Antoinette de Bont

Improving the quality of eye care with tele-ophthalmology: shared-care glaucoma screening

We evaluated a shared-care tele-ophthalmology service initiated by the Rotterdam Eye Hospital and 10 optometrists working in retail optician stores. The optometrists screened their clients with a nerve fibre analyser and the resulting images were then further assessed by trained technicians at the hospital. We analysed data from 1729 patients and measured several indicators of the quality of the work as well as its efficiency and effectiveness. The quality of the images was at least satisfactory in most cases (89%), and the agreement between the optometrists and the hospital about normal or suspect test results was high (81%). Only 27% of the patients were called for additional testing at the hospital department and 11% consulted an ophthalmologist. Eighty new cases of glaucoma were detected. The combination of task redesign and telemedicine accounted for the success of the screening service. Task redesign was needed to transfer screening from the hospital to primary care in a safe and responsible way. Telemedicine was crucial for assuring quality, facilitating information exchange and for coordination.

Telemedicine in interdisciplinary work practices: On an IT system that met the criteria for success set out by its sponsors, yet failed to become part of every-day clinical routines

BackgroundInformation systems can play a key role in care innovations including task redesign and shared care. Many demonstration projects have presented evidence of clinical and cost effectiveness and high levels of patient satisfaction. Yet these same projects often fail to become part of everyday clinical routines. The aim of the paper is to gain insight into a common paradox that a technology can meet the criteria for success set out at the start of the project yet fail to become part of everyday clinical routines.MethodsWe evaluated a telecare service set up to reduce the workload of ophthalmologists. In this project, optometrists in 10 optical shops made digital images to detect patients with glaucoma which were further assessed by trained technicians in the hospital. Over a period of three years, we conducted interviews with the project team and the users about the workability of the system and its integration in practice. Beside the interviews, we analyzed record data to measure the quality of the images. We compared the qualitative accounts with these measurements.ResultsAccording to our measurements, the quality of the images was at least satisfactory in 90% of the cases, i.e. the images could be used to screen the patients – reducing the workload of the ophthalmologist considerably. However, both the ophthalmologist and the optometrists became increasingly dissatisfied respectively with the perceived quality of the pictures and the perceived workload.Through a detailed analysis of how the professionals discussed the quality of the pictures, we re-constructed how the notion of quality of the images and being a good professional were constructed and linked. The IT system transformed into a quality system and, at the same time, transformed the notions of being a good professional. While a continuous dialogue about the quality of the pictures became an emblem for the quality of care, this dialogue was hindered by the system and the way the care process was structured.ConclusionTo conceptualize what telemedicine does in interdisciplinary work practices, a fine-tuned analysis is needed to assess how IT systems re-shape the social relations between professional groups. Such transformations should not be exclusively attributed to the technology itself or to the professionals working with it. Instead we need to assess these technologies through an empirically grounded study of the sociotechnical functioning of telemedicine.

Looking for answers, constructing reliability: An exploration into how Dutch patients check web-based medical information

INTRODUCTION In the discussion about helping lay end users find reliable health-related information on the web, lay assessment practices of the reliability of information are often dismissed as insufficient. It is suggested that patients do not check important background information (authors, dates) for the medical content on websites. However, little effort has been made to understand how lay practices enable patients to assess information reliability in respect to their specific health situations. OBJECTIVE This paper draws upon ethnographic research among Dutch patients to understand lay assessment practices. METHODS We conducted qualitative interviews and observed patient search practices. Patients were asked to describe and then repeat the last searches they had conducted. They were also given standardized questions for searching for information. RESULTS Patients did not utilize special user tools (checklists, seals, portals) to assist in searching for and evaluating information. However, we saw explicit strategies for checking information within their established patterns of searching, such as on and offline triangulation of information and checking information provider information and dates. CONCLUSION Although patients do not follow standardized checklists, this is not to say that they are not assessing information. Their assessment processes are more extensive than current literature suggests.

Information Rx: Prescribing Good Consumerism and Responsible Citizenship

Recent medical informatics and sociological literature has painted the image of a new type of patient—one that is reflexive and informed, with highly specified information needs and perceptions, as well as highly developed skills and tactics for acquiring information. Patients have been re-named “reflexive consumers.” At the same time, literature about the questionable reliability of web-based information has suggested the need to create both user tools that have pre-selected information and special guidelines for individuals to use to check the individual characteristics of the information they encounter. In this article, we examine suggestions that individuals must be assisted in developing skills for “reflexive consumerism” and what these particular skills should be. Using two types of data (discursive data from websites and promotional items, and supplementary data from interviews and ethnographic observations carried out with those working to sustain these initiatives), we examine how users are directly addressed and discussed. We argue that these initiatives prescribe skills and practices that extend beyond finding and assessing information on the internet and demonstrate that they include ideals of consumerism and citizenship.

Characteristics of Patient Portals Developed in the Context of Health Information Exchanges: Early Policy Effects of Incentives in the Meaningful Use Program in the United States

Background In 2014, the Centers for Medicare & Medicaid Services in the United States launched the second stage of its Electronic Health Record (EHR) Incentive Program, providing financial incentives to providers to meaningfully use their electronic health records to engage patients online. Patient portals are electronic means to engage patients by enabling secure access to personal medical records, communication with providers, various self-management tools, and administrative functionalities. Outcomes of patient portals have mainly been reported in large integrated health systems. This may now change as the EHR Incentive Program enables and supports the use of patient portals in other types of health systems. In this paper, we focus on Health Information Exchanges (HIE): entities that facilitate data exchange within networks of independent providers. Objective In response to the EHR Incentive Program, some Health Information Exchanges in the United States are developing patient portals and offering them to their network of providers. Such patient portals hold high value for patients, especially in fragmented health system contexts, due to the portals’ ability to integrate health information from an array of providers and give patients one access point to this information. Our aim was to report on the early effects of the EHR incentives on patient portal development by HIEs. Specifically, we describe the characteristics of these portals, identify factors affecting adoption by providers during the 2013-2014 time frame, and consider what may be the primary drivers of providers’ adoption of patient portals in the future. Methods We identified four HIEs that were developing patient portals as of spring 2014. We collected relevant documents and conducted interviews with six HIE leaders as well as two providers that were implementing the portals in their practices. We performed content analysis on these data to extract information pertinent to our study objectives. Results Our findings suggest that there are two primary types of patient portals available to providers in HIEs: (1) portals linked to EHRs of individual providers or health systems and (2) HIE-sponsored portals that link information from multiple providers’ EHRs. The decision of providers in the HIEs to adopt either one of these portals appears to be a trade-off between functionality, connectivity, and cost. Our findings also suggest that while the EHR Incentive Program is influencing these decisions, it may not be enough to drive adoption. Rather, patient demand for access to patient portals will be necessary to achieve widespread portal adoption and realization of potential benefits. Conclusions Optimizing patient value should be the main principle underlying policies intending to increase online patient engagement in the third stage of the EHR Incentive Program. We propose a number of features for the EHR Incentive Program that will enhance patient value and thereby support the growth and sustainability of patient portals provided by Health Information Exchanges.

Between Trust and Accountability: Different Perspectives on the Modernization of Postgraduate Medical Training in the Netherlands

Purpose Postgraduate medical training was reformed to be more responsive to changing societal needs. In the Netherlands, as in various other Western countries, a competency-based curriculum was introduced reflecting the clinical and nonclinical roles a modern doctor should fulfill. It is still unclear, however, what this modernization process exactly comprises and what its consequences might be for clinical practice and medical work. Method The authors conducted a Q methodological study to investigate which different perspectives exist on the modernization of postgraduate medical training among actors involved. Results The authors found four distinct perspectives, reflecting the different features of medical training. The accountability perspective stresses the importance of formal regulations within medical training and the monitoring of results in order to be more transparent and accountable to society. According to the educational perspective, medical training should be more formalized and directed at the educational process. The work–life balance perspective stresses the balance between a working life and a private life, as well as the changing professional relationship between staff members and residents. The trust-based perspective reflects the classic view of medical training in which role modeling and trust are considered most important. Conclusions The four perspectives on the modernization of postgraduate medical training show that various aspects of the modernization process are valued differently by stakeholders, highlighting important sources of agreement and disagreement between them. An important source of disagreement is diverging expectations of the role of physicians in modern medical practice.

What do we know about developing patient portals? a systematic literature review

OBJECTIVE Numerous articles have reported on the development of patient portals, including development problems and solutions. We review these articles to inform future patient portal development efforts and to provide a summary of the evidence base that can guide future research. MATERIALS AND METHODS We performed a systematic review of relevant literature to answer 5 questions: (1) What categories of problems related to patient portal development have been defined? (2) What causal factors have been identified by problem analysis and diagnosis? (3) What solutions have been proposed to ameliorate these causal factors? (4) Which proposed solutions have been implemented and in which organizational contexts? (5) Have implemented solutions been evaluated and what learning has been generated? Through searches on PubMed, ScienceDirect and LISTA, we included 109 articles. RESULTS We identified 5 main problem categories: achieving patient engagement, provider engagement, appropriate data governance, security and interoperability, and a sustainable business model. Further, we identified key factors contributing to these problems as well as solutions proposed to ameliorate them. While about half (45) of the 109 articles proposed solutions, fewer than half of these solutions (18) were implemented, and even fewer (5) were evaluated to generate learning about their effects. DISCUSSION Few studies systematically report on the patient portal development processes. As a result, the review does not provide an evidence base for portal development. CONCLUSION Our findings support a set of recommendations for advancement of the evidence base: future research should build on existing evidence, draw on principles from design sciences conveyed in the problem-solving cycle, and seek to produce evidence within various different organizational contexts.

Tailoring intervention procedures to routine primary health care practice; an ethnographic process evaluation

BackgroundTailor-made approaches enable the uptake of interventions as they are seen as a way to overcome the incompatibility of general interventions with local knowledge about the organisation of routine medical practice and the relationship between the patients and the professionals in practice. Our case is the Quattro project which is a prevention programme for cardiovascular diseases in high-risk patients in primary health care centres in deprived neighbourhoods. This programme was implemented as a pragmatic trial and foresaw the importance of local knowledge in primary health care and internal, or locally made, guidelines. The aim of this paper is to show how this prevention programme, which could be tailored to routine care, was implemented in primary care.MethodsAn ethnographic design was used for this study. We observed and interviewed the researchers and the practice nurses. All the research documents, observations and transcribed interviews were analysed thematically.ResultsOur ethnographic process evaluation showed that the opportunity of tailoring intervention procedures to routine care in a pragmatic trial setting did not result in a well-organised and well-implemented prevention programme. In fact, the lack of standard protocols hindered the implementation of the intervention. Although it was not the purpose of this trial, a guideline was developed. Despite the fact that the developed guideline functioned as a tool, it did not result in the intervention being organised accordingly. However, the guideline did make tailoring the intervention possible. It provided the professionals with the key or the instructions needed to achieve organisational change and transform the existing interprofessional relations.ConclusionAs tailor-made approaches are developed to enable the uptake of interventions in routine practice, they are facilitated by the brokering of tools such as guidelines. In our study, guidelines facilitated organisational change and enabled the transformation of existing interprofessional relations, and thus made tailoring possible. The attractive flexibility of pragmatic trial design in taking account of local practice variations may often be overestimated.

Coping with methodological dilemmas; about establishing the effectiveness of interventions in routine medical practice

BackgroundThe aim of this paper is to show how researchers balance between scientific rigour and localisation in conducting pragmatic trial research. Our case is the Quattro Study, a pragmatic trial on the effectiveness of multidisciplinary patient care teams used in primary health care centres in deprived neighbourhoods of two major cities in the Netherlands for intensified secondary prevention of cardiovascular diseases.MethodsFor this study an ethnographic design was used. We observed and interviewed the researchers and the practice nurses. All gathered research documents, transcribed observations and interviews were analysed thematically.ResultsConducting a pragmatic trial is a continuous balancing act between meeting methodological demands and implementing a complex intervention in routine primary health care. As an effect, the research design had to be adjusted pragmatically several times and the intervention that was meant to be tailor-made became a rather stringent procedure.ConclusionA pragmatic trial research is a dynamic process that, in order to be able to assess the validity and reliability of any effects of interventions must also have a continuous process of methodological and practical reflection. Ethnographic analysis, as we show, is therefore of complementary value.

Exploring the success of an integrated primary care partnership: a longitudinal study of collaboration processes

BackgroundForming partnerships is a prominent strategy used to promote integrated service delivery across health and social service systems. Evidence about the collaboration process upon which partnerships evolve has rarely been addressed in an integrated-care setting. This study explores the longitudinal relationship of the collaboration process and the influence on the final perceived success of a partnership in such a setting. The collaboration process through which partnerships evolve is based on a conceptual framework which identifies five themes: shared ambition, interests and mutual gains, relationship dynamics, organisational dynamics and process management.MethodsFifty-nine out of 69 partnerships from a national programme in the Netherlands participated in this survey study. At baseline, 338 steering committee members responded, and they returned 320 questionnaires at follow-up. Multiple-regression-analyses were conducted to explore the relationship between the baseline as well as the change in the collaboration process and the final success of the partnerships.ResultsMutual gains and process management were the most significant baseline predictors for the final success of the partnership. A positive change in the relationship dynamics had a significant effect on the final success of a partnership.ConclusionsInsight into the collaboration process of integrated primary care partnerships offers a potentially powerful way of predicting their success. Our findings underscore the importance of monitoring the collaboration process during the development of the partnerships in order to achieve their full collaborative advantage.