[Value of shared electronic health records for the management of homeless people]. / Prise en charge des personnes sans chez-soi : intérêt du dossier médical partagé ?

AIM: To assess the acceptability for GPS to use the French shared Electronic Health Record (Dossier Médical Partagé, "DMP") when caring for Homeless People (HP). METHODS: Mixed, sequential, qualitative-quantitative study. The qualitative phase consisted of semi-structured interviews with GPs involved in the care of HP. During the quantitative phase, questionnaires were sent to 150 randomized GPs providing routine healthcare in Marseille. Social and practical acceptability was studied by means of a Likert Scale. RESULTS: 19 GPs were interviewed during the qualitative phase, and 105 GPs answered the questionnaire during the quantitative phase (response rate: 73%). GPs had a poor knowledge about DMP. More than half (52.5%) of GPs were likely to effectively use DMP for HP. GPs felt that the "DMP" could improve continuity, quality, and security of care for HP. They perceived greater benefits of the use the DMP for HP than for the general population, notably in terms of saving time (p = 0.03). However, GPs felt that HP were vulnerable and wanted to protect their patients; they worried about security of data storage. GPs identified specific barriers for HP to use DMP: most of them concerned practical access for HP to DMP (lack of social security card, or lack of tool for accessing internet). CONCLUSION: A shared electronic health record, such as the French DMP, could improve continuity of care for HP in France. GPs need to be better informed, and DMP functions need to be optimized and adapted to HP, so that it can be effectively used by GPs for HP.

Sharing post-AML consolidation supportive therapy with local centers reduces patient travel burden without compromising outcomes.

Acute myeloid leukemia (AML) is frequently treated with induction and consolidation chemotherapy. Consolidation chemotherapy can be delivered on an ambulatory basis, requiring some patients to travel long distances for treatment at specialized centers. We developed a shared care model where patients receive consolidation chemotherapy at a quaternary center, but post-consolidation supportive care at local hospitals. To evaluate the impact of our model on patient travel and outcomes we conducted a retrospective analysis of AML and acute promyelocytic leukemia patients receiving consolidation over four years at our quaternary center. 73 patients received post-consolidation care locally, and 344 at the quaternary center. Gender, age and cytogenetic risk did not significantly differ between groups. Shared care patients saved mean round trip distance of 146.5km±99.6 and time of 96.7min±63.4 compared to travelling to quaternary center. There was no significant difference in overall survival between groups, and no increased hazard of death for shared care patients. 30, 60, and 90day survival from start of consolidation was 98.6%, 97.2%, and 95.9% for shared care and 98.8%, 97.1%, and 95.3% for quaternary center patients. Thus, a model utilizing regional partnerships for AML post-consolidation care reduces travel burden while maintaining safety.

Shared maternity care: all care--not enough responsibility? An audit of patient care communications pre- and post- a multi-faceted intervention.

BACKGROUND: Shared maternity care is an important model of care in Australia and overseas, but Victorian studies have shown patient dissatisfaction and widespread communication problems. AIMS: This study aimed to implement and evaluate initiatives to improve communication between three maternity hospitals and general practitioners involved in shared maternity care in Melbourne. METHODS: A pre- and post-design with audit of 150 hospital records at each of three hospitals plus audit of 20 general practitioner files for evidence of key communications on shared care patients, before and after a multifaceted intervention. RESULTS: Significant improvements at individual hospitals were seen if one person was made responsible for a communication outcome. Other initiatives did not lead to improvements if they did not include individual accountability. CONCLUSION: The standard of integration of shared maternity care is unacceptable low. Improvements to communication are achievable but depend on the allocation of individual time and responsibility, plus a commitment by hospitals to ongoing audit of their performance.

How a three-campus heart service line improves clinical processes and outcomes.

BACKGROUND: In 1993, Intermountain Health Care's three Salt Lake Valley Hospitals formed service lines in four clinical areas, one of which was heart services. After experimenting with various organizational structures, the Salt Lake Valley Hospitals formed a cardiac executive council and three specialty work teams--the clinical process and outcome, satisfaction, and resource teams--to allow for unified planning and greater teamwork. CASE STUDY--OPEN HEART TEAM: The team mapped out the current process and identified areas for potential improvement in the care of patients undergoing coronary artery bypass graft (CABG) surgery. One of the key processes selected for study was extubation. Patients were extubated for an average of 20.41 hours (range, 6 to 120 hours). Analysis of practice patterns demonstrated that extubation was related to staffing patterns, not the patient's readiness. The team created a weaning path, which reduced extubation time to an average of 8.89 hours. LESSONS LEARNED: A common vision and an organized structure to support integrated services is essential. Cross-training of staff helps ensure that the same standards of care apply across the three campuses. Even when the medical staff and hospital departments each have their own structures for dealing with quality issues, cohesiveness among physicians treating a certain group of patients, such as cardiac patients, can be promoted. In conclusion, a "cardiac culture" that is evident throughout the three hospitals promotes performance improvement.

Collaboration as a source of strength. Specific criteria guide potential collaborative relationships.

Leaders at SSM Health Care System (SSMHCS), St. Louis, believe collaboration can ensure that existing Catholic healthcare ministries continue to serve and to provide a full continuum of care. They see collaboration as both a source of strength and an expression of their Catholicism. To facilitate collaboration, SSMHCS leaders have developed six relationship models in which two types of collaborative arrangements are possible--informal and formal. Informal cooperative relationships may include consultation and participation by non-SSMHCS entities in established SSMHCS activities. Formal collaborative relationships include joint ventures at the operating entity level and in contract management, joint ventures at the governance-management level, and total affiliation (merger-acquisition). To ensure that SSMHCS leaders adequately evaluate healthcare providers with whom they may collaborate, in 1987 the system established criteria for collaboration. The criteria are based on specific mission, planning, financial, and operations principles. SSMHCS weights the mission criteria more heavily than other criteria because of the emphasis on mission in all its ministries.