Use of the equity implementation model to review clinical system implementation efforts: a case report.
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This paper presents the equity implementation model (EIM) in the context of a case that describes the implementation of a medical scheduling system. The model is based on equity theory, a well-established theory in the social sciences that has been tested in hundreds of experimental and field studies. The predictions of equity theory have been supported in organizational, societal, family, and other social settings. Thus, the EIM helps provide a theory-based understanding for collecting and reviewing users' reactions to, and acceptance or rejection of, a new technology or system. The case study (implementation of a patient scheduling and appointment setting system in a large health maintenance organization) illustrates how the EIM can be used to examine users' reactions to the implementation of a new system. (+info)
A controlled time-series trial of clinical reminders: using computerized firm systems to make quality improvement research a routine part of mainstream practice.
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OBJECTIVE: To explore the feasibility of conducting unobtrusive interventional research in community practice settings by integrating firm-system techniques with time-series analysis of relational-repository data. STUDY SETTING: A satellite teaching clinic divided into two similar, but geographically separated, primary care group practices called firms. One firm was selected by chance to receive the study intervention. Forty-two providers and 2,655 patients participated. STUDY DESIGN: A nonrandomized controlled trial of computer-generated preventive reminders. Net effects were determined by quantitatively combining population-level data from parallel experimental and control interrupted time series extending over two-month baseline and intervention periods. DATA COLLECTION: Mean rates at which mammography, colorectal cancer screening, and cholesterol testing were performed on patients due to receive each maneuver at clinic visits were the trial's outcome measures. PRINCIPAL FINDINGS: Mammography performance increased on the experimental firm by 154 percent (0.24 versus 0.61, p = .03). No effect on fecal occult blood testing was observed. Cholesterol ordering decreased on both the experimental (0.18 versus 0.1 1, p = .02) and control firms (0.13 versus 0.07, p = .03) coincident with national guidelines retreating from recommending screening for young adults. A traditional uncontrolled interrupted time-series design would have incorrectly attributed the experimental-firm decrease to the introduction of reminders. The combined analysis properly indicated that no net prompting effect had occurred, as the difference between firms in cholesterol testing remained stochastically stable over time (0.05 versus 0.04, p = .75). A logistic-regression analysis applied to individual-level data produced equivalent findings. The trial incurred no supplementary data collection costs. CONCLUSIONS: The apparent validity and practicability of our reminder implementation study should encourage others to develop computerized firm systems capable of conducting controlled time-series trials. (+info)
Recruiting patients to randomized trials in primary care: principles and case study.
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BACKGROUND: There are many factors affecting recruitment to trials in primary care, and trials are often jeopardized due to the inability to enter sufficient patient numbers. It is generally agreed that the interest in and commitment of GPs to the project are important, and their forgetfulness and time pressures are major factors which mitigate against maximal recruitment. OBJECTIVES: The aim of this study is to focus on maximizing recruitment of patients to a randomized controlled trial of exercise classes for back pain patients. METHODS: Two distinct methods of recruitment were used. One practice provided a computerized list of names and asked patients' permission, by letter, to be contacted by the researchers. The other 18 practices manually recorded referrals after the consultation by the GP. RESULTS: Referral rates were slower than expected. Many patients either did not fit the inclusion criteria or excluded themselves due to domestic commitments or work. During 24 months, 1588 patients were referred. A total of 187 patients (12%) met the criteria and could be included in the study. The practice which referred patients through a computerized listing contributed 44% of the patients successfully included in the study. CONCLUSIONS: Recruitment rates depended on the method and rate of GP referrals, the proportion of referrals meeting the entry criteria and the proportion of patients available to attend the exercise classes. (+info)
Towards improvement of the accuracy and completeness of medication registration with the use of an electronic medical record (EMR).
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BACKGROUND: Approximately 80% of GPs use a GP information system (GIS) and an electronic medical record (EMR) in their daily practice. To reap the full benefits of an EMR for patient care, post-graduate education and research, the data input must be well structured and accurately coded. OBJECTIVES: The quality and user-friendliness of the software positively influence the completeness and reliability of the data recorded in the GIS. To assess this in actual practice, this study examined whether or not an increase occurred in the accuracy and completeness of indication-related medication registration after the GIS's software package was upgraded. METHOD: GPs recorded data for the Registration Network Groningen (RNG) concerning four medication groups: insulin, trimethoprim, the contraceptive pill and beta-blocking agents. The completeness and accuracy of the registered data were assessed both before and after the change to the new software package. The completeness is evaluated on the basis of the indications missing for the prescribed medications. To assess accuracy, a check was made to determine whether the indications corresponded to those deemed relevant for that particular medication according to National Pharmaceutical Guidelines. RESULTS: The percentage of missing indications decreased notably, especially in the chronically prescribed medication groups. For insulin, the percentage decreased from 40.5 to 3% and for the contraceptive pill from 34.5 to 1%. For trimethoprim, the percentage decreased from 10 to 1%, and for beta-blocking agents from 22 to 1.5%. Of the indications present, the percentage of relevant indications showed a slight increase, with the largest increase observed for the contraceptive pill where the percentage rose from 86 to 96%. CONCLUSIONS: The completeness of recorded indications improved considerably after the change of software. This is due mostly to the efforts of the GPs, their practice assistants and the support of the RNG organization involved in the conversion procedure. Accuracy improved slightly, especially due to the software modifications which ensured that non-existent codes could not be entered. To summarize, with increased user-friendliness of the software, combined with the training of motivated GPs, the quality of recorded data improved. (+info)
Is there a digital divide among physicians? A geographic analysis of information technology in Southern California physician offices.
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OBJECTIVE: The aim of this study was to determine whether physician offices located in high-minority and low-income neighborhoods have different levels of access to information technology than offices located in lower-minority and higher-income areas. DESIGN: A cross-sectional survey was conducted of pediatrics, family medicine, and general practice offices in Orange County, California. Survey data were linked with community demographic data from the 2000 Census using a geographical information system. RESULTS: Of 307 offices surveyed, 141 responded (46%). Offices located in high-minority and high-poverty areas were as likely to respond as other offices. Among responding offices, 94% had a computer, 77% had Web access, 29% had broadband Internet access, and 53% used computerized scheduling and billing systems. Offices located in minority and low-income communities had equivalent access to each technology. Offices in communities with larger proportions of Hispanics were less likely to have practice Web pages, but other uses of the Internet were not associated with practice location. Offices reported high levels of interest in online clinical systems but also high levels of concern about these systems' usability and confidentiality. Offices with Web access and those with practice management systems expressed greater interest in online clinical systems but also greater levels of concern about usability and confidentiality. These attitudes were equivalent among offices in different communities. CONCLUSION: Primary care offices located in poor and minority communities in a large, suburban county had high levels of access to and interest in Web-based systems. Physicians' offices may therefore provide a venue for online services aimed at improving health outcomes for poor and minority communities. Research is needed in other geographic regions to determine the generalizability of these findings. (+info)
Electronic communication between providers of primary and secondary care.
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OBJECTIVE: To study the effects of the introduction of electronic data interchange between primary and secondary care providers on speed of communication, efficiency of data handling, and satisfaction of general practitioners with communication. DESIGN: Comparison of traditional paper based communication for laboratory reports and admission-discharge reports between hospital and general practitioners and electronic data interchange. SETTING: Twenty-seven general practitioners whose offices were equipped with a practice information system and two general hospitals. OUTCOME MEASURES: Paper based communication was evaluated by questionnaire responses from and interviews with care providers; electronic communication was evaluated by measuring time intervals between generation and delivery of messages and by assessing doctors' satisfaction with electronic data interchange by questionnaire. RESULTS: Via paper mail admission-discharge reports took a median of 2-4 days, and laboratory reports 2 days, to reach general practitioners. With electronic data interchange almost all admission-discharge reports were available to general practitioners within one hour of generation. When samples were analysed on the day of collection (as was the case for 174/542 samples in one hospital and 443/854 in the other) the laboratory reports were also available to the general practitioner the same day via electronic data interchange. Fifteen general practitioners (of the 24 who returned the questionnaire) reported that the use of electronic admission-discharge reports provided more accurate and complete information about the care delivered to their patients. Ten general practitioners reported that electronic laboratory reports lessened the work of processing the data. CONCLUSION: Electronic communication between primary and secondary care providers is a feasible option for improving communication. (+info)
Continuous quality improvement and medical informatics: the convergent synergy.
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Continuous quality improvement (CQI) and medical informatics specialists need to converge their efforts to create synergy for improving health care. Health care CQI needs medical informatics' expertise and technology to build the information systems needed to manage health care organizations according to quality improvement principles. Medical informatics needs CQI's philosophy and methods to build health care information systems that can evolve to meet the changing needs of clinicians and other stakeholders. This paper explores the philosophical basis for convergence of CQI and medical informatics efforts, and then examines a clinical computer workstation development project that is applying a combined approach. (+info)
While the Department of Veteran's Affairs Decentralized Hospital Computer Program (DHCP) is one of the most widely disseminated and successful hospital information systems in existence, it currently is accessed through a user interface which is not as mature as the rest of the system. This interface is a VT-100 compatible, character oriented interface using menus accessed by typed commands for feature access. This project demonstrated that a mature graphical user interface (MailMinder) can be successfully used as a "front-end" to DHCP. MailMinder is completely compatible with the existing unmodified DHCP electronic mail program, Mailman. MailMinder allows the user to be more efficient than the current interface and offers additional features over the current mail system. The program has undergone evaluation and limited deployment at five separate sites. The feature set of this program and its operation will be shown at this demonstration. The demonstration has implications for all current hospital information systems. (+info)