A Comparison of One- and Four-Open-Chart Access: No Change in Computerized Provider Order Entry Error Rates.

OBJECTIVE: To assess changes in computerized provider order entry error rates among providers who with less than 24-hour notice were switched from four-chart access to one-chart-only access. METHODS: An interrupted time series analysis of emergency medicine providers, hospitalists, and maternal child health providers was performed with pairwise comparison of computerized provider order entry error rates within and between specialties. This retrospective snapshot consisted of four phases. Phase 1 was the baseline 2 weeks where providers were privileged to work with up to four charts open. Phase 2 was the 2-week period where providers were limited to one-chart access. Phase 3 was the 2-week period where providers were returned to four-chart access. And phase 4 was a 2-week period 3 months following the end of phase 3. RESULTS: Analysis of the overall and specialty-stratified cohorts revealed no statistically significant differences in median computerized provider order entry error rates across the four phases (Wilcoxon signed-rank test, α = 0.05). However, statistically significant differences in median computerized provider order entry error rates were detected between the three specialties within each phase of the study (Kruskal-Wallis, p < 0.001). CONCLUSION: Allowing providers in select specialties to have access to four charts simultaneously does not increase their computerized provider order entry error rates. Significant differences in error rates between specialties suggest the need for further study of the use of standardized order sets, charting, and workflow variations.

Impact of a decision aid on reducing uncertainty: pilot study of women in their 40s and screening mammography.

BACKGROUND: In 2009 the United States Preventive Services Task Force updated its breast cancer screening guidelines to recommend that average-risk women obtain a screening mammogram every two years starting at age 50 instead of annually starting at age 40. Inconsistencies in data regarding the benefit versus risk of routine screening for women less than 50-years-of-age led to a second recommendation - that women in their forties engage in a shared decision making process with their provider to make an individualized choice about screening mammography that was right for them. In response, a web-based interactive mammography screening decision aid was developed and evaluated. METHODS: The decision aid was developed using an agile, iterative process. It was further honed based on feedback from clinical and technical subject matter experts. A convenience sample of 51 age- and risk-appropriate women was recruited to pilot the aid. Pre-post decisional conflict and screening choice was assessed. RESULTS: Women reported a significant reduction in overall decisional conflict after using the decision aid (Z = -5.3, p < 0.001). These participants also reported statistically significant reductions in each of the decisional conflict subscales: feeling uncertain (Z = -4.7, p < 0.001), feeling uninformed (Z = -5.2, p < 0.001), feeling unclear about values (Z = -5.0, p < 0.001), and feeling unsupported (Z = -4.0, p < 0.001). However, a woman's intention to obtain a screening mammogram in the next 1-2 years was not significantly changed (Wilcoxon signed-rank Z = -1.508, p = 0.132). CONCLUSION: This mammography screening decision aid brings value to patient care not by impacting what a woman chooses but by lending clarity to why or how she chooses it.

Mammography Decision Aid Reduces Decisional Conflict for Women in Their Forties Considering Screening.

BACKGROUND: Clinical guidelines recommend a personalized approach to mammography screening for women in their forties; however, methods to do so are lacking. An evidence-based mammography screening decision aid was developed as an electronic mobile application and evaluated in a before-after study. METHODS: The decision aid (Mammopad) included modules on breast cancer, mammography, risk assessment, and priority setting about screening. Women aged 40-49 years who were patients of rural primary care clinics, had no major risk factors for breast cancer, and no mammography during the previous year were invited to use the decision aid. Twenty women participated in pretesting of the decision aid and 75 additional women completed the before-after study. The primary outcome was decisional conflict measured before and after using Mammopad. Secondary outcomes included decision self-efficacy and intention to begin or continue mammography screening. Differences comparing measures before versus after use were determined using Wilcoxon signed rank tests. RESULTS: After using Mammopad, women reported reduced decisional conflict based on mean Decisional Conflict Scale scores overall (46.33 versus 8.33; Z = -7.225; p < 0.001) and on all subscales (p < 0.001). Women also reported increased mean Decision Self-Efficacy Scale scores (79.67 versus 95.73; Z = 6.816, p < 0.001). Although 19% of women changed their screening intentions, this was not statistically significant. CONCLUSIONS: Women reported less conflict about their decisions for mammography screening, and felt more confident to make decisions after using Mammopad. This approach may help guide women through the decision making process to determine personalized screening choices that are appropriate for them.

The utility of a health risk assessment in providing care for a rural free clinic population.

BACKGROUND: Free clinics are an important part of our country's health safety net, serving a working poor uninsured population. With limited resources and heavily dependent upon volunteer health care providers, these clinics have historically focused on stopgap, band-aid solutions to the population's health problems. Embracing a new paradigm, free clinics are now prioritizing resources for disease prevention and health promotion. METHODS: We initiated a Healthy Friday Clinic project in a rural, southwest Virginia free clinic. The clinic operated every Friday and was open to all people eligible for care in the free clinic. Each participant completed a 43 question Health Risk Appraisal which was used to calculate current risk age (age as determined by current lifestyle choices), optimal risk age (age with optimal lifestyle choices) and potential risk years gained (current risk age - optimal risk age) as well as a ranked listing of modifiable risk factors. RESULTS: The total sum of potential risk years gained in the free clinic population of 186 subjects was 371.4. Frequency distributions on potential risk years gained by each of the eleven modifiable risk factors revealed the following, in order of impact: quitting smoking could result in a total of 173.5 risk years gained; reducing alcohol consumption, 64.2 years gained; reducing blood pressure, 50.8 years gained; increasing seatbelt use, 38.2 years gained; weight reduction, 24.7 years gained; having regular mammograms, 6.8 years gained; reducing cholesterol levels, 5.8 years gained; reducing frequency of speeding while driving, 3.5 years gained; having regular pap tests, 2.3 years gained; improving HDL levels, 0.9 years gained; and reducing use of smokeless tobacco, 0.8 years gained. Each person received an individualized letter explaining his evaluation along with resources for making changes. DISCUSSION: Health risk assessments play a role in changing health beliefs and behaviors by providing subjects with individualized feedback on how their lifestyle choices impact their health and well-being. Summed data from health risk appraisals can also be a useful tool in determining the allocation of limited health resources. Whether health risk assessments impact health outcomes directly needs to be studied.

Beating asthma: a community-based asthma education initiative.

Beating Asthma is a community-based educational intervention designed to empower people with asthma by providing them with information about their pulmonary disease. The project consists of a series of three lectures delivered in a single 2-hour evening program by a pulmonologist, a health educator, and a licensed clinical psychologist. Surveys were distributed to participants before and after the program to assess general knowledge of asthma, the disease's pathophysiology, and asthma-management skills. Seventy-eight (77%) of the 101 families participating in the event completed both questionnaires. Regression model analysis of survey results showed that participants with the lowest scores before intervention achieved the greatest gains after intervention (P<.001). Analysis of the three topic areas revealed that only the subscore for disease management differed significantly from zero (P<.001). The authors assess the quality and usefulness of the survey instrument and the lecture content for future use.

Having the talk--and it's not about sex!

The end of life is a difficult time for individuals and their families; some families find it devastating. Although the majority of Americans express a desire to die at home, only 25% achieve this goal. This finding and others from the landmark Last Acts state-by-state report card suggest we can do more to help ease the end-of-life transition. Report card results are reported, highlighting the need for better communication between physicians and patients. Physicians have a key role to play in helping individuals and their families understand their choices and deal with end-of-life care issues. Resources and recommendations are offered to help facilitate planning discussions. Information about hospice use and eligibility is also outlined.