Henry J. Feldman

A Randomized Trial of Teaching Clinical Skills Using Virtual and Live Standardized Patients

AbstractBACKGROUND: We developed computer-based virtual patient (VP) cases to complement an interactive continuing medical education (CME) course that emphasizes skills practice using standardized patients (SP). Virtual patient simulations have the significant advantages of requiring fewer personnel and resources, being accessible at any time, and being highly standardized. Little is known about the educational effectiveness of these new resources. We conducted a randomized trial to assess the educational effectiveness of VPs and SPs in teaching clinical skills. OBJECTIVE: To determine the effectiveness of VP cases when compared with live SP cases in improving clinical skills and knowledge. DESIGN: Randomized trial. PARTICIPANTS: Fifty-five health care providers (registered nurses 45%, physicians 15%, other provider types 40%) who attended a CME program. INTERVENTIONS: Participants were randomized to receive either 4 live cases (n=32) or 2 live and 2 virtual cases (n=23). Other aspects of the course were identical for both groups. RESULTS: Participants in both groups were equivalent with respect to pre-post workshop improvement in comfort level (P=.66) and preparedness to respond (P=.61), to screen (P=.79), and to care (P=.055) for patients using the skills taught. There was no difference in subjective ratings of effectiveness of the VPs and SPs by participants who experienced both (P=.79). Improvement in diagnostic abilities were equivalent in groups who experienced cases either live or virtually. CONCLUSIONS: Improvements in performance and diagnostic ability were equivalent between the groups and participants rated VP and SP cases equally. Including well-designed VPs has a potentially powerful and efficient place in clinical skills training for practicing health care workers.

Improving personal health records for patient-centered care

OBJECTIVE To assess the patient-centeredness of personal health records (PHR) and offer recommendations for best practice guidelines. DESIGN Semi-structured interviews were conducted in seven large early PHR adopter organizations in 2007. Organizations were purposively selected to represent a variety of US settings, including medium and large hospitals, ambulatory care facilities, insurers and health plans, government departments, and commercial sectors. MEASUREMENTS Patient-centeredness was assessed against a framework of care that includes: (1) respect for patient values, preferences, and expressed needs; (2) information and education; (3) access to care; (4) emotional support to relieve fear and anxiety; (5) involvement of family and friends; (6) continuity and secure transition between healthcare providers; (7) physical comfort; (8) coordination of care. Within this framework we used evidence for patient preferences (where it exists) to compare existing PHR policies, and propose a best practice model. RESULTS Most organizations enable many patient-centered functions such as data access for proxies and minors. No organization allows patient views of clinical progress notes, and turnaround times for PHR reporting of normal laboratory results can be up to 7 days. CONCLUSION Findings suggest patient-centeredness for personal health records can be improved, and recommendations are made for best practice guidelines.

Governance for Personal Health Records

Personal health records (PHR) are a modern health technology with the ability to engage patients more fully in their healthcare. Despite widespread interest, there has been little discussion around PHR governance at an organizational level. We develop a governance model and compare it to the practices of some of the early PHR adopters, including hospitals and ambulatory care settings, insurers and health plans, government departments, and commercial sectors. Decision-making structures varied between organizations. Business operations were present in all groups, but patients were not represented in any of the governance structures surveyed. To improve patient-centered care, policy making for PHRs needs to include patient representation at a governance level.

A randomized trial of a brief multimedia intervention to improve comprehension of food labels.

OBJECTIVE Food label use is associated with better food choices, an essential part of the management of many chronic diseases. Previous studies suggest lack of comprehension of food labels. We studied a multimedia intervention to improve food label comprehension in a sample of low income patients in New York City. METHODS This randomized study took place at Gouverneur Healthcare Services from 2005 until 2007. The intervention group (n=29) received a Nutrition Facts Label pocket card and viewed a video explaining card use. The control group (n=27) received written materials. Participants completed a 12-item pre- and post-intervention nutrition food label quiz. Quiz scores were analyzed using repeated measures analysis of variance. RESULTS The intervention group had greater improvement on the quiz than the control group (p<0.001). There was a three way interaction by time with health literacy and treatment group where the greatest improvement occurred in patients with adequate health literacy in the intervention group (p<0.05). There was no improvement in patients with limited health literacy. CONCLUSION A multimedia intervention is an effective way to improve short-term food label comprehension in patients with adequate health literacy. Further research is necessary to improve understanding of food labels in patients with limited health literacy.

Using trigger phrases to detect adverse drug reactions in ambulatory care notes

Background: As medical care moves towards an outpatient focus, monitoring systems for ambulatory patients are increasingly important. Because adverse outcomes due to medications are an important problem in outpatients, the authors developed an automated monitoring system for detecting adverse drug reactions (ADRs) in ambulatory patients. Methods: The authors obtained a set of approximately 110 000 ambulatory care notes from the medicine clinic at Bellevue Hospital Centre for 2003–4, and manually analysed a representative sample of 1250 notes to obtain a gold standard. To detect ADRs in the text of electronic ambulatory notes, the authors used a “trigger phrases” methodology, based on a simple grammar populated with a limited set of keywords. Results: Under current functionality, this system detected 38 of 54 cases in the authors’ gold standard set, of which 17 were true positives, for a sensitivity of 31%, a specificity of 98%, and a positive predictive value of 45%. Their proxy measure correlated with 70% of the ADRs in the gold standard. These values are comparable or superior to other systems described in the literature. Conclusions: These results show that an automated system can detect ADRs with moderate sensitivity and high specificity, and has the potential to serve as the basis for a larger scale reporting system.

ResEval: a web-based evaluation system for internal medicine house staff

The evaluation and assessment of physicians-in-training (house staff) is a complex task. Residency training programs are under increasing pressure [1] to provide accurate and comprehensive evaluations of performance of resident physicians [2,3]. For many years, the Internal Medicine training program at NYU School of Medicine used a single standardized paper form for all evaluation scenarios. This strategy was inadequate as physicians train in multiple diverse settings evaluation of physicians in the intensive care unit is quite different from those in the general clinics. The paper system resulted in poor compliance by house staff and faculty in the completion of evaluations. In addition, the data being collected from the paper forms was of poor quality due to the non-specific nature of the questions. A committee was formed in 2001, which created a new strategy for evaluating the core competencies of house staff. Given the ubiquity of web accessible computers in the clinical and non-clinical areas of hospitals and the flexibility a computerized system would provide, a web-based evaluation system was designed and implemented. This system allows for on-the-spot evaluations tailored to the evaluator, evaluatee and the venue of the evaluation. During the 2002 residency year, data was collected on satisfaction and use of the system and compared with the previous paper evaluation.

Hospital information system survey in qatar.

UNLABELLED Healthcare can be enhanced by the effective use of information technology to improve the quality and safety of care and many healthcare providers are adopting advanced health information technology to improve their healthcare delivery process. Qatar is a relatively young Middle Eastern country with an ambitious and progressive national strategy to develop its healthcare system, including an advanced e-health infrastructure delivering the right medical information at the right time to clinicians and patients. To assess the effectiveness of such programs, it is important to have a pre-intervention baseline from which comparisons, performance against target measures and forward thinking strategic planning can be grounded. This study presents the first published campus wide survey of Hospital Information Systems in large public and private hospitals in Qatar. OBJECTIVE To qualitatively assess and describe the current state of Hospital Information Systems in large hospitals in Qatar, and to establish a baseline or reference point for Qatars readiness for, and adoption of Hospital Information Systems.

Computer modeling of intracoronary stents undergoing MRI scanning: simulating electrogenesis

The use of intracoronary artery stents in general medical care is increasing, as is the use of magnetic resonance imaging (MRI) scanning. We have developed software to model the risk of electrical generation from these intracoronary stents being placed in an MRI scanners magnetic field, while the heart is beating. This has not been specifically modeled in the past. We developed a pair of programs to first measure the coronary artery movement, from cine-MRI scans of the heart; we used this data to calculate local voltages between the stents and adjacent myocardial tissue in various locations of the heart using a software model. The software is written in RealBasic and Python under Macintosh OS X.