Barriers to end-of-life care for African Americans from the providers' perspective: opportunity for intervention development.

Research has shown that African Americans (AAs) are less likely to complete advance directives and enroll in hospice. We examined barriers to use of these end-of-life (EOL) care options by conducting semi-structured interviews with hospice and palliative medicine providers and leaders of a national health care organization. Barriers identified included: lack of knowledge about prognosis, desires for aggressive treatment, family members resistance to accepting hospice, and lack of insurance. Providers believed that acceptance of EOL care options among AAs could be improved by increasing cultural sensitivity though education and training initiatives, and increasing staff diversity. Respondents did not have programs currently in place to increase awareness of EOL care options for underrepresented minorities, but felt that there was a need to develop these types of programs. These data can be used in future research endeavors to create interventions designed to increase awareness of EOL care options for AAs and other underrepresented minorities.

The good, the bad and the early adopters: providers' attitudes about a common, commercial EHR.

RATIONALE, AIMS AND OBJECTIVES: To describe primary care providers' (PCP) attitudes about the impact of a mature, commercial electronic health records (EHR) on clinical practice in settings with experience using the system and to evaluate whether a provider's propensity to adopt new technologies is associated with more favourable perceptions. METHOD: We surveyed PCPs in 11 practices affiliated with three health systems in Texas. Most practices had greater than 5 years of experience with the Epic EHR. The effect of early adopter of technology status was evaluated using logistic regression. RESULTS: One hundred forty-six PCPs responded (70%). Most thought the EHR had a positive impact on routine tasks, such as prescription refills (94%), whereas fewer agreed for complex tasks, such as delivery of guideline-concordant care for chronic illnesses (51%). Two-thirds (62%) thought it interfered with eye contact with patients, and 40% reported that it interfered with in-visit communication. Early adopters of technology reported greater positive effects of the EHR, even after adjusting for age, ranging from 2% to 15% higher on satisfaction ratings. CONCLUSION: PCPs practicing in settings with considerable experience using a common commercial EHR identified many positive effects, as well as two key areas for improvement - patient centredness and intelligent decision support. Providers with a propensity to adopt new technologies have more favourable perceptions of the EHR.

Use and satisfaction with key functions of a common commercial electronic health record: a survey of primary care providers.

BACKGROUND: Despite considerable financial incentives for adoption, there is little evidence available about providers' use and satisfaction with key functions of electronic health records (EHRs) that meet "meaningful use" criteria. METHODS: We surveyed primary care providers (PCPs) in 11 general internal medicine and family medicine practices affiliated with 3 health systems in Texas about their use and satisfaction with performing common tasks (documentation, medication prescribing, preventive services, problem list) in the Epic EHR, a common commercial system. Most practices had greater than 5 years of experience with the Epic EHR. We used multivariate logistic regression to model predictors of being a structured documenter, defined as using electronic templates or prepopulated dot phrases to document at least two of the three note sections (history, physical, assessment and plan). RESULTS: 146 PCPs responded (70%). The majority used free text to document the history (51%) and assessment and plan (54%) and electronic templates to document the physical exam (57%). Half of PCPs were structured documenters (55%) with family medicine specialty (adjusted OR 3.3, 95% CI, 1.4-7.8) and years since graduation (nonlinear relationship with youngest and oldest having lowest probabilities) being significant predictors. Nearly half (43%) reported spending at least one extra hour beyond each scheduled half-day clinic completing EHR documentation. Three-quarters were satisfied with documenting completion of pneumococcal vaccinations and half were satisfied with documenting cancer screening (57% for breast, 45% for colorectal, and 46% for cervical). Fewer were satisfied with reminders for overdue pneumococcal vaccination (48%) and cancer screening (38% for breast, 37% for colorectal, and 31% for cervical). While most believed the problem list was helpful (70%) and kept an up-to-date list for their patients (68%), half thought they were unreliable and inaccurate (51%). CONCLUSIONS: Dissatisfaction with and suboptimal use of key functions of the EHR may mitigate the potential for EHR use to improve preventive health and chronic disease management. Future work should optimize use of key functions and improve providers' time efficiency.

Formative assessment of use of behavioral data in HIV prevention: Texas.

A formative assessment was conducted with Texas HIV prevention community planning group (CPG) members, prevention provider staff, and supervisors of those staff to better understand how to enhance their use of epidemiologic and behavioral data in the selection and prioritization of prevention interventions. Semi-structured interviews, mail surveys, and content analysis of funding proposals were used to determine the current use of these data, their perceived value, and the most trusted sources for data. CPG members, prevention provider staff, and supervisors valued information from their peers and networking most, and made more use of socially available information than they did research or systematically collected assessment data. CPG members wanted more local data and data on specific sub-populations of interest. Prevention providers viewed the utility of behavioral data as limited, and were primarily concerned with the pragmatic aspects of fielding interventions; however, this group also expressed an interest in rapid community assessment methods and learning more about new and effective prevention interventions. These results led to the development of training and technical assistance materials.

Bridging data and decision making: development of techniques for improving the HIV prevention community planning process.

Assessments of community planning in Massachusetts and Texas were used to develop tools for increasing the use of data by HIV prevention community planning groups (CPGs) and prevention providers while also increasing participation of CPG members. Barriers to data use included organizational problems in CPGs (e.g., lack of clear procedures, distrust of peers and leadership) and technical assistance needs for CPG members and researchers who provide data. The absence of data relevant to local epidemics was another barrier. Specific linkages are provided between the assessments of these needs and the development of a technical assistance tools (e.g., websites, templates for data presentation, experiential involvement in data use) and strategies for organizational change in CPGs, as well as efforts to better use available data and create or identify new sources of local data.

After the innovation: outcomes from the Texas behavioral data project.

The Texas Department of Health and University of Texas Southwestern staff, using formative assessment data, developed a set of innovative methods and tools to increase the use of behavioral and epidemiologic data in decision-making about HIV prevention interventions by HIV prevention community planning groups (CPGs) and HIV prevention providers. Semistructured interviews, mail surveys, meeting observations, and content analysis of funding proposals were used to measure the results of the multifaceted intervention. Compared to baseline measures, CPG members reported that data played a more central and desired role in their decision-making. HIV prevention providers exposed to the project's materials were more likely to choose evidence-based interventions to conduct. The tools and structural intervention methods of this project were diffused and had an impact on the use of behavioral data by community planning groups and HIV prevention providers. The structural interventions were not sufficient without the additional effect of the trained peers acting as advocates and intervention innovators.

Improving the use of data for HIV prevention decision making: lessons learned.

HIV prevention community planning was developed to promote identification of local prevention priorities through a process that was evidence-based and provided community input. There are a variety of barriers to effective use of data in community planning which include characteristics of data (availability, timeliness, relevance to planning tasks), characteristics of planning group members and providers of data (e.g., skills in understanding and applying data), and social-organizational aspects of community-planning groups (CPGs). Lessons learned from this project illustrate how to create locally relevant sources of data, build data use skills of CPG members and data providers, and address social-organizational aspects of planning, while also better integrating community planning with implementation of prevention plans. Adaptation of tools and methods is discussed along with future considerations for research and planning practice.