Decreasing inter-resident conflict by using computer-generated on-call schedules.

OBJECTIVE: Although significant attention has been paid to the number of hours worked by residents, little consideration has been given to how the hours are assigned. This project describes an alternative to having Chief Residents manually create on-call schedules. In order to enhance objectivity and transparency, reduce perceived inequities in the process, and reduce inter-resident conflict, Harvard South Shore Psychiatry Residency Training Program experimented with a computer-generated on-call schedule. METHOD: A locally written MATLAB script generated an on-call schedule for academic year (AY) 2012-2013. Measurements to assess the manual scheduling method (from AY 2011-2012) and the computer-generated method included the balance in the total number of hours assigned to individual residents; the number of call switches over two six-month periods; and survey of the residents' perception of fairness of the two scheduling methods and preferences. RESULTS: A retrospective analysis of the AY 2011-2012 Chief Resident-generated call schedule found a range of differences of up to 25.8% between total hours assigned to individual residents in a given year. In the AY 2012-2013 computer-generated schedule, the differences in total hours assigned were reduced to a maximum of 6.1%. There were 63% fewer call switches resulting from the computer-generated as compared to the Chief Resident-generated method. Resident survey response rate was 76%. Seventy-seven percent of resident respondents (N = 22) perceived the computer-generated method to be fairer, and 90.9% of residents preferred having a summary table of hours of call per resident. Residents perceived the computer-generated method as resulting in less inter-resident conflict. CONCLUSION: Methods for assigning duty hour schedules that are transparent, equitable, and require less Chief involvement may result in perceptions of greater fairness and less inter-resident conflict.

The electronic medical office: optimizing solutions.

Optimizing the care for patients in the orthopaedic clinical setting involves a wide range of issues. Surgical techniques, preoperative and postoperative care, long-term outcomes follow-up, continuing education, and patient communication are a few of the important areas that surgeons deal with on a regular basis. Successful management of this information has an impact on clinical outcomes, direct patient care, financial decisions, and management of the surgeon's time. The development of a comprehensive electronic medical office is a powerful and probably necessary tool to successfully manage such information and achieve the goals of an effective and safe orthopaedic practice.

Measuring and improving preventive care for patients with diabetes in primary health centers.

Diabetes care among medically underserved patients is suboptimal. Few studies, however, have described successful strategies to improve diabetes care in these patient populations. To address this issue, 4 Montana community health centers and 1 urban Indian health center implemented quality improvement efforts along with an office-based electronic system for monitoring diabetes care. After a median of 17 months follow-up, preventive services and clinical outcomes were assessed for all patients at baseline (N = 332) and follow-up (N = 590), and for a cohort (N = 164) who had 1 or more visits 6 months after baseline. In cross-sectional analyses, there were increases from baseline to follow-up in the percent of patients who had received an annual foot examination (50% to 68%), microalbuminuria testing (34% to 62%), annual retinal examination (14% to 30%), pneumococcal immunization (30% to 61%), and smoking assessment (77% to 91%). But neither HbA1c testing in the previous 6 months (64% to 55%) nor annual LDL-C testing (59% to 61%) showed any improvement. There were no significant changes from baseline to follow-up in the median hemoglobin A1c (HbAlc), low density lipoprotein-cholesterol (LOL-C), or in systolic and diastolic blood pressure values. Similar improvements in preventive care were seen in the cohort of patients with diabetes. But overall outcomes were not improved. Our findings suggest that office-based monitoring systems can support systems' changes to improve the delivery of preventive services to patients with diabetes in primary care facilities for the underserved, but outcomes are more difficult to enhance over a short period of follow-up. Also, our findings suggest that over a relatively short-term period, cross-sectional and cohort analyses of quality improvement measures do yield similar measures of diabetes care in such settings.

Towards improvement of the accuracy and completeness of medication registration with the use of an electronic medical record (EMR).

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.

A standardized message for supporting shared care.

As health care becomes more complex, interest in the benefits of coordination of care has increased. Especially patients that are being treated jointly by more than one physician (shared care), are vulnerable to adverse effects resulting from inadequate coordination and communication. We describe a study in which care providers support shared care by using computer-based patient records for data storage, and structured electronic data interchange as a means of communication. In this study, we are aiming at the development and implementation of protocols for shared care.

HL7 looks beyond the hospital walls.

HL7 is trying to build a bridge linking more than just providers and payers. Through electronic data interchange, the standards group hopes to better link physicians' practice management systems with their affiliated hospitals' information system, creating a crossfeed of information that could ultimately have profound effects on the quality of patient care.

Who's in charge here? You or your computer?!

To pinpoint problems, look at hardware, software, support training and the user. The problem may reside in any one, or several, of these areas.

Evaluation of a facsimile (fax) transfer system for medication order delivery.

Delivery of medication orders for initial processing is often slowed by distance between the nursing unit and the pharmacy. Messengers and pneumatic tubes are not always available or reliable. Facsimile (fax) machines are able to transmit photocopies of medication orders in seconds. An initial evaluation of available fax machines led to selection of three models for a trial installation. Criteria for fax evaluation included medication order turnaround time (TAT), percentage of orders requiring more than 2 hours to be received by the nursing unit, and number of orders recopied by nursing personnel for pharmacy use. An initial review identified the time required for order processing using a reliable pneumatic tube system to deliver orders to the central pharmacy. The number of orders recopied by nurses into the chart to provide working copies of misplaced or lost orders for pharmacy was also recorded. The fax system was installed and the initial data collection process was repeated. Statistics focused on the total time required to transmit an order to pharmacy and provide the initial dose to the nursing unit. Analysis of the mean (+/- SD) showed an initial TAT of 1.59 (+/- 1.30) hours (n = 92). TAT after initiation of fax transmission was 1.36 (+/- 1.15) hours, P = 0.20 (n = 104). This improvement is greater than it appears because 1.10 hours of both of these times are fixed times involving pharmacy order processing. The percentage of orders that required more than two hours to provide medication to the nursing unit was reduced from 29% (27/92) to 18% (19/104) P less than 0.05. The average number of nursing recopies into the chart was reduced.

Electronic mail and privacy: setting your company's policy.

In setting a privacy policy, a company must consider not only its interest and the interests of its employees, but also the interests of third parties, including suppliers, customers, law enforcement agencies, and others who may have a legal right to or interest in accessing company records, including electronic mail.

Computerization of the urologic office. Billing, record keeping, and education.

Careful initial evaluation of the options is vital to successful medical office automation. The many available software programs should be scrutinized to be certain the one chosen satisfies all one's listed needs. In addition to the usual functions expected of computers, the data gathered can be used to market the urologic practice. Word processing, spreadsheet, and database programs can enhance relations among the urologist's office, referring physicians, and patients.