Bottom-up and middle-out approaches to electronic patient information systems: a focus on healthcare pathways.

BACKGROUND: A study is reported that examines the use of electronic health record (EHR) systems in two UK local health communities. OBJECTIVE: These systems were developed locally and the aim of the study was to explore how well they were supporting the coordination of care along healthcare pathways that cross the organisational boundaries between the agencies delivering health care. RESULTS: The paper presents the findings for two healthcare pathways; the Stroke Pathway and a pathway for the care of the frail elderly in their own homes. All the pathways examined involved multiple agencies and many locally tailored EHR systems are in use to aid the coordination of care. However, the ability to share electronic patient information along the pathways was patchy. The development of systems that did enable effective sharing of information was characterised by sociotechnical system development, i.e. associating the technical development with process changes and organisational changes, with local development teams that drew on all the relevant agencies in the local health community and on evolutionary development, as experience grew of the benefits that EHR systems could deliver. CONCLUSIONS: The study concludes that whilst there may be a role for a national IT strategy, for example, to set standards for systems procurement that facilitate data interchange, most systems development work needs to be done at a 'middle-out' level in the local health community, where joint planning between healthcare agencies can occur, and at the local healthcare pathway level where systems can be matched to specific needs for information sharing.

Cost-effectiveness and cost-utility of tricyclic antidepressants, selective serotonin reuptake inhibitors and lofepramine: randomised controlled trial.

BACKGROUND: The cost-effectiveness of tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) has not been compared in a prospective study in primary care. AIMS: To determine the relative cost-effectiveness of TCAs, SSRIs and lofepramine in UK primary care. METHOD: An open-label, three-arm randomised trial with a preference arm. Practitioners referred 327 patients with incident depression. RESULTS: No significant differences were found in effectiveness or cost-effectiveness. The numbers of depression-free weeks over 12 months (on the Hospital Anxiety and Depression Scale) were 25.3 (95% CI 21.3-29.0) for TCAs, 28.3 (95% CI 24.3-32.2) for SSRIs and 24.6 (95% CI 20.6-28.9) for lofepramine. Mean health service costs per patient were pound 762 (95% CI 553-1059) for TCAs, pound 875 (95% CI 675-1355) for SSRIs and pound 867 (95% CI 634-1521) for lofepramine. Cost-effectiveness acceptability curves suggested SSRIs were most cost-effective (with a probability of up to 0.6). CONCLUSIONS: The findings support a policy of recommending SSRIs as first-choice antidepressants in primary care.

Characteristics of career advisors for general practice--a qualitative study of UK GPs.

BACKGROUND: Career support needs of general practitioners are poorly described in the literature. METHOD: Semi-structured interviews of 26 practising GPs from two United Kingdom counties. RESULTS: General practitioners believed they would benefit from the provision of career advice and guidance provided by trained peers. They were looking for advisors to whom they could relate and who understood their professional and personal needs, in particular: listening skills, life experience, credibility, protected time, ability to challenge, give careful consideration, trustworthiness, knowledge about GP careers, facilitation skills, and empathy. DISCUSSION: A strategy put in place in Australia might enable GPs to implement career plans.

Do we have the training? The ethics of workplace drug testing and the GP.

BACKGROUND: Workplace drug testing has been in place in Australia since the early 1990s. In some industries it is required by legislation, while in others, employers have introduced it as an apparent cost effective way of improving productivity, safety and the health of its workforce while reducing absenteeism, accident rates and even deaths. There are national standards in place for workplace drug testing regarding specimen collection and testing, and well documented processes to follow in establishing a drug screening program within a workforce. OBJECTIVE: This article explores the ethics of workplace drug testing and questions the assumed rights and obligations of employer, employee and the clinician involved in occupational medicine. DISCUSSION: It is questionable whether most general practitioners have the appropriate training to deal with these ethical issues comprehensively.

Membership of the Royal College of General Practitioners and recognition of depression in primary care.

To determine the effect of membership of the Royal College of General Practitioners (RCGP) on recognition of depression, odds ratios, Lowess-smoothed plots, and regression models were produced for recognition rates in a representative sample of 20,818 patient contacts for members and non-members of the RCGP Membership of the RCGP did not appear to convey greater ability to discriminate between depressed and non-depressed patients, but members were more likely to recognise depression in both depressed and non-depressed individuals.

Credibility of problem-solving therapy and medication for the treatment of depression among primary care patients.

BACKGROUND: Patient beliefs in the effectiveness of treatment may have an important influence on treatment outcome. MATERIAL/METHODS: Associations between patient beliefs in the credibility of treatment and outcome were explored in a randomised controlled trial of major depression in primary care (n=155). The four treatments were antidepressant medication given by research general practitioner, problem solving treatment given by research general practitioner or research practice nurse over 12 weeks or a combination of problem solving treatment and antidepressant medication. Patients' belief in the credibility of treatment was assessed using a brief Credibility Scale, that was completed following randomisation and after treatment. Depression outcome was measured at 6, 12 and 52 weeks using the Hamilton Rating Scale for depression, and the Beck depression inventory. RESULTS: Pre-treatment, medication treatment was associated with a higher certainty of recovery than was problem-solving treatment from the nurse (p=0.018). Post-treatment, medication and combination treatment were seen as more logical than problem-solving treatment from the nurse (p<0.03). Post-treatment medication had higher certainty of recovery and was more highly recommended to a friend. Linear regression demonstrated that the depression outcome measures were not associated with either pre- or post-treatment credibility. CONCLUSIONS: Patients found all four treatments highly credible following their initial explanation. There was a significant difference both pre- and post-treatment in favour of patients finding treatment involving medication more credible than problem-solving from a nurse. Pre- and post-treatment scores of credibility were not associated with outcome.