Clinical information technology capabilities in four U.S. hospitals: testing a new structural performance measure.

BACKGROUND: Few tools exist to quantify the performance of a hospital's information system from a user perspective. OBJECTIVES: Our objective was to develop and evaluate a survey-based metric that assesses the automation and usability of a hospital's information system. RESEARCH DESIGN AND METHODS: This is a cross-sectional study of 117 physicians and 3 chief information officers (CIOs) working in 2 community hospitals with historically low investment in IT (Hospitals A and B), an academic hospital with an advanced IT system (Hospital C), or a major Veterans Affairs hospital (Hospital D). Respondents completed a survey assessing their institution's information system. The mean of 90 summed responses yields the clinical information technology (CIT) index, a global measure of a hospital's information system performance on a 100-point scale. RESULTS: On the global CIT index, mean physician scores were significantly higher for hospitals with advanced IT (61.1 and 64.3 for C and D) compared with those with low investment in IT (32.6 and 29.4 for A and B, P < 0.001). These differences also were observed for each of 7 separate subdomains. The CIO scores, 74.7, 78.0 for Hospitals C and D, and 44.5 for Hospitals A and B, paralleled the mean physician scores for these hospitals. All measures exhibited low variance for each hospital (eg, standard deviations for the CIT index ranged from 5.9 to 8.1) and intraclass correlation was high (Chronbach's alpha >.70). CONCLUSIONS: This assessment tool demonstrates initial evidence of validity and reliability.

Reporting elder abuse: a medical, legal, and ethical overview.

Elder abuse is a growing public health problem in the United States, with research suggesting that women may be at higher risk of abuse than men are. Laws on elder abuse have emerged over the recent decades, with nearly all states requiring mandatory reporting of suspected elder abuse cases. Physicians play key roles in helping their elder patients; they are often the only accessible individuals outside a frail elderly patient's family circle and are therefore in an ideal position to detect, manage, and prevent elder abuse. Unfortunately, they are not living up to their potential for reporting elder abuse. Physicians must confront and overcome barriers to detecting and reporting in order to provide appropriate care to elderly patients. This article defines elder abuse, outlines barriers to detecting and reporting elder abuse, provides an overview of the existing elder abuse laws, discusses the dilemmas surrounding mandatory reporting, and offers suggestions on how to manage cases of suspected abuse.

Pelvic examination training for interns: a randomized controlled trial.

PURPOSE: To evaluate the effectiveness of pelvic examination training for internal medicine interns conducted by instructors who also serve as models for the examination. METHOD: In 2001, 80 interns from three university internal medicine residencies completed questionnaires about their experiences with pelvic examinations. Interns who were available for training underwent baseline assessment of their pelvic examination skills and were randomized to training or to a control group that received only educational literature. Skills were assessed with a 29-item checklist at baseline and at follow-up by evaluators blinded to group assignment, and interrater agreement was estimated by review of audiotapes. RESULTS: Seventy-two interns were randomized and underwent baseline skills assessment. Seventy interns returned for follow-up assessment after approximately 14 weeks (range, 10-17 weeks). The 39 interns randomized to training and 33 randomized to the control group did not differ with respect to age, gender, or prior pelvic examination training. In both groups there was substantial variability in skills at baseline, with graduates of U.S. medical schools scoring significantly higher than did graduates of non-U.S. medical schools (0.66 versus 0.41, p < 10(-5)). Interns randomized to training had significantly higher scores at follow-up than did interns in the control group (0.79 versus 0.57, p < 10(-6)). For seven items verifiable by audiotape, interrater agreement was good (overall kappa, 0.54; range among items, 0.3-0.85). CONCLUSION: Specialized trainers can reliably evaluate and improve the pelvic examination skills of interns, and improvements are demonstrable three months after training. Further research is needed to ascertain whether training efficiency can be improved and to measure the impact of training on patient satisfaction and clinical outcomes.

Ethnic disparity in the treatment of women with established low bone mass.

OBJECTIVE: To assess the extent of bone-health treatment and to test for racial differences in that treatment among black and white women with documented low bone mass. METHODS: All women who underwent central dual-energy X-ray absorptiometry testing at the Washington, DC Veterans Affairs Medical Center (VAMC) from January 1, 1998 through October 15, 2001 were identified via the VAMC's computerized patient record system. Self-administered questionnaires measuring patient demographics, fracture history, and presence of appropriate bone-health treatments were mailed to those with T scores < or = -1.0 (n=110). RESULTS: Seventy-five women (68%) completed the survey (mean 61 years old, 55% white and 35% black). There were no statistically significant differences between black and white women in smoking (71% nonsmokers), avoiding excess alcohol (95%), or exercising regularly (68%). Eighty-one percent reported taking calcium supplements, 71% vitamin D supplements, and 56% antiresorptive medications; whites were significantly more likely than blacks to be taking calcium supplements (90% v 69%, p=.048) and antiresorptive drugs (71% v 35%, p=.004). The racial difference in antiresorptive medication use remained significant after adjusting for bone loss severity and prior fractures (odds ratio 3.71; 95% confidence interval 1.24, 11.0). CONCLUSION: Women with low bone mass treated at the Washington, DC VAMC reported high rates of bone-building behaviors and the use of calcium and vitamin D supplements and somewhat lower rates of antiresorptive drug use. Whites were more likely than blacks to be taking calcium supplements and antiresorptive drugs. The causes of these disparities should be identified in future studies.

Improving patient satisfaction with the transfer of care. A randomized controlled trial.

OBJECTIVE: To determine whether educational sessions with medical residents, with or without letters to their patients, improve patient satisfaction with transfer of their care from a departing to a new resident in an internal medicine clinic. DESIGN: Observational study in Year 1 to establish a historical control, with a randomized intervention in Year 2. SETTING: An internal medicine clinic in a teaching hospital. PATIENTS/PARTICIPANTS: Patients of departing residents completed questionnaires in the waiting room at their first visit with a new resident, with mail-administered questionnaires for patients not presenting to the clinic within 3 months after transfer of their care. In Year 1, 376 patients completed questionnaires without intervention. The following spring, we conducted interactive seminars with 12 senior residents to improve their transfer of care skills (first intervention). Half of their patients were then randomized to receive a letter from the new doctor informing them of the change (second intervention). We assessed the efficacy of the interventions by administering questionnaires to 437 patients in the months following the interventions. MEASUREMENTS AND MAIN RESULTS: Multivariate analysis of Year 1 results identified doctors personally informing patients prior to leaving as the single strongest predictor of patient satisfaction (partial R2=.41). In Year 2, our first intervention increased the percentage of patients informed by their doctors from 71% in 1991 to 79% in 1992 (P <.001). Mean satisfaction dramatically improved, with the fraction of fully satisfied patients increasing from 47% at baseline, to 61% with the first intervention alone, and 72% with both interventions (P <.0001). CONCLUSIONS: Simple methods such as resident education and direct mailings to patients significantly ease the difficult process of transferring patients from one physician to another. This has implications not only for residency programs, but for managed care networks competing to attract and retain patients.