Creating a Web-accessible, point-of-care, team-based information system (PoinTIS): the librarian as publisher*

The Internet has created new opportunities for librarians to develop information systems that are readily accessible at the point of care. This paper describes the multiyear process used to justify, fund, design, develop, promote, and evaluate a rehabilitation prototype of a point-of-care, team-based information system (PoinTIS) and train health care providers to use this prototype for their spinal cord injury and traumatic brain injury patient care and education activities. PoinTIS is a successful model for librarians in the twenty-first century to serve as publishers of information created or used by their parent organizations and to respond to the opportunities for information dissemination provided by recent technological advances.

The Patient Informatics Consult Service (PICS): an approach for a patient-centered service

The Patient Informatics Consult Service (PICS) at the Eskind Biomedical Library at Vanderbilt University Medical Center (VUMC) provides patients with consumer-friendly information by using an information prescription mechanism. Clinicians refer patients to the PICS by completing the prescription and noting the patient's condition and any relevant factors. In response, PICS librarians critically appraise and summarize consumer-friendly materials into a targeted information report. Copies of the report are given to both patient and clinician, thus facilitating doctor-patient communication and closing the clinician-librarian feedback loop. Moreover, the prescription form also circumvents many of the usual barriers for patients in locating information, namely, patients' unfamiliarity with medical terminology and lack of knowledge of authoritative sources. PICS librarians capture the time and expertise put into these reports by creating Web-based pathfinders on prescription topics. Pathfinders contain librarian-created disease overviews and links to authoritative resources and seek to minimize the consumer's exposure to unreliable information. Pathfinders also adhere to strict guidelines that act as a model for locating, appraising, and summarizing information for consumers. These mechanisms—the information prescription, research reports, and pathfinders—serve as steps toward the long-term goal of full integration of consumer health information into patient care at VUMC.

Electronic patient records: Achieving best practice in information transfer between hospital and community providers - an integration success story

Effective healthcare integration is underpinned by clinical information transfer that is timely, legible and relevant. The aim of this study was to describe and evaluate a method for best practice information exchange. This was achieved based on the generic Mater integration methodology. Using this model the Mater Health Services have increased effective community fax discharge from 34% in 1999 to 86% in 2002. These results were predicated on applied information technology excellence involving the development of the Mater Electronic Health Referral Summary and effective change management methodology, which included addressing issues around patient consent, engaging clinicians, provision of timely and appropriate education and training, executive leadership and commitment and adequate resourcing. The challenge in achieving best practice information transfer is not solely in the technology but also in implementing the change process and engaging clinicians. General practitioners valued the intervention highly. Hospital and community providers now have an inexpensive, effective product for critical information exchange in a timely and relevant manner, enhancing the quality and safety of patient care.

Determinants in the development of advanced nursing practice: a case study of primary-care settings in Hong Kong

Different factors have been shown to influence the development of models of advanced nursing practice (ANP) in primary-care settings. Although ANP is being developed in hospitals in Hong Kong, China, it remains undeveloped in primary care and little is known about the factors determining the development of such a model. The aims of the present study were to investigate the contribution of different models of nursing practice to the care provided in primary-care settings in Hong Kong, and to examine the determinants influencing the development of a model of ANP in such settings. A multiple case study design was selected using both qualitative and quantitative methods of data collection. Sampling methods reflected the population groups and stage of the case study. Sampling included a total population of 41 nurses from whom a secondary volunteer sample was drawn for face-to-face interviews. In each case study, a convenience sample of 70 patients were recruited, from whom 10 were selected purposively for a semi-structured telephone interview. An opportunistic sample of healthcare professionals was also selected. The within-case and cross-case analysis demonstrated four major determinants influencing the development of ANP: (1) current models of nursing practice; (2) the use of skills mix; (3) the perceived contribution of ANP to patient care; and (4) patients' expectations of care. The level of autonomy of individual nurses was considered particularly important. These determinants were used to develop a model of ANP for a primary-care setting. In conclusion, although the findings highlight the complexity determining the development and implementation of ANP in primary care, the proposed model suggests that definitions of advanced practice are appropriate to a range of practice models and cultural settings. However, the findings highlight the importance of assessing the effectiveness of such models in terms of cost and long-term patient outcomes.

Controlled trial of multidisciplinary care teams for acutely ill medical inpatients: enhanced multidisciplinary care

Background: Acute hospital general medicine services care for ageing complex patients, using the skills of a range of health-care providers. Evidence suggests that comprehensive early assessment and discharge planning may improve efficiency and outcomes of care in older medical patients. Aim: To enhance assessment, communication, care and discharge planning by restructuring consistent, patient-centred multidisciplinary teams in a general medicine service. Methods: Prospective controlled trial enrolling 1538 consecutive medical inpatients. Intervention units with additional allied health staff formed consistent multidisciplinary teams aligned with inpatient admitting units rather than wards; implemented improved communication processes for early information collection and sharing between disciplines; and specified shared explicit discharge goals. Control units continued traditional, referral-based multidisciplinary models with existing staffing levels. Results: Access to allied health services was significantly enhanced. There was a trend to reduced index length of stay in the intervention units (7.3 days vs 7.8 days in control units, P = 0.18), with no change in 6-month readmissions. in-hospital mortality was reduced from 6.4 to 3.9% (P = 0.03); less patients experienced functional decline in hospital (P = 0.04) and patients' ratings of health status improved (P = 0.02). Additional staffing costs were balanced by potential bed-day savings. Conclusion: This model of enhanced multidisciplinary inpatient care has provided sustainable efficiency gains for the hospital and improved patient outcomes.

Reducing patient mortality in hospitals:the role of human resource management

Developing effective health care organizations is increasingly complex as a result of demographic changes, globalization, and developments in medicine. This study examines the potential contribution of organizational behavior theory and research by investigating the relationship between systems of human resource management (HRM) practices and effectiveness of patient care in hospitals. Relatively little research has been conducted to explore these issues in health care settings. In a sample of 52 hospitals in England, we examine the relationship between the HRM system and health care outcome. Specifically, we study the association between high performance HRM policies and practices and standardized patient mortality rates. The research reveals that, after controlling for prior mortality and other potentially confounding factors such as the ratio of doctors to patients, greater use of a complementary set of HRM practices has a statistically and practically significant relationship with patient mortality. The findings suggest that managers and policy makers should focus sharply on improving the functioning of relevant HR management systems in health care organizations as one important means by which to improve patient care. Copyright © 2006 John Wiley & Sons, Ltd.

The use of anticholinergic agents to treat excessive oropharyngeal and tracheal secretions in palliative care

Palliative care involves a multi-professional team approach to the provision of active, holistic care for patients and their families when the patient's disease is no longer responsive to curative treatment. Patient care encompasses medical and pharmacological intervention for symptom control, together with psychological, spiritual and social support for patients and families. Care is provided by teams in hospice, hospital or community environments. Although traditionally associated with providing care for cancer patients, palliative care services are increasingly providing for patients with non-malignant disease. Symptoms commonly associated with terminal phase of disease include pain, nausea, agitation, respiratory symptoms and general fatigue. During the last few days of life, patients may become weak, resulting in difficulty taking oral medication and have periods of unconsciousness. Some patients may require drug administration via subcutaneous infusion. A proportion of patients may develop difficulty clearing respiratory secretions causing a characteristic ‘death rattle’, which although not generally considered to be distressing for the patient, is often treated with a variety of anticholinergic drugs in an attempt to reduce the ‘noisy breathing’ for the benefit of relatives and others who may be closely associated with the patient.This study examined treatment of death rattle in two Hospices focusing on objective and subjective outcome measures in order to determine the efficacy of anticholinergic regimens in current use. Qualitative methods were employed to elicit attitudes of professionals and carers working closely with the patient. The number of patients recruited and monitored were small, many confounding factors were identified which questioned firstly the clinical rationale for administering anticholinergic drugs routinely to treat death rattle and secondly, the ethics of administering drug regimens to patients to treat death rattle with the primary aim of relieving distress for others. Ethnical issues, including those of consent are discussed in relation to their impact on the methodology of end of life studies in medicines management in palliative care.

Automatic indexing and retrieval of encounter-specific evidence for point-of-care support

Evidence-based medicine relies on repositories of empirical research evidence that can be used to support clinical decision making for improved patient care. However, retrieving evidence from such repositories at local sites presents many challenges. This paper describes a methodological framework for automatically indexing and retrieving empirical research evidence in the form of the systematic reviews and associated studies from The Cochrane Library, where retrieved documents are specific to a patient-physician encounter and thus can be used to support evidence-based decision making at the point of care. Such an encounter is defined by three pertinent groups of concepts - diagnosis, treatment, and patient, and the framework relies on these three groups to steer indexing and retrieval of reviews and associated studies. An evaluation of the indexing and retrieval components of the proposed framework was performed using documents relevant for the pediatric asthma domain. Precision and recall values for automatic indexing of systematic reviews and associated studies were 0.93 and 0.87, and 0.81 and 0.56, respectively. Moreover, precision and recall for the retrieval of relevant systematic reviews and associated studies were 0.89 and 0.81, and 0.92 and 0.89, respectively. With minor modifications, the proposed methodological framework can be customized for other evidence repositories. © 2010 Elsevier Inc.

Provision of pharmaceutical care by community pharmacists:a comparison across Europe

Objective To investigate the provision of pharmaceutical care by community pharmacists across Europe and to examine the various factors that could affect its implementation. Methods A questionnaire-based survey of community pharmacies was conducted within 13 European countries. The questionnaire consisted of two sections. The first section focussed on demographic data and services provided in the pharmacy. The second section was a slightly adapted version of the Behavioral Pharmaceutical Care Scale (BPCS) which consists of three main dimensions (direct patient care activities, referral and consultation activities and instrumental activities). Results Response rates ranged from 10–71% between countries. The mean total score achieved by community pharmacists, expressed as a percentage of the total score achievable, ranged from 31.6 (Denmark) to 52.2% (Ireland). Even though different aspects of pharmaceutical care were implemented to different extents across Europe, it was noted that the lowest scores were consistently achieved in the direct patient care dimension (particularly those related to documentation, patient assessment and implementation of therapeutic objectives and monitoring plans) followed by performance evaluation and evaluation of patient satisfaction. Pharmacists who dispensed higher daily numbers of prescriptions in Ireland, Germany and Switzerland had significantly higher total BPCS scores. In addition, pharmacists in England and Ireland who were supported in their place of work by other pharmacists scored significantly higher on referral and consultation and had a higher overall provision of pharmaceutical care. Conclusion The present findings suggest that the provision of pharmaceutical care in community pharmacy is still limited within Europe. Pharmacists were routinely engaged in general activities such as patient record screening but were infrequently involved in patient centred professional activities such as the implementation of therapeutic objectives and monitoring plans, or in self-evaluation of performance.

A comprehensive approach to quality management of intensive care services

Purpose – The purpose of this paper is to develop a comprehensive framework for improving intensive care unit performance. Design/methodology/approach – The study introduces a quality management framework by combining cause and effect diagram and logical framework. An intensive care unit was identified for the study on the basis of its performance. The reasons for not achieving the desired performance were identified using a cause and effect diagram with the stakeholder involvement. A logical framework was developed using information from the cause and effect diagram and a detailed project plan was developed. The improvement projects were implemented and evaluated. Findings – Stakeholders identified various intensive care unit issues. Managerial performance, organizational processes and insufficient staff were considered major issues. A logical framework was developed to plan an improvement project to resolve issues raised by clinicians and patients. Improved infrastructure, state-of-the-art equipment, well maintained facilities, IT-based communication, motivated doctors, nurses and support staff, improved patient care and improved drug availability were considered the main project outputs for improving performance. The proposed framework is currently being used as a continuous quality improvement tool, providing a planning, implementing, monitoring and evaluating framework for the quality improvement measures on a sustainable basis. Practical implications – The combined cause and effect diagram and logical framework analysis is a novel and effective approach to improving intensive care performance. Similar approaches could be adopted in any intensive care unit. Originality/value – The paper focuses on a uniform model that can be applied to most intensive care units.

What are tests for? The implications of stuttering steps along the patient pathway

This article explores the implications of how US family physicians make decisions about ordering diagnostic tests for their patients. Data is based on a study of 256 physicians interviewed after viewing a video vignette of a presenting patient. The qualitative analysis of 778 statements relating to trustworthiness of evidence for their decision making, the use of any kind of technology and diagnostic testing suggests a range of internal and external constraints on physician decision making. Test-ordering for family physicians in the United States is significantly influenced by both hidden cognitive processes related to the physician's calculation of patient resources and a health insurance system that requires certain types of evidence in order to permit further tests or particular interventions. The consequence of the need for physicians to meet multiple forms of proof that may not always relate to relevant treatment delays a diagnosis and treatment plan agreed not only by the physician and patient but also the insurance company. This results in a patient journey that is made up of stuttering steps to a confirmed diagnosis and treatment undermining patient-centred practice, compromising patient care, constraining physician autonomy and creating additional expense. © 2014 Elsevier Ltd.

A KM perspective on implementing an electronic patient record within an NHS hospital

The Electronic Patient Record (EPR) is being developed by many hospitals in the UK and across the globe. We class an EPR system as a type of Knowledge Management System (KMS), in that it is a technological tool developed to support the process of knowledge management (KM). Healthcare organisations aim to use these systems to provide a vehicle for more informed and improved clinical decision making thereby delivering reduced errors and risks, enhanced quality and consequently offering enhanced patient safety. Finding an effective way for a healthcare organisation to practically implement these systems is essential. In this study we use the concept of the business process approach to KM as a theoretical lens to analyse and explore how a large NHS teaching hospital developed, executed and practically implemented an EPR system. This theory advocates the importance of taking into account all organizational activities - the business processes - in considering any KM initiatives. Approaching KM through business processes allows for a more holistic view of the requirements across a process: emphasis is placed on how particular activities are performed, how they are structured and what knowledge demanded and not just supplied across each process. This falls in line with the increased emphasis in healthcare on patient-centred approaches to care delivery. We have found in previous research that hospitals are happy with the delivery of patient care being referred to as their 'business'. A qualitative study was conducted over a two and half year period with data collected from semi-structured interviews with eight members of the strategic management team, 12 clinical users and 20 patients in addition to non- participant observation of meetings and documentary data. We believe that the inclusion of patients within the study may well be the first time this has been done in examining the implementation of a KMS. The theoretical propositions strategy was used as the overarching approach for data analysis. Here Initial theoretical research themes and propositions were used to help shape and organise the case study analysis. This paper will present preliminary findings about the hospital's business strategy and its links to the KMS strategy and process.

Improving the description of the retinal vasculature and patient history taking for monitoring systemic hypertension

Systemic hypertension is an important public health concern. If optometrists are to perform a more active role in the detection and monitoring of high blood pressure (BP), there is a need to improve the consistency of describing the retinal vasculature and to assess patient's ability to correctly report the diagnosis of hypertension, its control and medication. One hundred and one patients aged >40 years were dilated and had fundus photography performed. BP was measured and a self-reported history of general health and current medication was compared with the records of their general practitioner (GP). The status of the retinal vasculature was quantified using a numeric scale by five clinicians and this was compared to the same evaluation performed with the aid of a basic pictorial grading scale. Image analysis was used to objectively measure the artery-to-vein (A/V) ratio and arterial reflex. Arteriolar tortuosity and calibre changes were found to be the most sensitive retinal signs of high BP. Using the grading scale to describe the retinal vasculature significantly improved inter- and intra-observer repeatability. Almost half the patients examined were on medication for high BP or cardiovascular disease. Patients' ability to give their complete medical history was poor, as was their ability to recall what medication they had been prescribed. GPs indicated it was useful to receive details of their patient's BP when it was >140/90 mmHg. The use of improved description of the retinal vasculature and stronger links between optometrists and GPs may enhance future patient care. © 2001 The College of Optometrists. Published by Elsevier Science Ltd. All rights reserved.

Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool, GRiST

Aim: To explore current risk assessment processes in general practice and Improving Access to Psychological Therapies (IAPT) services, and to consider whether the Galatean Risk and Safety Tool (GRiST) can help support improved patient care. Background: Much has been written about risk assessment practice in secondary mental health care, but little is known about how it is undertaken at the beginning of patients' care pathways, within general practice and IAPT services. Methods: Interviews with eight general practice and eight IAPT clinicians from two primary care trusts in the West Midlands, UK, and eight service users from the same region. Interviews explored current practice and participants' views and experiences of mental health risk assessment. Two focus groups were also carried out, one with general practice and one with IAPT clinicians, to review interview findings and to elicit views about GRiST from a demonstration of its functionality. Data were analysed using thematic analysis. Findings Variable approaches to mental health risk assessment were observed. Clinicians were anxious that important risk information was being missed, and risk communication was undermined. Patients felt uninvolved in the process, and both clinicians and patients expressed anxiety about risk assessment skills. Clinicians were positive about the potential for GRiST to provide solutions to these problems. Conclusions: A more structured and systematic approach to risk assessment in general practice and IAPT services is needed, to ensure important risk information is captured and communicated across the care pathway. GRiST has the functionality to support this aspect of practice.

Giving whistleblowers greater protection:improving quality of care

This year, an independent review of whisleblowing in the NHS made recommendations as to how whistleblowers could be given greater protection. The review, chaired by Sir Robert Francis, intended to improve the quality of patient care and safety in the health service. But with many practitioners remaining unregulated, there are unanswered questions as to how reports of mistakes can be properly investigated and the necessary action taken against incompetent or negligent practitioners. Amanda Casey, Chair of the Registration Council for Clinical Physiologists, makes the case for regulation of professionals whose work poses potential risks to patients and can place healthcare managers in an invidious position.