Using computerized provider order entry to enforce documentation of tests with pending results at hospital discharge.

BACKGROUND: Small numbers of tests with pending results are documented in hospital discharge summaries leading to breakdown in communication and medical errors due to inadequate followup. OBJECTIVE: Evaluate effect of using a computerized provider order entry (CPOE) system to enforce documentation of tests with pending results into hospital discharge summaries. METHODS: We assessed the percent of all tests with pending results and those with actionable results that were documented before (n = 182 discharges) and after (n = 203 discharges) implementing the CPOE-enforcement tool. We also surveyed providers (n = 52) about the enforcement functionality. RESULTS: Documentation of all tests with pending results improved from 12% (87/701 tests) before to 22% (178/812 tests) (p = 0.02) after implementation. Documentation of tests with eventual actionable results increased from 0% (0/24) to 50% (14/28)(p<0.001). Survey respondents felt the intervention improved quality of summaries, provider communication, and was not time-consuming. CONCLUSIONS: A CPOE tool enforcing documentation of tests with pending results into discharge summaries significantly increased documentation rates, especially of actionable tests. However, gaps in documentation still exist.

Home-based HIV counselling and testing in western Kenya.

BACKGROUND: The World Health Organisation (WHO) estimates that only 12% of men and 10% of women in sub-Saharan Africa have been tested for HIV and know their test results. Home-based counselling and testing (HBCT) offers a novel approach to complement facility-based provider initiated testing and counselling (PITC) and voluntary counselling and testing (VCT) and could greatly increase HIV prevention opportunities. However, there is almost no evidence that large-scale, door-to-door testing is even feasible in settings with both limited resources and significant stigma around HIV and AIDS. OBJECTIVE: To describe our experience with the feasibility and acceptance of home-based HIV counselling and testing (HBCT) in two large, rural, administrative divisions of western Kenya. DESIGN: The USAID-AMPATH Partnership conducted population-based, house-to-house HIV counselling and testing in western Kenya between June 2007 and June 2009. All individuals aged > or = 13 years and all eligible children were offered HBCT. Children were eligible if they were above 13 years of age, and their mother was either HIV-positive or had unknown HIV serostatus, or if their mother was deceased or whose vital status was unknown. SETTING: Kosirai and Turbo Divisions, Rift Valley Province, Kenya. RESULTS: There were 47,066 households approached in 294 villages: 97% of households allowed entry. Of the 138,026 individuals captured, 101,167 individuals were eligible for testing: 89% of adults and 58% of children consented to HIV testing. The prevalence of HIVin these communities was 3.0%: 2.7% in adults and 3.7% among children. Prevalence was highest in the 36-45 year age group and was almost always higher among women and girls. All persons testing HIV-positive were referred to Academic Model Providing Access to Healthcare (AMPATH) for further assessment and care; all consenting persons were counselled on HIV risk-lowering behaviours. CONCLUSION: Home-based HIV counselling and testing was feasible among this rural population in western Kenya, with a majority of the population accepting to get tested. These data suggest that scaling-up of HBCT is possible and may enable large numbers of individuals to know their HIV serostatus in sub-Saharan Africa. More research is needed to describe the cost-effectiveness and clinical impact of this approach.

Patterns of care in two HIV continuity clinics in Uganda, Africa: a time-motion study.

The study objectives were to identify opportunities to improve the quality of care in resource-limited settings by examining the workflow and patient activities at two large outpatient HIV clinics in Uganda. Using time motion study techniques, we collected detailed data on all activities of patients and clinicians in two government-sponsored HIV clinics in Uganda. Processes measured included amount of time clinicians (physicians, nurse practitioners and clinical officers) spend in clinic, the daily patient census and patient visit-length. We also recorded the time spent on various activities by providers and patients. We found that the mean time in clinic per workday at Masaka was 5.5 hours and at Mbarara 4.9 hours, with about 60% of this time spent in direct and indirect care of patients at both sites. Workday start-times varied by two hours in Masaka and one-and-a half hours in Mbarara and end-times by five and three hours respectively. One-hundred-and-nineteen patients (SD 34) visited Masaka each day and 107 (SD 45) visited Mbarara. The mean duration of the patient visit was 77 minutes at Masaka and 196 minutes at Mbarara, with 66% and 62% of the time spent at respective sites waiting for care. We conclude that clinicians in resource-poor settings spend limited amounts of time at the clinic site, with a large portion of the clinic-time taken up by tasks that do not require specialized patient-care skills. This study demonstrates that opportunities exist to improve clinic productivity and visit experience for patients, and provides a baseline for designing and evaluating the impact of process improvement interventions.