patient-centered throughout their nursing education (p<0.001). Comparing to students in the second and fourth academic years (p<0.001) nurses' scores were significantly lower both in total PPOS and in caring and sharing subscales. Conclusions - These results reinforce the idea that patient centeredness may be developed in academic context. The scores obtained highlight the importance of studies that aim to identify factors that may explain the decrease of patient centeredness in professional practice.

Interface HL7 para observation patterns

Com a generalização das tecnologias de informação e comunicação na área da saúde, a monitorização remota de pacientes, a partir de dispositivos móveis, é uma realidade que contribui para uma melhor qualidade de vida dos pacientes. Mas, não são só os pacientes que ganham com a introdução destas tecnologias, também os profissionais de saúde e os hospitais retiram as suas vantagens. Os profissionais de saúde são munidos de uma ferramenta móvel de monitorização permanente de sinais vitais, aumentando desta forma a ligação médico-paciente. Relativamente aos hospitais, estes vêem os custos de manutenção reduzirem, em virtude da possibilidade dos pacientes puderem ser monitorizados a partir dos seus lares. Neste projecto pretende-se identificar mecanismos que possibilitem responder de forma eficaz à necessidade de partilha de informação, nomeadamente protocolos de comunicação, segurança e sistemas de integração. Foi projectado um protótipo, constituído por um middleware e uma aplicação cliente móvel, onde o middleware tem como missão garantir a interoperabilidade entre um servidor HL7 e a aplicação cliente, utilizada pelo profissional de saúde. A normalização da informação médica trocada entre o servidor HL7 e o middleware obedece à norma internacional HL7.

Relevância da assertividade na comunicação profissional de saúde-paciente

Actualmente existem evidências suficientes sobre os problemas de comunicação entre profissionais de saúde e pacientes e os benefícios de uma comunicação eficaz. Alguns autores chegam mesmo a considerar a comunicação como a ferramenta mais importante nos cuidados de saúde. Desde o início dos anos 90, as escolas médicas têm aumentado o interesse no ensino de competências comunicacionais; contudo, e não obstante este interesse crescente, a comunicação assertiva parece ser votada ao esquecimento. Na verdade, enquanto a assertividade tem recebido atenção crescente na literatura da Psicologia, os profissionais de saúde têm-se mostrado relutantes em aderir a esta área do saber, sendo os treinos assertivos para cuidadores ainda muito escassos. O objectivo deste trabalho é apresentar uma visão geral da assertividade e dos contributos desta para a comunicação eficaz dos profissionais de saúde com os pacientes e apontar seis temáticas específicas (por exemplo, lidar com reacções emocionais excessivas; elaborar pedidos) que devem integrar os treinos de comunicação para estudantes da área da saúde e profissionais de saúde.

Da responsabilidade civil do médico por falta de consentimento informado

Dissertação de mestrado em Direito dos Contratos e da Empresa

Older persons' perceptions of general practitioner or specialist primary care physicians : same point of view?

BACKGROUND: Identification of a Primary Care Physician (PCP) by older patients is considered as essential for the coordination of care, but the extent to which identified PCPs are general practitioners or specialists is unknown. This study described older patients' experiences with their PCP and tested the hypothesis of differences between patients who identify a specialist as their PCP (SP PCP) and those who turn to a general practitioner (GP PCP). METHODS: In 2012, a cross-sectional postal survey on care was conducted in the 68+ year old population of the canton of Vaud. Data was provided by 2,276 participants in the ongoing Lausanne cohort 65+ (Lc65+), a study of those born between 1934 and 1943, and by 998 persons from an additional sample drawn to include the population outside of Lausanne or born before 1934. RESULTS: Participants expressed favourable perceptions, at rates exceeding 75% for most items. However, only 38% to 51% responded positively for out-of-hours availability, easy access and at home visits, likelihood of prescribing expensive medication if needed, and doctors' awareness of over-the-counter drugs. 12.0% had an SP PCP, in 95.9% specialised in a discipline implying training in internal medicine. Bivariate and multivariate analyses did not result in significant differences between GP and SP PCPs regarding perceptions of accessibility/availability, doctor-patient relationship, information and continuity of care, prevention, spontaneous use of the emergency department or ambulatory care utilisation. CONCLUSIONS: Experiences of old patients were mostly positive despite some lack in reported hearing, memory testing, and colorectal cancer screening. We found no differences between GP and SP PCP groups.

Expectations, experiences and attitudes of patients and primary care health professionals regarding online psychotherapeutic interventions for depression: protocol for a qualitative study.

BACKGROUND In the year 2020, depression will cause the second highest amount of disability worldwide. One quarter of the population will suffer from depression symptoms at some point in their lives. Mental health services in Western countries are overburdened. Therefore, cost-effective interventions that do not involve mental health services, such as online psychotherapy programs, have been proposed. These programs demonstrate satisfactory outcomes, but the completion rate for patients is low. Health professionals' attitudes towards this type of psychotherapy are more negative than the attitudes of depressed patients themselves. The aim of this study is to describe the profile of depressed patients who would benefit most from online psychotherapy and to identify expectations, experiences, and attitudes about online psychotherapy among both patients and health professionals that can facilitate or hinder its effects. METHODS A parallel qualitative design will be used in a randomised controlled trial on the efficiency of online psychotherapeutic treatment for depression. Through interviews and focus groups, the experiences of treated patients, their reasons for abandoning the program, the expectations of untreated patients, and the attitudes of health professionals will be examined. Questions will be asked about training in new technologies, opinions of online psychotherapy, adjustment to therapy within the daily routine, the virtual and anonymous relationship with the therapist, the process of online communication, information necessary to make progress in therapy, process of working with the program, motivations and attitudes about treatment, expected consequences, normalisation of this type of therapy in primary care, changes in the physician-patient relationship, and resources and risks. A thematic content analysis from the grounded theory for interviews and an analysis of the discursive positions of participants based on the sociological model for focus groups will be performed. DISCUSSION Knowledge of the expectations, experiences, and attitudes of both patients and medical personnel regarding online interventions for depression can facilitate the implementation of this new psychotherapeutic tool. This qualitative investigation will provide thorough knowledge of the perceptions, beliefs, and values of patients and clinicians, which will be very useful for understanding how to implement this intervention method for depression.

Benzodiazepinas: riesgos y estrategias para su retirada

Benzodiazepines and hypnotic Z-drugs are indicated for the short-term treatment of insomnia and anxiety (4 weeks maximum) at the lowest dose possible. Despite the recommendations for short-term use and its unfavourable effects, the level of consumption of benzodiazepines in our context is high and it is continually rising. Prolonged medication usage is associated with adverse effects and significant risks, particularly in the elderly, and should, therefore, be avoided when approaching new treatment. If a previous treatment assessed is found to be inappropriate, its possible withdrawal must be considered. Benzodiazepines withdrawal is based on a gradual dose reduction and should be managed by establishing a doctor-patient relationship of trust to encourage and accomplish discontinuation.

'Doctor, what would you do in my position?' Health professionals and the decision-making process in pregnancy monitoring.

OBJECTIVE: Routine prenatal screening for Down syndrome challenges professional non-directiveness and patient autonomy in daily clinical practices. This paper aims to describe how professionals negotiate their role when a pregnant woman asks them to become involved in the decision-making process implied by screening. METHODS: Forty-one semi-structured interviews were conducted with gynaecologists-obstetricians (n=26) and midwives (n=15) in a large Swiss city. RESULTS: Three professional profiles were constructed along a continuum that defines the relative distance or proximity towards patients' demands for professional involvement in the decision-making process. The first profile insists on enforcing patient responsibility, wherein the healthcare provider avoids any form of professional participation. A second profile defends the idea of a shared decision making between patients and professionals. The third highlights the intervening factors that justify professionals' involvement in decisions. CONCLUSIONS: These results illustrate various applications of the principle of autonomy and highlight the complexity of the doctor-patient relationship amidst medical decisions today.

Au-delà de l'ennui: l'effort pour rendre l'autre intéressant [Beyond boredom: the effort to make a patient interesting]

The doctors' emotional reaction towards the patients has an impact on the doctor-patient relationship. This article focuses on a particular emotion, boredom which is evoked by certain patients. By means of a case vignette, this phenomenon is elucidated and confronted with the psycho-analytical concept of "pensée opératoire", and ways are identified to raise the interest in patients.