Clare Tanner

Baseline Predictors of Fatigue 1 Year After Mild Head Injury

OBJECTIVE To compare reports of fatigue 12 months after minor trauma by participants with mild head injury (MHI) with those with other injury, and identify injury and baseline predictors of fatigue. DESIGN An inception cohort study of participants with MHI and other nonhead injuries recruited from and interviewed at the emergency department (ED), with a follow-up telephone interview at 12 months. SETTING Level II community hospital ED. PARTICIPANTS Participants (n=58) with MHI and loss of consciousness (LOC) of 30 minutes or less and/or posttraumatic amnesia (PTA) less than 24 hours, 173 with MHI but no PTA/LOC, and 128 with other mild nonhead injuries. INCLUSION CRITERIA age 18 years or older, within 24 hours of injury, Glasgow Coma Scale score of 13 or higher, and discharge from the ED. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Medical Outcomes Study 36-Item Short-Form Health Survey Vitality subscale. RESULTS Significant predictors of fatigue severity at 12 months were baseline fatigue, having seen a counselor for a mental health issue, medical disability, marital status, and in some stage of litigation. Injury type was not a significant predictor. CONCLUSIONS Fatigue severity 12 months after injury is associated with baseline characteristics and not MHI. Clinicians should be cautious about attributing persisting fatigue to MHI without comprehensive consideration of other possible etiologic factors.

A partnership model for implementing electronic health records in resource-limited primary care settings: experiences from two nurse-managed health centers

OBJECTIVE To present a partnership-based and community-oriented approach designed to ease provider anxiety and facilitate the implementation of electronic health records (EHR) in resource-limited primary care settings. MATERIALS AND METHODS The approach, referred to as partnership model, was developed and iteratively refined through the research teams previous work on implementing health information technology (HIT) in over 30 safety net practices. This paper uses two case studies to illustrate how the model was applied to help two nurse-managed health centers (NMHC), a particularly vulnerable primary care setting, implement EHR and get prepared to meet the meaningful use criteria. RESULTS The strong focus of the model on continuous quality improvement led to eventual implementation success at both sites, despite difficulties encountered during the initial stages of the project. DISCUSSION There has been a lack of research, particularly in resource-limited primary care settings, on strategies for abating provider anxiety and preparing them to manage complex changes associated with EHR uptake. The partnership model described in this paper may provide useful insights into the work shepherded by HIT regional extension centers dedicated to supporting resource-limited communities disproportionally affected by EHR adoption barriers. CONCLUSION NMHC, similar to other primary care settings, are often poorly resourced, understaffed, and lack the necessary expertise to deploy EHR and integrate its use into their day-to-day practice. This study demonstrates that implementation of EHR, a prerequisite to meaningful use, can be successfully achieved in this setting, and partnership efforts extending far beyond the initial software deployment stage may be the key.

Toward a national nurse-managed health center data set: Findings and lessons learned over 3 years

Although primary care nurse-managed health centers (NMHCs) have gained increasing recognition, there are limited standardized clinical and financial data on these centers. The purpose of this paper is to present the process, benefits, and challenges in collecting standardized national data based on a consensus process from NMHCs over 3 consecutive years. The Institute for Nursing Centers (INC) NMHC Survey focuses on demographic, clinical, and financial data. A detailed codebook accompanied the INC NMHC Survey. A total of 42 NMHCs responded in at least 1 of the 3 years. Despite the challenges in collecting some of the data, especially for the first survey year, data quality improved remarkably when the INC NMHC Survey was repeated. Financial data seemed to be more easily reported than demographic or clinical data. NMHCs increase access to care, often for vulnerable populations, yet to date there are limited standardized clinical and financial data on these centers. The INC NHMC Survey and data described in this paper begins to address that gap.

Diabetes and hypertension quality measurement in four safety-net sites: lessons learned after implementation of the same commercial electronic health record.

BACKGROUND In this new era after the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the literature on lessons learned with electronic health record (EHR) implementation needs to be revisited. OBJECTIVES Our objective was to describe what implementation of a commercially available EHR with built-in quality query algorithms showed us about our care for diabetes and hypertension populations in four safety net clinics, specifically feasibility of data retrieval, measurements over time, quality of data, and how our teams used this data. METHODS A cross-sectional study was conducted from October 2008 to October 2012 in four safety-net clinics located in the Midwest and Western United States. A data warehouse that stores data from across the U.S was utilized for data extraction from patients with diabetes or hypertension diagnoses and at least two office visits per year. Standard quality measures were collected over a period of two to four years. All sites were engaged in a partnership model with the IT staff and a shared learning process to enhance the use of the quality metrics. RESULTS While use of the algorithms was feasible across sites, challenges occurred when attempting to use the query results for research purposes. There was wide variation of both process and outcome results by individual centers. Composite calculations balanced out the differences seen in the individual measures. Despite using consistent quality definitions, the differences across centers had an impact on numerators and denominators. All sites agreed to a partnership model of EHR implementation, and each center utilized the available resources of the partnership for Center-specific quality initiatives. CONCLUSIONS Utilizing a shared EHR, a Regional Extension Center-like partnership model, and similar quality query algorithms allowed safety-net clinics to benchmark and improve the quality of care across differing patient populations and health care delivery models.

Electronic health records and patient safety: co-occurrence of early EHR implementation with patient safety practices in primary care settings.

BACKGROUND The role of electronic health records (EHR) in enhancing patient safety, while substantiated in many studies, is still debated. OBJECTIVE This paper examines early EHR adopters in primary care to understand the extent to which EHR implementation is associated with the workflows, policies and practices that promote patient safety, as compared to practices with paper records. Early adoption is defined as those who were using EHR prior to implementation of the Meaningful Use program. METHODS We utilized the Physician Practice Patient Safety Assessment (PPPSA) to compare primary care practices with fully implemented EHR to those utilizing paper records. The PPPSA measures the extent of adoption of patient safety practices in the domains: medication management, handoffs and transition, personnel qualifications and competencies, practice management and culture, and patient communication. RESULTS Data from 209 primary care practices responding between 2006-2010 were included in the analysis: 117 practices used paper medical records and 92 used an EHR. Results showed that, within all domains, EHR settings showed significantly higher rates of having workflows, policies and practices that promote patient safety than paper record settings. While these results were expected in the area of medication management, EHR use was also associated with adoption of patient safety practices in areas in which the researchers had no a priori expectations of association. CONCLUSIONS Sociotechnical models of EHR use point to complex interactions between technology and other aspects of the environment related to human resources, workflow, policy, culture, among others. This study identifies that among primary care practices in the national PPPSA database, having an EHR was strongly empirically associated with the workflow, policy, communication and cultural practices recommended for safe patient care in ambulatory settings.

Comparison of Nurse Managed Health Centers With Federally Qualified Health Centers as Safety Net Providers

Nurse Managed Health Centers (NMHCs) provide a critical safety net function in their communities, yet they often remain invisible and challenged in terms of financial sustainability. This paper presents a comparison of demographics and financial status of NMHCs and Federally Qualified Health Centers (FQHCs). The comparison is based on four years of annual NMHC national survey data that includes 42 NMHCs overall and the 2008 FQHC data in the Uniform Data System. Findings indicate that NMHCs and FQHCs serve very similar diverse populations yet funding and revenue differences were significant. NMHCs tend to rely more on grants and donations from the private sector as well as contracts while FQHCs have access to considerable federal support that is cost based when serving the underserved. In addition, NMHCs are challenged by the array of state, federal and third party insurers’ regulations that often disadvantage nurse practitioners as primary care providers.

Assessing organisational readiness for adopting an electronic health record systems a case study in ambulatory practices

The adoption of health IT systems in the United States has significantly lagged behind other industrialized countries. While the structure of the healthcare system (payer models, and other cultural norms) is major factors accounting for this deficiency, the mindless implementation of health IT systems is another significant barrier. This paper presents our field experience of implementing an Electronic Health Record System in several safety net ambulatory clinical practices across the US. In particular, we discuss the organizational readiness assessment and pre-implementation planning, the key technology considerations for this stratification of practices, and a research-based formative evaluation designed to ensure an implementation’s long-term success. We exemplify our strategies using a case study of successfully implementing an EHRS in an ambulatory care clinic at a university health centre.

Medication safety after implementation of a commercial electronic health record system in five safety-net practices: a mixed methods approach.

Purpose: This study, conducted in five safety‐net practices, including two nurse‐managed health centers (NMHCs) and three federally qualified health centers (FQHCs), examined the impact of implementing a commercial electronic health records (EHRs) system on medication safety. Data source: A mixed methods approach with two sources of data were used: (a) a query of prescription records captured by the EHR retrieving co‐prescribed medications with identified drug–drug interaction (DDI) risks, and (b) semistructured interviews with clinicians and leadership about the usability and benefits of EHR‐embedded clinical decision support in the form of DDI alerts. Conclusions: We found an exceptionally low rate of DDI pairs in all five practices. Only 130 “true” DDI pairs were confirmed representing 149,087 visits and 62 providers. Among the 130, the largest categories were related to antihypertensive medications, which are in fact often prescribed together. There were no significant differences between physicians and nurse practitioners on the rate of DDI pairs nor between NMHCs and FQHCs. Implications for practice: Implementation of an EHR in these five safety‐net settings had a positive impact on medication safety. The issue of missing end dates is noteworthy in terms of DDIs and unnecessary alerts that could lead to alert fatigue.

Use of a comprehensive patient safety tool in primary care practices

Purpose: To present a tool that can be used to evaluate patient safety in both nurse‐led and physician‐led practices. Data source: This article describes our experience with the Physician Practice Patient Safety Assessment (PPPSA) tool in six safety net practices—three of which were primary care nurse‐managed health centers and three were physician‐led federally qualified health centers. The information provided is from the tool itself and how it might be used in clinical settings, especially primary care. Conclusions: The PPPSA is a tool to measure the extent to which patient safety practices are rigorously and systematically implemented throughout a health center. The tools methodology requires discussion and consensus, incorporating a team approach with multiple perspectives within a center. It is designed to promote changes in practices that would improve patient safety. Implications for practice: The tool has enormous relevance for primary care settings, especially those preparing themselves for patient‐centered medical home status and meaningful use. But most important, it has relevance as we create healthcare environments that promote patient safety and a practice culture that is truly patient centered.