Patient-centered medical home technology effects on hypertension and diabetes control

Background: Hypertension and Diabetes is a public health and economic concern in the United States. The utilization of medical home concepts increases the receipt of preventive services, however, do they also increase adherence to treatments? This study examined the effect of patient-centered medical home technologies such as the electronic health record, clinical support system, and web-based care management in improving health outcomes related to hypertension and diabetes. Methods: A systematic review of the literature used a best evidence synthesis approach to address the general question " Do patient-centered medical home technologies have an effect of diabetes and hypertension treatment?" This was followed by an evaluation of specific examples of the technologies utilized such as computer-assisted recommendations and web-based care management provided by the patient's electronic health record. Ebsco host, Ovid host, and Google Scholar were the databases used to conduct the literature search. Results: The initial search identified over 25 studies based on content and quality that implemented technology interventions to improve communication between provider and patient. After further assessing the articles for risk of bias and study design, 13 randomized controlled studies were chosen. All of the studies chosen were conducted in various primary care settings in both private practices and hospitals between the years 2000 and 2007. The sample sizes of the studies ranged from 42 to 2924 participants. The mean age for all of the studies ranged from 56 to 71 years. The percent women in the studies ranged from one to 78 percent. Over one-third of the studies did not provide the racial composition of the participants. For the seven studies that did provide information about the ethnic composition, 64% of the intervention participants were White. All of the studies utilized some type of web-based or computer-based communication to manage hypertension or diabetes care. Findings on outcomes were mixed, with nine out of 13 studies showing no significant effect on outcomes examined, and four of the studies showing significant and positive impact on health outcomes related to hypertension or diabetes Conclusion: Although the technologies improved patient and provider satisfaction, the outcomes measures such as blood pressure control and glucose control were inconclusive. Further research is needed with diverse ethnic and SES population to investigate the role of patient-centered technologies on hypertension and diabetes control. Also, further research is needed to investigate the effects of innovative medical home technologies that can be used by both patients and providers to increase quality of communication concerning adherence to treatments.^

Comparing Patient-Centered Medical Home Implementation in Urban and Rural VHA Clinics: Results from the Patient Aligned Care Team (PACT) Initiative

Thesis (Master's)--University of Washington, 2016-06

How patient-centered do female physicians need to be? Analogue patients' satisfaction with male and female physicians' identical behaviors (Published online: 30 Aug 2014)

Previous research suggests that female physicians may not receive appropriate credit in patients' eyes for their patient-centered skills compared to their male counterparts. An experiment was conducted to determine whether a performance of higher (versus lower) verbal patient-centeredness would result in a greater difference in analogue patient satisfaction for male than female physicians. Two male and two female actors portrayed physicians speaking to a patient using high or low patient-centered scripts while not varying their nonverbal cues. One hundred ninety-two students served as analogue patients by assuming the patient role while watching one of the videos and rating their satisfaction and other evaluative responses to the physician. Greater verbal patient-centeredness had a stronger positive effect on satisfaction and evaluations for male than for female physicians. This pattern is consistent with the hypothesis that the different associations between patient-centeredness and patients' satisfaction for male versus female physicians occur because of the overlap between stereotypical female behavior and behaviors that comprise patient-centered medical care. If this is the case, high verbal patient-centered behavior by female physicians is not recognized as a marker of clinical competence, as it is for male physicians, but is rather seen as expected female behavior.

Analyse de la logique d’intervention d’une adaptation québécoise d’un modèle de soins centré sur le patient appuyé par un dossier médical personnel dans les suivis pédiatriques au sein d’un groupe de médecine de famille

Dans l'optique d'améliorer la performance des services de santé en première ligne, un projet d'implantation d'une adaptation québécoise d'un modèle de soins centré sur le patient appuyé par un dossier médical personnel (DMP) a été mis sur pied au sein d'un groupe de médecine familiale (GMF) de la région de Montréal. Ainsi, ce mémoire constitue une analyse comparative entre la logique de l'intervention telle qu'elle est décrite dans les données probantes concernant les modèles de soins centrés sur le patient et le dossier médical personnel ainsi que la logique de l'intervention issue de nos résultats obtenus dans le cadre de ce projet au sein d'un GMF. L'analyse organisationnelle se situe durant la phase de pré-déploiement de l'intervention. Les principaux résultats sont que la logique d'intervention appliquée dans le cadre du projet est relativement éloignée de ce qui se fait de mieux dans la littérature sur le sujet. Ceci est en partie explicable par les différentes résistances en provenance des acteurs du projet (ex. médecins, infirmières, fournisseur technologique) dans le projet, mais aussi par l'absence de l'interopérabilité entre le DMP et le dossier médical électronique (DME). Par ailleurs, les principaux effets attendus par les acteurs impliqués sont l'amélioration de la continuité informationnelle, de l’efficacité-service, de la globalité et de la productivité. En outre, l’implantation d’un modèle centré sur le patient appuyé par un DMP impliquerait la mise en œuvre d’importantes transformations structurelles comme une révision du cadre législatif (ex. responsabilité médicale) et des modes de rémunérations des professionnels de la santé, sans quoi, les effets significatifs sur les dimensions de la performance comme l’accessibilité, la qualité, la continuité, la globalité, la productivité, l’efficacité et la réactivité pourraient être limités. Ces aménagements structuraux devraient favoriser la collaboration interprofessionnelle, l'interopérabilité des systèmes, l’amélioration de la communication multidirectionnelle (patient-professionnel de la santé) ainsi qu'une autogestion de la santé supportée (ex. éducation, prévention, transparence) par les professionnels de la santé.

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. ^

A Narrative Study of Patient Encounter Accounts of Physicians, Nurses, and Medical Receptionists after Two Decades of a Paradigm of Patient-Centered Care

Despite recent well-known advancements in patient care in the medical fields, such as patient-centeredness and evidence-based medicine and practice, there is rather less known about their effects on the particulars of clinician-patient encounters. The emphasis in clinical encounters remains mostly on treatment and diagnosis and less on communicative competency or engagement for medical professionals. The purpose of this narrative study was to explore interactive competencies in diagnostic and therapeutic encounters and intake protocols within the context of the physicians’, nurses’, and medical receptionists’ perspectives and experiences. Literature on narrative medicine, phenomenology and medicine, therapeutic relationships, cultural and communication competency, and non-Western perspectives on human communication provided the guiding theoretical frameworks for the study. Three data sets including 13 participant interviews (5 physicians, 4 nurses, and 4 medical receptionists), policy documents (physicians, nurses, and medical receptionists) and a website (Communication and Cultural Competency) were used. The researcher then engaged in triangulated analyses, including N-Vivo, manifest and latent, Mishler’s (1984, 1995) narrative elements and Charon’s (2005, 2006a, 2006b, 2013) narrative themes, in recursive, overlapping, comparative and intersected analysis strategies. A common factor affecting physicians’ relationships with their clients was limitation of time, including limited time (a) to listen, (b) to come up with a proper diagnosis, and (c) to engage in decision making in critical conditions and limited time for patients’ visits. For almost all nurse participants in the study establishing therapeutic relationships meant being compassionate and empathetic. The goals of intake protocols for the medical receptionists were about being empathetic to patients, being an attentive listener, developing rapport, and being conventionally polite to patients. Participants with the least iv amount of training and preparation (medical receptionists) appeared to be more committed to working narratively in connecting with patients and establishing human relationships as well as in listening to patients’ stories and providing support to narrow down the reason for their visit. The diagnostic and intake “success stories” regarding patient clinical encounters for other study participants were focused on a timely securing of patient information, with some acknowledgement of rapport and emapathy. Patient-centeredness emerged as a discourse practice, with ambiguous or nebulous enactment of its premises in most clinical settings.

L'orientation du patient souffrant d'un syndrome douloureux abdominal aigu a domicile [Hospitalisation criteria for the acute abdominal pain patient seen at home or in an ambulatory setting].

Dealing at patient's home with an acute abdominal pain may be particularly challenging for the primary care physician. In such a clinical situation, the part of laboratory and radiological investigations is increasing in the diagnostic process. The decision to keep the patient at home based on a clinical evaluation alone may represent a great medical responsibility for the physician. Emergency departments (ED) are of course in charge of investigating such patients with a wide panel of investigation techniques. But these structures are chronically overcrowded resulting frequently in long and difficult periods of waiting. Based on a literature review, a description of useful clinical symptoms and signs is summarized and should help the decision process for the orientation of the patient.

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.

Insights from Native American Veterans on Developing a Patient-Centered, Integrative Model for Mental Health Services

Thesis (Master's)--University of Washington, 2016-06

Prise en charge du patient avec bronchopneumopathie obstructive: ambulatoire ou hospitalière [Management of the patient with COPD: home case or hospitalization].

Acute exacerbation of COPD is one of the most common causes of hospital admission in patients affected with this disease. In most cases, consideration of differential diagnoses and assessment of important comorbidities will allow to make the decision whether or not the patient needs to be hospitalized. A decision to hospitalize will be based on specific symptoms and signs, as well on the patient's history. Contrary to bronchial asthma, a systematic action plan strategy is lacking for COPD. However, a disease management plan involving all the health care providers may have the potential to improve the patient's well being and to decrease costs related to these exacerbations.

Instances d'aliénation: portrait du patient tiraillé. 2. Dispositif médical et discours dominants [Instances of alienation: portrait of the torn patient. 2. Medical apparatus and dominant discourses].

The first part of the article focused on the individual mechanisms--body, psyche and relational context--alienating the patient. The second part addresses alienating mechanisms related to the medical apparatus and the dominant discourses produced within and by society. The aim is not to comprehensively list possible mechanisms, but to discuss some of them using illustrative examples.

Patient-centered Care in Maternity Services: A Critical Appraisal and Synthesis of the Literature.

BACKGROUND: Patient-centered care (PCC) has been recognized as a marker of quality in health service delivery. In policy documents, PCC is often used interchangeably with other models of care. There is a wide literature about PCC, but there is a lack of evidence about which model is the most appropriate for maternity services specifically. AIM: We sought to identify and critically appraise the literature to identify which definition of PCC is most relevant for maternity services. METHODS: The four-step approach used to identify definitions of PCC was to 1) search electronic databases using key terms (1995-2011), 2) cross-reference key papers, 3) search of specific journals, and 4) search the grey literature. Four papers and two books met our inclusion criteria. ANALYSIS: A four-criteria critical appraisal tool developed for the review was used to appraise the papers and books. MAIN RESULTS: From the six identified definitions, the Shaller's definition met the majority of the four criteria outlined and seems to be the most relevant to maternity services because it includes physiologic conditions as well as pathology, psychological aspects, a nonmedical approach to care, the greater involvement of family and friends, and strategies to implement PCC. CONCLUSION: This review highlights Shaller's definitions of PCC as the one that would be the most inclusive of all women using maternity services. Future research should concentrate on evaluating programs that support PCC in maternity services, and testing/validating this model of care.

Frequency of and predictors for patient-reported medical and medication errors in Switzerland

OBJECTIVES: To analyse the frequency of and identify risk factors for patient-reported medical errors in Switzerland. The joint effect of risk factors on error-reporting probability was modelled for hypothetical patients. METHODS: A representative population sample of Swiss citizens (n = 1306) was surveyed as part of the Commonwealth Fund’s 2010 lnternational Survey of the General Public’s Views of their Health Care System’s Performance in Eleven Countries. Data on personal background, utilisation of health care, coordination of care problems and reported errors were assessed. Logistic regression analysis was conducted to identify risk factors for patients’ reports of medical mistakes and medication errors. RESULTS: 11.4% of participants reported at least one error in their care in the previous two years (8% medical errors, 5.3% medication errors). Poor coordination of care experiences was frequent. 7.8% experienced that test results or medical records were not available, 17.2% received conflicting information from care providers and 11.5% reported that tests were ordered although they had been done before. Age (OR = 0.98, p = 0.014), poor health (OR = 2.95, p = 0.007), utilisation of emergency care (OR = 2.45, p = 0.003), inpatient-stay (OR = 2.31, p = 0.010) and poor care coordination (OR = 5.43, p <0.001) are important predictors for reporting error. For high utilisers of care that unify multiple risk factors the probability that errors are reported rises up to p = 0.8. CONCLUSIONS: Patient safety remains a major challenge for the Swiss health care system. Despite the health related and economic burden associated with it, the widespread experience of medical error in some subpopulations also has the potential to erode trust in the health care system as a whole.

Patient-centered outcomes after subepithelial connective tissue grafts and coronally advanced flaps

The use of a coronally advanced flap (CAF) and connective tissue graft (CTG) is a well-established procedure to cover single and multiple recessions and improve soft tissue esthetics. However, until now, there are still limited data evaluating patient morbidity, the fear of imminent tooth loss, and modification of sensitivity in surgical areas. The aim of the present study was to evaluate the patient-centered outcomes associated with CAF + CTG.