Joshua E. Richardson

Older adults are mobile too!Identifying the barriers and facilitators to older adults' use of mHealth for pain management.

BackgroundMobile health (mHealth) is a rapidly emerging field with the potential to assist older adults in the management of chronic pain (CP) through enhanced communication with providers, monitoring treatment-related side effects and pain levels, and increased access to pain care resources. Little is currently known, however, about older adults’ attitudes and perceptions of mHealth or perceived barriers and facilitators to using mHealth tools to improve pain management.MethodsWe conducted six focus groups comprised of 41 diverse older adults (≥60 years of age) with CP. Participants were recruited from one primary care practice and two multiservice senior community day-visit centers located in New York City that serve older adults in their surrounding neighborhoods. Focus group discussions were recorded and transcribed, and transcriptions were analyzed using direct content analysis to identify and quantify themes.ResultsFocus group discussions generated 38 individual themes pertaining to the use of mHealth to help manage pain and pain medications. Participants had low prior use of mHealth (5% of participants), but the vast majority (85%) were highly willing to try the devices. Participants reported that mHealth devices might help them reach their healthcare provider more expeditiously (27%), as well as help to monitor for falls and other adverse events in the home (15%). Barriers to device use included concerns about the cost (42%) and a lack of familiarity with the technology (32%). Facilitators to device use included training prior to device use (61%) and tailoring devices to the functional needs of older adults (34%).ConclusionsThis study suggests that older adults with CP are interested and willing to use mHealth to assist in the management of pain. Participants in our study reported important barriers that medical professionals, researchers, and mHealth developers should address to help facilitate the development and evaluation of age-appropriate, and function-appropriate, mHealth devices for older persons with CP.

Development and evaluation of a comprehensive clinical decision support taxonomy: comparison of front-end tools in commercial and internally developed electronic health record systems

BACKGROUND Clinical decision support (CDS) is a valuable tool for improving healthcare quality and lowering costs. However, there is no comprehensive taxonomy of types of CDS and there has been limited research on the availability of various CDS tools across current electronic health record (EHR) systems. OBJECTIVE To develop and validate a taxonomy of front-end CDS tools and to assess support for these tools in major commercial and internally developed EHRs. STUDY DESIGN AND METHODS We used a modified Delphi approach with a panel of 11 decision support experts to develop a taxonomy of 53 front-end CDS tools. Based on this taxonomy, a survey on CDS tools was sent to a purposive sample of commercial EHR vendors (n=9) and leading healthcare institutions with internally developed state-of-the-art EHRs (n=4). RESULTS Responses were received from all healthcare institutions and 7 of 9 EHR vendors (response rate: 85%). All 53 types of CDS tools identified in the taxonomy were found in at least one surveyed EHR system, but only 8 functions were present in all EHRs. Medication dosing support and order facilitators were the most commonly available classes of decision support, while expert systems (eg, diagnostic decision support, ventilator management suggestions) were the least common. CONCLUSION We developed and validated a comprehensive taxonomy of front-end CDS tools. A subsequent survey of commercial EHR vendors and leading healthcare institutions revealed a small core set of common CDS tools, but identified significant variability in the remainder of clinical decision support content.

Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study

BackgroundThe purpose of this study was to identify recommended practices for computerized clinical decision support (CDS) development and implementation and for knowledge management (KM) processes in ambulatory clinics and community hospitals using commercial or locally developed systems in the U.S.MethodsGuided by the Multiple Perspectives Framework, the authors conducted ethnographic field studies at two community hospitals and five ambulatory clinic organizations across the U.S. Using a Rapid Assessment Process, a multidisciplinary research team: gathered preliminary assessment data; conducted on-site interviews, observations, and field surveys; analyzed data using both template and grounded methods; and developed universal themes. A panel of experts produced recommended practices.ResultsThe team identified ten themes related to CDS and KM. These include: 1) workflow; 2) knowledge management; 3) data as a foundation for CDS; 4) user computer interaction; 5) measurement and metrics; 6) governance; 7) translation for collaboration; 8) the meaning of CDS; 9) roles of special, essential people; and 10) communication, training, and support. Experts developed recommendations about each theme. The original Multiple Perspectives framework was modified to make explicit a new theoretical construct, that of Translational Interaction.ConclusionsThese ten themes represent areas that need attention if a clinic or community hospital plans to implement and successfully utilize CDS. In addition, they have implications for workforce education, research, and national-level policy development. The Translational Interaction construct could guide future applied informatics research endeavors.

Rapid Assessment of Clinical Information Systems in the Healthcare Setting

OBJECTIVE Recent legislation in the United States provides strong incentives for implementation of electronic health records (EHRs). The ensuing transformation in U.S. health care will increase demand for new methods to evaluate clinical informatics interventions. Timeline constraints and a rapidly changing environment will make traditional evaluation techniques burdensome. This paper describes an anthropological approach that provides a fast and flexible way to evaluate clinical information systems. METHODS Adapting mixed-method evaluation approaches from anthropology, we describe a rapid assessment process (RAP) for assessing clinical informatics interventions in health care that we developed and used during seven site visits to diverse community hospitals and primary care settings in the U.S. SETTING Our multidisciplinary team used RAP to evaluate factors that either encouraged people to use clinical decision support (CDS) systems or interfered with use of these systems in settings ranging from large urban hospitals to single-practitioner, private family practices in small towns. RESULTS Critical elements of the method include: 1) developing a fieldwork guide; 2) carefully selecting observation sites and participants; 3) thoroughly preparing for site visits; 4) partnering with local collaborators; 5) collecting robust data by using multiple researchers and methods; and 6) analyzing and reporting data in a structured manner helpful to the organizations being evaluated. CONCLUSIONS RAP, iteratively developed over the course of visits to seven clinical sites across the U.S., has succeeded in allowing a multidisciplinary team of informatics researchers to plan, gather and analyze data, and report results in a maximally efficient manner.

Identifying Best Practices for Clinical Decision Support and Knowledge Management in the Field

To investigate best practices for implementing and managing clinical decision support (CDS) in community hospitals and ambulatory settings, we carried out a series of ethnographic studies to gather information from nine diverse organizations. Using the Rapid Assessment Process methodology, we conducted surveys, interviews, and observations over a period of two years in eight different geographic regions of the U.S.A. We first utilized a template organizing method for an expedited analysis of the data, followed by a deeper and more time consuming interpretive approach. We identified five major categories of best practices that require careful consideration while carrying out the planning, implementation, and knowledge management processes related to CDS. As more health care organizations implement clinical systems such as computerized provider order entry with CDS, descriptions of lessons learned by CDS pioneers can provide valuable guidance so that CDS can have optimal impact on health care quality.

A needs assessment of health information technology for improving care coordination in three leading patient-centered medical homes

OBJECTIVE We investigated ways that patient-centered medical homes (PCMHs) are currently using health information technology (IT) for care coordination and what types of health IT are needed to improve care coordination. MATERIALS AND METHODS A multi-disciplinary team of researchers conducted semi-structured telephone interviews with 28 participants from 3 PCMHs in the United States. Participants included administrators and clinicians from PCMHs, electronic health record (EHR) and health information exchange (HIE) representatives, and policy makers. RESULTS Participants identified multiple barriers to care coordination using current health IT tools. We identified five areas in which health IT can improve care coordination in PCMHs: 1) monitoring patient populations, 2) notifying clinicians and other staff when specific patients move across care settings, 3) collaborating around patients, 4) reporting activities, and 5) interoperability. To accomplish these tasks, many participants described using homegrown care coordination systems separate from EHRs. DISCUSSION The participants in this study have resources, experience, and expertise with using health IT for care coordination, yet they still identified multiple areas for improvement. We hypothesize that focusing health IT development in the five areas we identified can enable more effective care coordination. Key findings from this work are that homegrown systems apart from EHRs are currently used to support care coordination and, also, that reporting tools are key components of care coordination. CONCLUSIONS New health IT that enables monitoring, notifying, collaborating, reporting, and interoperability would enhance care coordination within PCMHs beyond what current health IT enables.

The Current and Ideal State of Mental Health Training: Pediatric Resident Perspectives

Phenomenon: Mental health (MH) problems are prevalent in the pediatric population, and in a setting of limited resources, pediatricians need to provide MH care in the primary medical home yet are uncomfortable doing so citing a lack of training during residency as one barrier. Approach: The purpose of this study is to describe pediatric residents’ experiences and perspectives on the current and ideal states of MH training and ideas for curriculum development to bridge this gap. A qualitative study using focus groups of pediatric residents from an urban academic medical center was performed. Audio recordings were transcribed and analyzed using a grounded theory approach. Findings: Twenty-six residents participated in three focus groups, which is when thematic saturation was achieved. The team generated five major themes: capabilities, comfort, organizational capacity, coping, and education. Residents expressed uncertainty at every step of an MH visit. Internal barriers identified included low levels of comfort and negative emotional responses. External barriers included a lack of MH resources and mentorship in MH care, or an inadequate organizational capacity. These internal and external barriers resulted in a lack of perceived capability in handling MH issues. In response, residents reported inadequate coping strategies, such as ignoring MH concerns. To build knowledge and skills, residents prefer educational modalities including didactics, experiential learning through collaborations with MH specialists, and tools built into patient care flow. Insights: Pediatric residency programs need to evolve in order to improve resident training in MH care. The skills and knowledge requested by residents parallel the American Academy of Pediatrics statement on MH competencies. Models of collaborative care provide similar modalities of learning requested by residents. These national efforts have not been operationalized in training programs yet may be useful for curriculum development and dissemination to enhance trainees’ MH knowledge and skills to provide optimal MH care for children.

The promises and pitfalls of leveraging mobile health technology for pain care.

Mobile health technology (mHealth) includes cell phones, smartphones, and wearable sensors that offer several putative advantages over customary approaches when generating and/or communicating personal data from patients with acute, cancer, and non-cancer pain. Due to their flexibility, simplicity, and increasing affordability, mHealth devices represent a new generation of tools with the potential to improve pain management by reliably and safely collecting pain, function, and activity data outside of the clinical setting and facilitate delivery of interventions (e.g., instruction in cognitive-behavioral methods of pain management). mHealth is defined as “handheld [or wearable] transmitting device[s] with multi-functional capabilities [that can be] used to store, transmit and receive health information and has user control over the access to the health information.” ⇓ The growing popularity of mobile devices among patients means that clinical data can be collected while patients engage in their usual daily activities. These data have substantial potential to impact patient care in a number of ways to include informing clinician decision-making for symptom management, promoting positive patient behavior change through real-time feedback, and providing supplemental data that enrich patient–provider communication. In the near future, collecting and sharing mHealth data between patients and multiple authorized stakeholders will produce new and perhaps revolutionary models of health care delivery including pain care ⇓. The promise of mHealth does not come without potential pitfalls. The design of mHealth devices may have significant effects on data quality and accuracy. Design issues are of particular concern for older patients as many experience functional (e.g., physical and cognitive) changes with age. Other considerations include the ways in which mHealth-derived data can be optimally presented to health care providers and caregivers, and protecting them from being overwhelmed by a sea of data. Indeed, a review of 111 pain apps for patient use (released on the market in …

The Community Preceptor Crisis: Recruiting and Retaining Community-Based Faculty to Teach Medical Students—A Shared Perspective From the Alliance for Clinical Education

ABSTRACT Issue: Community-based instruction is invaluable to medical students, as it provides “real-world” opportunities for observing and following patients over time while refining history taking, physical examination, differential diagnosis, and patient management skills. Community-based ambulatory settings can be more conducive to practicing these skills than highly specialized, academically based practice sites. The Association of American Medical Colleges and other national medical education organizations have expressed concern about recruitment and retention of preceptors to provide high-quality educational experiences in community-based practice sites. These concerns stem from constraints imposed by documentation in electronic health records; perceptions that student mentoring is burdensome resulting in decreased clinical productivity; and competition between allopathic, osteopathic, and international medical schools for finite resources for medical student experiences. Evidence: In this Alliance for Clinical Education position statement, we provide a consensus summary of representatives from national medical education organizations in 8 specialties that offer clinical clerkships. We describe the current challenges in providing medical students with adequate community-based instruction and propose potential solutions. Implications: Our recommendations are designed to assist clerkship directors and medical school leaders overcome current challenges and ensure high-quality, community-based clinical learning opportunities for all students. They include suggesting ways to orient community clinic sites for students, explaining how students can add value to the preceptors practice, focusing on educator skills development, recognizing preceptors who excel in their role as educators, and suggesting forms of compensation.

POETIC: A system for gathering and disseminating traffic information

The Portable Extendable Traffic Information Collator (POETIC) is a software system that extracts traffic information from police incident logs and initiates (simulated) broadcasts of traffic bulletins to motorists when appropriate. The initial prototype system (TIC) was limited to the practices and requirements of a single police force. In this paper, the authors describe the second stage prototype system ( POETIC), in which the architecture and data representations have been generalized to make the system tailorable to many different police force domains.