Practicing Clinicians' Recommendations to Reduce Burden from the Electronic Health Record Inbox: a Mixed-Methods Study.

BACKGROUND: Workload from electronic health record (EHR) inbox notifications leads to information overload and contributes to job dissatisfaction and physician burnout. Better understanding of physicians' inbox requirements and workflows could optimize inbox designs, enhance efficiency, and reduce safety risks from information overload. DESIGN: We conducted a mixed-methods study to identify strategies to enhance EHR inbox design and workflow. First, we performed a secondary analysis of national survey data of all Department of Veterans Affairs (VA) primary care practitioners (PCP) to identify major themes in responses to a free-text question soliciting suggestions to improve EHR inbox design and workflows. We then conducted expert interviews of clinicians at five health care systems (1 VA and 4 non-VA settings using 4 different EHRs) to understand existing optimal strategies to improve efficiency and situational awareness related to EHR inbox use. Themes from survey data were cross-validated with interview findings. RESULTS: We analyzed responses from 2104 PCPs who completed the free-text inbox question (of 5001 PCPs who responded to survey) and used an inductive approach to identify five themes: (1) Inbox notification content should be actionable for patient care and relevant to recipient clinician, (2) Inboxes should reduce risk of losing messages, (3) Inbox functionality should be optimized to improve efficiency of processing notifications, (4) Team support should be leveraged to help with EHR inbox notification burden, (5) Sufficient time should be provided to all clinicians to process EHR inbox notifications. We subsequently interviewed 15 VA and non-VA clinicians and identified 11 unique strategies, each corresponding directly with one of these five themes. CONCLUSION: Feedback from practicing end-user clinicians provides robust evidence to improve content and design of the EHR inbox and related clinical workflows and organizational policies. Several strategies we identified could improve clinicians' EHR efficiency and satisfaction as well as empower them to work with their local administrators, health IT personnel, and EHR developers to improve these systems.

Analysis of referrals after a synergic work between Primary Care and Urology. Impact of joint protocol implementation and a continuing education program in our healthcare area. / Evolución de las derivaciones desde Atención Primaria a Urología tras la creación de un grupo de trabajo y la instauración de protocolos y cursos de formación continuada.

OBJECTIVE: To analyse the evolution and adequacy of referrals from Primary Care to Urology, after the implementation of referral protocols on the most frequent urological diseases and the establishment of a continuing education program. MATERIAL AND METHODS: A Primary Care-Urology work group was created in 2011. Initially, performance and clinical practice protocols in prostatic pathology (BPH and PSA) were established. These were supported by training sessions for primary care physicians. After analysing the effect of the mentioned joint work, 3more (scrotal pathology, urinary tract infections and urinary incontinence) were included. We analysed and compared the referrals and their adequacy before and after the establishment of the protocols. RESULTS: The most common referral causes were symptoms of the lower urinary tract due to BPH, which initially represented 22.8% of the total, and decreased to 16.9%. After the introduction of the new algorithms, we observed a decrease in referrals for scrotal pathology (13-14% to 7.8%), an increase in urinary incontinence referrals (3% al 10.3%) and those related to urinary tract infections remained stable. The adequacy to the protocols improved progressively: LUTS from 46% to 65.3%; PSA from 55% to 84.4% and urinary incontinence from 66.2% to 73.1%. Adequacy in scrotal pathology decreased (de 67.1% a 63.3%), while in UTI it stayed much the same (around 76%). CONCLUSIONS: The joint work between Urology and Primary Care achieves an improvement in referrals adequacy regarding the most frequent urological pathologies.

Patient Perspectives on Advance Care Planning via a Patient Portal.

BACKGROUND: Patient portals can offer patients an opportunity to engage in the advance care planning (ACP) process outside of clinical visits. OBJECTIVE: To describe patient perspectives on use of patient portal-based ACP tools. DESIGN: Interviews with patients who used portal-based ACP tools. The tools included an electronic Medical Durable Power of Attorney (MDPOA) form to designate a medical decision maker, a patient-centered educational web page, online messaging, and patient access to completed advance directives stored in the electronic health record (EHR). SETTING: Regional health-care system with a common EHR. MEASUREMENTS: Semistructured interviews with purposefully sampled patients who used the ACP tools. Questions explored motivations for using the tools and perceptions about how the tools fit into ACP. Analysis followed a grounded hermeneutic editing approach. RESULTS: From 46 patients (mean age: 49, 63% female), 4 key themes emerged: (1) individualized explorations of the ACP tools, (2) personal initiation and engagement with ACP tools through the portal, (3) value of connecting ACP portal tools to clinical care, and (4) practicality of the ACP tools. Patients described benefits of communicating with health-care team members who referred them to online ACP tools, as well as having the electronic MDPOA form connected to clinical care. CONCLUSIONS: Patients considered the portal-based ACP tools to be practical and feasible to use within the scope of their own ACP experiences. Further study is needed to understand whether portal-based ACP tools increase the quality and quantity of ACP conversations and documentation that is available to inform medical decision-making.

Balancing for an Effective Communication in Organizations.

Communication is an essential part of all activities of organizations. However, it is affected by technology. Today, email and social media are popular methods of communication in organizations. Each of the listed methods has advantages and disadvantages which will be discussed in this letter which tries to drive the attention of organizations to the need for a standard and balanced approach toward communication.

The relationship between the external environment and physician e-mail communication: The mediating role of health information technology availability.

BACKGROUND: Physician e-mail communication, with patients and other providers, is one of the cornerstones of effective care coordination but varies significantly across physicians. A physician's external environment may contribute to such variations by enabling or constraining a physician's ability to adopt innovations such as health information technology (HIT) that can be used to support e-mail communication. PURPOSE: The aim of the study was to examine whether the relationship of the external environment and physician e-mail communication with patients and other providers is mediated by the practice's HIT availability. METHODOLOGY: The data were obtained from the Health Tracking Physician Survey (2008) and the Area Resource File (2008). Cross-sectional multivariable subgroup path analysis was used to investigate the mediating role of HIT availability across 2,850 U.S. physicians. FINDINGS: Solo physicians' perceptions about malpractice were associated with 0.97 lower odds (p < .05) of e-mail communication with patients and other providers, as compared to group and hospital practices, even when mediated by HIT availability. Subgroup analyses indicated that different types of practices are responsive to the different dimensions of the external environment. Specifically, solo practitioners were more responsive to the availability of resources in their environment, with per capita income associated with lower likelihood of physician e-mail communication (OR = 0.99, p < .01). In contrast, physicians working in the group practices were more responsive to the complexity of their environment, with a physician's perception of practicing in environments with higher malpractice risks associated with greater information technology availability, which in turn was associated with a greater likelihood of communicating via e-mail with patients (OR = 1.02, p < .05) and other physicians (OR = 1.03, p < .001). PRACTICAL APPLICATIONS: The association between physician e-mail communication and the external environment is mediated by the practice's HIT availability. Efforts to improve physician e-mail communication and HIT adoption may need to reflect the varied perceptions of different types of practices.

Electronic Care Coordination From the Preoperative Clinic.

Fragmented and variable perioperative care exposes patients to unnecessary risks and handoff errors. The perioperative surgical home aims to optimize quality, value-based care. We performed a retrospective evaluation of how a preoperative assessment center could coordinate care through e-mails sent to a patient's healthcare team that initiate discussion on critical clinical information. During 100 clinic days on which 8122 patients were evaluated, 606 triggered e-mails, with a potential impact on 19 elements across the perioperative care spectrum. Four cases were canceled, and 42 cases were rescheduled. By fostering information exchange, these communications could advance patient-centered, value-enhanced quality and safety outcomes.

Intervención con rumba y educación nutricional para modificar factores de riesgo cardiovascular en adultos con síndrome metabólico / Intervention with rumba and nutrition education to modify cardiovascular risk factors in adults with metabolic syndrome

Objetivo. Evaluar el efecto de una intervención de rumba y educación nutricional sobre los factores de riesgo cardiovascular en un grupo de personas con síndrome metabólico de un área rural de Colombia. Métodos. Ensayo clínico controlado con asignación aleatoria, que incluyó 59 personas entre 30 y 60 años con síndrome metabólico. El grupo de intervención (n = 30) participó en un programa de 12 semanas de ejercicio con rumba aeróbica, 60 minutos, tres días por semana y trabajo de fortalecimiento muscular, 30 minutos, dos veces por semana. Además, recibió educación nutricional durante dos horas cada semana. El grupo control (n = 29) continuó con los cuidados convencionales. Se evaluó el efecto de la intervención de grupo sobre los factores de riesgo cardiovascular: fisiológicos, metabólicos, antropométricos y nutricionales. Resultados. En el grupo de intervención disminuyó la tensión arterial sistólica (-10,0 mmHg; IC95%: -14,3 a -5,6, P < 0,001), la diastólica (-4,8 mmHg; IC95%: -8,4 a -1,1, P < 0,05) y la puntuación del riesgo cardiovascular global a 10 años (-1,5%; IC95%: -2,7 a - 0,3, P < 0,05). Además, aumentaron el consumo de oxígeno máximo (1,7 mL O2.kg-1.min-1; IC95%: 0,1 a 3,3, P < 0,05) y la fuerza muscular (P < 0,001). También se observaron cambios favorables en la composición corporal, en la ingesta calórica y en el consumo de macro y micronutrientes (P < 0,05). No se detectaron diferencias entre los dos grupos en las variables metabólicas ni en los marcadores inflamatorios (P > 0,05). Conclusiones. Un programa de ejercicio con rumba y fortalecimiento muscular, unido a educación nutricional, modifica favorablemente los factores de riesgo cardiovascular en personas con síndrome metabólico.

Objective. Evaluate the effect of an intervention with rumba dance and nutrition education on the cardiovascular risk factors in a group of people with metabolic syndrome in a rural area of Colombia. Methods. Controlled, randomized clinical trial that included 59 people between 30 and 60 years of age with metabolic syndrome. The intervention group (n = 30) participated in a 12-week exercise program of aerobic rumba (60 minutes, 3 days per week) and muscle-strengthening work (30 minutes, twice a week). Each week the group also received two hours of nutrition education. The control group (n = 29) continued with conventional care. An assessment was made of the effect on the cardiovascular risk factors (physiological, metabolic, anthropometric, and nutritional) in the intervention group. Results. The intervention group showed a reduction in systolic blood pressure (-10.0 mmHg; CI95%: -14.3 to -5.6, P < 0.001), diastolic blood pressure (-4.8 mmHg; CI95%: -8.4 to -1.1, P < 0.05) and overall cardiovascular risk at 10 years (-1.5%; CI95%: -2.7 to -0.3, P < 0.05). Furthermore, there was an increase in peak oxygen con­sumption (1.7 ml O2∙kg-1∙min-1; CI95%: 0.1 to 3.3, P < 0.05) and muscular strength (P < 0.001). Positive changes were also observed in body composition, caloric intake, and consumption of macro and micronutrients (P < 0.05). No differences were detected between metabolic variables in the two groups or in inflammatory markers (P < 0.05). Conclusions. An exercise program with rumba and muscular strengthening, combined with nutrition education, favorably modifies cardiovascular risk factors in people with metabolic syndrome.

Puesta en marcha de una consulta por correo electrónico, para dar soluciones y no para crear problemas / Launching a consultation by email, to provide solutions, not to create problems

Objetivo: las tecnologías digitales ofrecen nuevas posibilidades para la promoción de la salud y la gestión de la enfermedad. Planteamos utilizar el correo electrónico en la consulta de Pediatría como una herramienta para extender y mejorar la comunicación con los pacientes ya conocidos. Metodología: se creó una cuenta de correo electrónico específica, ofertando a las familias adscritas al cupo de Pediatría la posibilidad de comunicación a través de este medio. Se les entregó una hoja con recomendaciones y acuerdos sobre aspectos prácticos de funcionamiento, para un uso correcto por ambas partes. Resultados: en estos casi cuatro años de funcionamiento, la experiencia ha sido positiva para ambas partes, profesionales implicados y familias. En una encuesta anónima, más del 90% de las familias expresó su satisfacción con esta forma de comunicación. Conclusiones: los padres o tutores en Pediatría utilizan las nuevas tecnologías y les resulta cómodo poder consultar temas de salud que no necesitan valoración presencial del niño, con los profesionales que atienden de forma habitual a su hijo, sin tener que pedir cita y desplazarse al centro de salud. Los profesionales podemos aportarles información meditada y seleccionada que pueden guardar para consultar en cualquier momento. Antes de poner en marcha una consulta por correo electrónico es importante evaluar cómo se va a utilizar este medio de comunicación, y acordar los aspectos prácticos necesarios para su correcto uso. Ha de ser resolutiva para los problemas planteados, y no una fuente de problemas para el profesional (AU)

Objective: digital technologies offer us new possibilities to promote health and management of diseases. We propose to use the e-mail in the pediatric office as a way for opening and improving the communication between the patients and the pediatrician. Methodology: we created a specific e-mail account, offering it to the assigned families so that they can communicate with their paediatrician. We give them some recommendations and agreements about how to use it correctly. Results: in these four years, the experiment has being satisfactory for both parts, pedriatricians and families. In an anonymous survey, 90% of the families were happy with this way of communication. Conclusions: in paediatrics, parents and guardians of children use new technologies and they find it convenient to consult health issues that do not require face to face assessment of the child, all of this with professionals who regularly attend their children without having to make an appointment and travel to the health center. Professionals can provide them thoughtfully and select information they can save to consult at any time. Before launching a consultation by e-mail it’s important to evaluate how you are going to use this medium, and agree on the practical aspects needed for proper use. It must be decisive for the posed problems and not a source of problems for the professional (AU)

[Innovative teleradiology network: concept and experience report]. / Innovativer Teleradiologieverbund: Konzept und Erfahrungsbericht.

(DICOM E-MAIL provides a standardized way for exchanging DICOM objects (Digital Imaging and Communications in Medicine) and further relevant patient data for the treatment context reliably and securely via encrypted e-mails. The current version of the DICOM E-MAIL standard recommendations of the"Deutsche Röntgengesellschaft" (DRG, German Röntgen Society) defines for the first time options for setting up a special directory service for the provision and distribution of communication data of all participants in a network. By using such"telephone books", networks of any size can be operated independent of the provider. Compared to a Cross-Enterprise Document Sharing (XDS) scenario, the required infrastructure is considerably less complex and quicker to realize. Critical success factors are, in addition to the technology and an effective support, that the participants themselves contribute to the further development of the network and in this way, the network approach can be practiced.

Timely response to secure messages from primary care patients.

PURPOSE: To assess delays in response to patient secure e-mail messages in primary care. BACKGROUND: Secure electronic messages are initiated by primary care patients. Timely response is necessary for patient safety and quality. DATA SOURCE: A database of secure messages. SAMPLE: A random sample of 353 secure electronic messages initiated by primary care patients treated in 4 clinics. OUTCOME MEASURES: Message not opened after 12 hours or messages not responded to after 36 hours. RESULTS: A total of 8.5% of electronic messages were not opened within 12 hours, and 17.6% did not receive a response in 36 hours. Clinic location, being a clinic employee, and patient sex were not related to delays. Patients older than 50 years were more likely to receive a delayed response (25.7% delayed, P = .013). The risk of both kinds of delays was higher on weekends (P < .001 for both). CONCLUSION: The e-mail message system resulted in high rates of delayed response. Delays were concentrated on weekends (Friday-Sunday). Reducing delayed responses may require automatic rerouting of messages to message centers staffed 24-7 or other mechanisms to manage this after-hours work flow.

Meaningful use and meaningful curricula: a survey of health informatics programmes in the USA.

The introduction of the US government's Meaningful Use criteria carries with it many implications including the training curriculum of healthcare personnel. This study examines 108 health informatics degree programmes across the USA. First, the courses offered are identified and classified into generic classes. Next, these generic groupings are mapped to two important frameworks: the Learning to Manage Health Information (LMHI) academic framework; and the Meaningful Use criteria policy framework. Results suggest that while current curricula seemed acceptable in addressing Meaningful Use Stage 1 objective, there was insufficient evidence that these curricula could support Meaningful Use Stage 2 and Stage 3. These findings are useful to both curriculum developers and the healthcare industry. Curriculum developers in health informatics must match curriculum to the emerging healthcare policy goals and the healthcare industry must now recruit highly trained and qualified personnel to help achieve these new goals of data-capture, data-sharing and intelligence.

Using a LISTSERV™ to develop a community of practice in end-of-life, hospice, and palliative care social work.

An e-mail discussion group (SW-PALL-EOL) connects the growing number of social workers interested in palliative and end-of-life care. The article discusses the concept of a technology supported "Community of Practice." Using content analysis, the article shows empirically how this electronic discussion group has contributed to the growth and expansion of a Community of Practice dedicated to improving palliative and end-of-life care among social workers. Examples are provided of the topics posted by subscribers and the guidance provided by the group's facilitators. Comments indicate satisfaction with the electronic discussion group.