Developing a medication communication framework across continuums of care using the Circle of Care Modeling approach.

BACKGROUND: Medication errors are a common type of preventable errors in health care causing unnecessary patient harm, hospitalization, and even fatality. Improving communication between providers and between providers and patients is a key aspect of decreasing medication errors and improving patient safety. Medication management requires extensive collaboration and communication across roles and care settings, which can reduce (or contribute to) medication-related errors. Medication management involves key recurrent activities (determine need, prescribe, dispense, administer, and monitor/evaluate) with information communicated within and between each. Despite its importance, there is a lack of conceptual models that explore medication communication specifically across roles and settings. This research seeks to address that gap. METHODS: The Circle of Care Modeling (CCM) approach was used to build a model of medication communication activities across the circle of care. CCM positions the patient in the centre of his or her own healthcare system; providers and other roles are then modeled around the patient as a web of relationships. Recurrent medication communication activities were mapped to the medication management framework. The research occurred in three iterations, to test and revise the model: Iteration 1 consisted of a literature review and internal team discussion, Iteration 2 consisted of interviews, observation, and a discussion group at a Community Health Centre, and Iteration 3 consisted of interviews and a discussion group in the larger community. RESULTS: Each iteration provided further detail to the Circle of Care medication communication model. Specific medication communication activities were mapped along each communication pathway between roles and to the medication management framework. We could not map all medication communication activities to the medication management framework; we added Coordinate as a separate and distinct recurrent activity. We saw many examples of coordination activities, for instance, Medical Office Assistants acting as a liaison between pharmacists and family physicians to clarify prescription details. CONCLUSIONS: Through the use of CCM we were able to unearth tacitly held knowledge to expand our understanding of medication communication. Drawing out the coordination activities could be a missing piece for us to better understand how to streamline and improve multi-step communication processes with a goal of improving patient safety.

Provider connectedness and communication patterns: extending continuity of care in the context of the circle of care.

BACKGROUND: Continuity is an important aspect of quality of care, especially for complex patients in the community. We explored provider perceptions of continuity through a system's lens. The circle of care was used as the system. METHODS: Soft systems methodology was used to understand and improve continuity for end of life patients in two communities. PARTICIPANTS: Physicians, nurses, pharmacists in two communities in British Columbia, involved in end of life care. Two debates/discussion groups were completed after the interviews and initial analysis to confirm findings. Interview recordings were qualitatively analyzed to extract components and enablers of continuity. RESULTS: 32 provider interviews were completed. Findings from this study support the three types of continuity described by Haggerty and Reid (information, management, and relationship continuity). This work extends their model by adding features of the circle of care that influence and enable continuity: Provider Connectedness the sense of knowing and trust between providers who share care of a patient; a set of ten communication patterns that are used to support continuity across the circle of care; and environmental factors outside the circle that can indirectly influence continuity. CONCLUSIONS: We present an extended model of continuity of care. The components in the model can support health planners consider how health care is organized to promote continuity and by researchers when considering future continuity research.

A scoping review on health records for child-in-care.

A scoping review was conducted to determine the current state of knowledge on child-in-care health records in academic literature. Eight studies describing five such health records were found. Different terms were found between countries. A key finding from the studies was that research needs to report on "what worked" to inform policy and practice for positive changes. Complete, accurate and consistent health records for child-in-care are needed that can support care and be aggregated to identify policy and practice gaps and interventions that were effective. Such health records enabled moving from reactive to proactive care for the child. Social work case data elements found in a child-in-care health record not included in a child personal health record include: court dates, dental, abuse, placement, and education. Including these data elements allows looking at the overall wellbeing and development of the child. With the exception of two, all studies reported positively on their implementation. Further, all studies advocated for continued development of a tailored child-in-care health record. The evidence points toward child-in-care health records as a tool toward achieving healthy outcomes and policy development.

It's not about pager replacement: an in-depth look at the interprofessional nature of communication in healthcare.

BACKGROUND: Institutions have tried to replace the use of numeric pagers for clinical communication by implementing health information technology (HIT) solutions. However, failing to account for the sociotechnical aspects of HIT or the interplay of technology with existing clinical workflow, culture, and social interactions may create other unintended consequences. OBJECTIVE: To evaluate a Web-based messaging system that allows asynchronous communication between health providers and identify the unintended consequences associated with implementing such technology. DESIGN: Intervention-a Web-based messaging system at the University Health Network to replace numeric paging practices in May 2010. The system facilitated clinical communication on the medical wards for coordinating patient care. Study design-pre-post mixed methods utilizing both quantitative and qualitative measures. PARTICIPANTS: Five residents, 8 nurses, 2 pharmacists, and 2 social workers were interviewed. Pre-post interruption-15 residents from 5 clinical teams in both periods. MEASUREMENTS: The study compared the type of messages sent to physicians before and after implementation of the Web-based messaging system; a constant comparative analysis of semistructured interviews was used to generate key themes related to unintended consequences. RESULTS: Interruptions increased 233%, from 3 pages received per resident per day pre-implementation to 10 messages received per resident per day post-implementation. Key themes relating to unintended consequences that emerged from the interviews included increase in interruptions, accountability, and tactics to improve personal productivity. CONCLUSIONS: Meaningful improvements in clinical communication can occur but require more than just replacing pagers. Introducing HIT without addressing the sociotechnical aspects of HIT that underlie clinical communication can lead to unintended consequences.

A method for encoding clinical datasets with SNOMED CT.

BACKGROUND: Over the past decade there has been a growing body of literature on how the Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) can be implemented and used in different clinical settings. Yet, for those charged with incorporating SNOMED CT into their organisation's clinical applications and vocabulary systems, there are few detailed encoding instructions and examples available to show how this can be done and the issues involved. This paper describes a heuristic method that can be used to encode clinical terms in SNOMED CT and an illustration of how it was applied to encode an existing palliative care dataset. METHODS: The encoding process involves: identifying input data items; cleaning the data items; encoding the cleaned data items; and exporting the encoded terms as output term sets. Four outputs are produced: the SNOMED CT reference set; interface terminology set; SNOMED CT extension set and unencodeable term set. RESULTS: The original palliative care database contained 211 data elements, 145 coded values and 37,248 free text values. We were able to encode ~84% of the terms, another ~8% require further encoding and verification while terms that had a frequency of fewer than five were not encoded (~7%). CONCLUSIONS: From the pilot, it would seem our SNOMED CT encoding method has the potential to become a general purpose terminology encoding approach that can be used in different clinical systems.

Collaborative technology use by healthcare teams.

This paper reviews the literature on the use of collaborative technologies by healthcare teams between 1980 and 2003. Multiple databases were searched with explicit inclusion criteria that yielded 17 conceptual and empirical papers. The discussions of these literatures centered on the individual, team, and technological dimensions of collaborative technology use within healthcare teams. Results show that collaborative healthcare technologies can have positive effects on team work processes at both the individual and group level. The limited number of research studies accentuates the need for additional research in this area. Future research should focus on defining team tasks; determining which type of groupware works for a particular health setting; and exploring the effects of groupware on patient care delivery and the organization. Without research in these areas, it will be difficult to harness the full advantages of using groupware technologies by collaborative healthcare teams.

Project based experiential distance education: an oxymoron?

In the context of a program in Health Information Science at the University of Victoria in Victoria, BC, Canada, we have over the past 20 years made progress and gained experience in delivering a number of courses in a project-based experiential learning mode which links professionals and students in real world projects. As we are moving towards distance education, we are facing the challenge of translating these achievements into distance mode. The paper reviews the principles which make project-based educational mode involving collaboration with professionals desirable. We then review the experience with two specific courses, in which local students work with distant and local representatives of health institutions, respectively, on projects defined in the professional environment. This experience showed that the approach is of mutual interest and benefit to both the students and the professionals involved, but that a long lead time, and considerable detail in the preparation are required to lead such endeavors to success. We then discuss three alternatives to translating the principles of these approaches into distance mode. Among the alternatives, conducting a local project, closely affiliated with the teaching institution, or relying on a mock project which is based on recorded examples from previous projects, seem to be the most promising options. The alternative of having every student pursuing a different project, which may be local for the student but distant for the educational institution, is less attractive if faculty are expected to assume responsibility for successful project completion. It may, however, be the preferred solution if students are health professionals residing at distant health care institutions. All three alternatives have drawbacks that may limit the feasibility of project-based experiential learning in distance mode.

Introducing a technology-enabled problem-based learning approach into a health informatics curriculum.

PURPOSE: To investigate the effect on learner satisfaction of introducing a technology-enabled problem-based learning (PBL) approach into a health informatics curriculum. Course redesign was undertaken to prepare students for three 4-month work terms and a rapidly changing professional environment upon graduation. METHODS: Twenty-six Canadian undergraduate students of a redesigned course in biomedical fundamentals completed a midterm questionnaire in 2002. Eight of these students participated in a focus group. RESULTS: Students agreed that seven of nine functions provided by the web-based online course management system enhanced their learning: private email (92.3%), calendaring (88.5%), course notes (88.5%), discussion forums (84.5%), online grades (84.5%) assignment descriptions (80.8%) and online quizzes (80.8%). Although students agreed that two PBL activities enhanced learning (learning to present information) (84.5%) and learning to identify information needed (73.1%), the majority of students (69.2%) expressed a preference for the traditional lecture approach over the PBL approach. Students reported feeling uncertain of what was required of them and related anxiety accounted for most of the negative feedback. CONCLUSION: These findings give us clear goals for improvement in the course beginning with a comprehensive, carefully guided introduction to the processes of PBL. The positive trends are encouraging for the use of web-enabled courseware and for the further development of the PBL approach.

Left atrial cardiac hemangioma associated with shortness of breath and palpitations.

We present a patient with a left atrial hemangioma associated with shortness of breath and irregular heart-beats. Imaging modalities used to evaluate this rare tumor demonstrated characteristic features of its vascular nature. After successful surgical excision of the tumor under cardiopulmonary bypass, there were no clinical or echocardiographic evidence of recurrence at 18 months.