Marjan Askari

Health Information–Seeking Behavior of Seniors Who Use the Internet: A Survey

Background The Internet is viewed as an important source for health information and a medium for patient empowerment. However, little is known about how seniors use the Internet in relation to other sources for health information. Objective The aim was to determine which information resources seniors who use the Internet use and trust for health information, which sources are preferred, and which sources are used by seniors for different information needs. Methods Questions from published surveys were selected based on their relevance to the study objectives. The Autonomy Preference Index was used to assess information needs and preferences for involvement in health decisions. Invitation to participate in this online survey was sent to the email list of a local senior organization (298 addresses) in the Netherlands. Results There were 118 respondents with a median age of 72 years (IQR 67-78 years). Health professionals, pharmacists, and the Internet were the most commonly used and trusted sources of health information. Leaflets, television, newspapers, and health magazines were also important sources. Respondents who reported higher use of the Internet also reported higher use of other sources (P<.001). Use of health professionals, pharmacists, leaflets, telephone, television, and radio were not significantly different; use of all other resources was significantly higher in frequent Internet users. When in need of health information, preferred sources were the Internet (46/105, 43.8%), other sources (eg, magazines 38/105, 36.2%), health professionals (18/105, 17.1%), and no information seeking (3/105, 2.8%). Of the 51/107 respondents who indicated that they had sought health information in the last 12 months, 43 sought it after an appointment, 23 were preparing for an appointment, and 20 were deciding if an appointment was needed. The source used varied by the type of information sought. The Internet was used most often for symptoms (27/42, 64%), prognosis (21/31, 68%), and treatment options (23/41, 62%), whereas health professionals were asked for additional information on medications (20/36, 56%), side effects (17/36, 47%), coping (17/31, 55%), practical care (12/14, 86%), and nutrition/exercise (18/30, 60%). Conclusions For these seniors who use the Internet, the Internet was a preferred source of health information. Seniors who report higher use of the Internet also report higher use of other information resources and were also the primary consumers of paper-based resources. Respondents most frequently searched for health information after an appointment rather than to prepare for an appointment. Resources used varied by health topic. Future research should seek to confirm these findings in a general elderly population, investigate how seniors seek and understand information on the Internet, and investigate how to reach seniors who prefer not to use the Internet for health information.

Assessing quality of care of elderly patients using the ACOVE quality indicator set: a systematic review.

Background Care of the elderly is recognized as an increasingly important segment of health care. The Assessing Care Of Vulnerable Elderly (ACOVE) quality indicators (QIs) were developed to assess and improve the care of elderly patients. Objectives The purpose of this review is to summarize studies that assess the quality of care using QIs from or based on ACOVE, in order to evaluate the state of quality of care for the reported conditions. Methods We systematically searched MEDLINE, EMBASE and CINAHL for English-language studies indexed by February 2010. Articles were included if they used any ACOVE QIs, or adaptations thereof, for assessing the quality of care. Included studies were analyzed and relevant information was extracted. We summarized the results of these studies, and when possible generated an overall conclusion about the quality of care as measured by ACOVE for each condition, in various settings, and for each QI. Results Seventeen studies were included with 278 QIs (original, adapted or newly developed). The quality scores showed large variation between and within conditions. Only a few conditions showed a stable pass rate range over multiple studies. Overall, pass rates for dementia (interquartile range (IQR): 11%–35%), depression (IQR: 27%–41%), osteoporosis (IQR: 34%–43%) and osteoarthritis (IQR: 29–41%) were notably low. Medication management and use (range: 81%–90%), hearing loss (77%–79%) and continuity of care (76%–80%) scored higher than other conditions. Out of the 278 QIs, 141 (50%) had mean pass rates below 50% and 121 QIs (44%) had pass rates above 50%. Twenty-three percent of the QIs scored above 75%, and 16% scored below 25%. Conclusions Quality of care per condition varies markedly across studies. Although there has been much effort in improving the care for elderly patients in the last years, the reported quality of care according to the ACOVE indicators is still relatively low.

Frequency and nature of drug-drug interactions in the intensive care unit

Drug‐drug interactions (DDIs) may compromise patient safety. However, there are no good estimates of their frequency or understanding of their nature in the intensive care unit (ICU). The objective of this study was to determine the frequency and nature of potential DDIs (pDDIs) in the ICU when assessed in light of documented and perceived clinical relevance.

LERM (Logical Elements Rule Method): A method for assessing and formalizing clinical rules for decision support

PURPOSE The aim of this study was to create a step-by-step method for transforming clinical rules for use in decision support, and to validate this method for usability and reliability. METHODS A sample set of clinical rules was identified from the relevant literature. Using an iterative approach with a focus group of mixed clinical and informatics experts, a method was developed for assessing and formalizing clinical rules. Two assessors then independently applied the method to a separate validation set of rules. Usability was assessed in terms of the time required and the error rate, and reliability was assessed by comparing the results of the two assessors. RESULTS The resulting method, called the Logical Elements Rule Method, consists of 7 steps: (1) restate the rule proactively; (2) restate the rule as a logical statement (preserving key phrases); (3) assess for conflict between rules; (4) identify concepts which are not needed; (5) classify concepts as crisp or fuzzy, find crisp definitions corresponding to fuzzy concepts, and extract data elements from crisp concepts; (6) identify rules which are related by sharing patients, actions, etc.; (7) determine availability of data in local systems. Validation showed that the method was usable with rules from various sources and clinical conditions, and reliable between users provided that the users agree on a terminology and agree on when the rule will be evaluated. CONCLUSIONS A method is presented to assist in assessing clinical rules for their amenability to decision support, and formalizing the rules for implementation. Validation shows that the method is usable and reliable between users. Use of a terminology increases reliability but also the error rate. The method is useful for future developers of systems which offer decision support based on clinical rules.

Improved communication in post-ICU care by improving writing of ICU discharge letters: a longitudinal before‐after study

Background The discharge letter is the primary means of communication at patient discharge, yet discharge letters are often not completed on time. A multifaceted intervention was performed to improve communication in patient hand-off from the intensive care unit (ICU) to the wards by improving the timeliness of discharge letters. Methods A management directive was operationalised by a working group of ICU staff in a longitudinal before–after study. The intervention consisted of (a) changing policy to require a letter for use as a transfer note at the time of ICU discharge, (b) changing the assignment of responsibility to an automatic process, (c) leveraging positive peer pressure by making the list of patients in need of letters visible to colleagues and (d) provision of decision support, through automatic copying of important content from the patient record to the letter and email reminders if letters were not written on time. Statistical process control charts were used to monitor the longitudinal effect of the intervention. Results The intervention resulted in a 77.9% absolute improvement in the proportion of patients with a complete transfer note at the time of discharge, and an 85.2% absolute improvement in the number of discharge letters written. Statistical process control shows that the effect was sustained over time. Conclusions A multifaceted intervention can be highly effective for improving discharge communication from the ICU.

Efficiency of Clinical Decision Support Systems Improves with Experience

Efficiency, or the resources spent while performing a specific task, is widely regarded as one the determinants of usability. In this study, the authors hypothesize that having a group of users perform a similar task over a prolonged period of time will lead to improvements in efficiency of that task. This study was performed in the domain of decision-supported medication reviews. Data was gathered during a randomized controlled trial. Three expert teams consisting of an independent physician and an independent pharmacist conducted 150 computerized medication reviews on patients in 13 general practices located in Amsterdam, the Netherlands. Results were analyzed with a linear mixed model. A fixed effects test on the linear mixed model showed a significant difference in the time required to conduct medication reviews over time; F(31.145) = 14.043, p < .001. The average time in minutes required to conduct medication reviews up to the first quartile was M = 20.42 (SD = 9.00), while the time from the third quartile up was M = 9.81 (SD = 6.13). This leads the authors to conclude that the amount of time users needed to perform similar tasks decreased significantly as they gained experience over time.

From assessment to improvement of elderly care in general practice using decision support to increase adherence to ACOVE quality indicators: study protocol for randomized control trial

BackgroundPrevious efforts such as Assessing Care of Vulnerable Elders (ACOVE) provide quality indicators for assessing the care of elderly patients, but thus far little has been done to leverage this knowledge to improve care for these patients. We describe a clinical decision support system to improve general practitioner (GP) adherence to ACOVE quality indicators and a protocol for investigating impact on GPs’ adherence to the rules.DesignWe propose two randomized controlled trials among a group of Dutch GP teams on adherence to ACOVE quality indicators. In both trials a clinical decision support system provides un-intrusive feedback appearing as a color-coded, dynamically updated, list of items needing attention. The first trial pertains to real-time automatically verifiable rules. The second trial concerns non-automatically verifiable rules (adherence cannot be established by the clinical decision support system itself, but the GPs report whether they will adhere to the rules). In both trials we will randomize teams of GPs caring for the same patients into two groups, A and B. For the automatically verifiable rules, group A GPs receive support only for a specific inter-related subset of rules, and group B GPs receive support only for the remainder of the rules. For non-automatically verifiable rules, group A GPs receive feedback framed as actions with positive consequences, and group B GPs receive feedback framed as inaction with negative consequences. GPs indicate whether they adhere to non-automatically verifiable rules. In both trials, the main outcome measure is mean adherence, automatically derived or self-reported, to the rules.DiscussionWe relied on active end-user involvement in selecting the rules to support, and on a model for providing feedback displayed as color-coded real-time messages concerning the patient visiting the GP at that time, without interrupting the GP’s workflow with pop-ups. While these aspects are believed to increase clinical decision support system acceptance and its impact on adherence to the selected clinical rules, systems with these properties have not yet been evaluated.Trial registrationControlled Trials NTR3566

Development of Computerized Clinical Decision Support to Assist in Detecting and Preventing Delirium in the Hospital Setting

Delirium is an acute confusional state commonly affecting hospitalized older patients. As a part of the Improving Care of Vulnerable Elders (ICOVE) project, interventions were designed to improve delirium screening and reduce use of strong anticholinergic medications while avoiding contributing to alert fatigue. Methods: Baseline compliance was assessed for each step in the workflow. The intervention was designed in cooperation with the clinicians who are responsible for those steps and built using the integrated decision support facilities of the electronic patient record system. Compliance after the intervention is assessed using the same computerized measures used to determine the baseline and using statistical process control charts. Results: Baseline compliance for delirium screening was 62.3%. Baseline compliance for avoiding strong anticholinergics was 84.3%, but varied from 17.2% to 97.3% for different therapeutic classes. Clinicians asked for a column added to a patient summary table to indicate whether delirium screening had been performed, and a non-interruptive onscreen alert for strong anticholinergic medications. However, the prescribing alert could only be implemented as a modal dialog alert or a passive alert accessed through clicking a tab in the patient record. We implemented the modal dialog alert for orders and the passive alert for active medications. Conclusions: We were able to perform computerized assessment of delirium screening and avoidance of strong anticholinergic medications, although both rules contained ambiguous terms which needed to be defined for the intervention. Assessment of multiple outcomes proved useful both for assessing the quality of care and for identifying where additional support was needed. Assessing the specificity of inferences about data not recorded in structured fields also revealed areas for improvement that would otherwise be missed. Additional functionality for flexibility in decision support in electronic patient record systems may be needed to combat alert fatigue, although this must be weighed against the need to maintain a consistent user experience.

Application of the logical elements rule method for formalization of clinical rules : case study of ACOVE-NLI

The Logical Elements Rule Method (LERM) is a step-wise method for formalizing if-then clinical rules. We applied LERM to a set of 40 clinical rules used in pharmacological quality assessment initiatives to assess (1) the amenability of the rules to formalization for decision support application (2) comparing adherence to rules that can and cannot be formalized, and (3) the usefulness of LERM as a tool for this task. Five rules could not be formalized, all due to unclear decision criteria. The adherence to ambiguous, non-formalizable rules was significantly lower than for formalizable ones (<0.001). We modified LERM with three additions for this task: (a) adding the sub-step of restating the rules in a consistent natural-language grammar before decomposing them into normal form, (b) creating rules to use in lieu of a controlled vocabulary, and (c) adding the requirement that a time frame must be defined for all medications (before hospitalization, current medication, new medication, or discharge medication). Although the clinical rules in this sample are all stated as semi-structured if-then recommendations and are used in quality assessment initiatives, many ambiguities and inconsistencies in the clinical rules were identified by using LERM.

Speech Technology in Dutch Health Care: A Qualitative Study.

This study investigates the opportunities of speech technology in Dutch hospitals, and to what extent speech technology can be used for documentation. Furthermore, we clarify why speech technology is used only marginally by Dutch hospital staff. We performed interviews where speech technology users, managers in hospitals and software suppliers were contacted as participants. We then transcribed our interviews and synthesized the pros and cons of speech technology as well as major barriers for the adoption. Our results show various influencing factors that could be clarifications for the fact that only 1% of the medical staff uses speech technology in the Netherlands. The major reasons we found are: speech technology usage at only radiology and pathology departments, \emph{smarttexts} and \emph{smartphrases} of the Electronic Health Record (EHR) compete with speech technology, caregivers have to adjust their way of working which evokes resistance, lack of central authorization at Dutc h hospitals and finally, financial barriers. Our results show that speech technology works for radiology and pathology as a tool for documentation, but is found less useful for other departments. For the remaining departments, different applications show potential, such as structured reporting.