Peter G. Rossos

Patient-Perceived Usefulness of Online Electronic Medical Records: Employing Grounded Theory in the Development of Information and Communication Technologies for Use by Patients Living with Chronic Illness

OBJECTIVE Patient use of online electronic medical records (EMR) holds the potential to improve health outcomes. The purpose of this study is to discover how patients living with chronic inflammatory bowel disease (IBD) value Internet-based patient access to electronic patient records. DESIGN This was a qualitative, exploratory, descriptive study using in-depth interviews and focus groups of a total of 12 patients with IBD of at least one-year duration at University Health Network, a tertiary care center in Toronto, Ontario. RESULTS Four themes have been elucidated that comprise a theoretical framework of patient-perceived information and communication technology usefulness: promotion of a sense of illness ownership, of patient-driven communication, of personalized support, and of mutual trust. CONCLUSIONS For patients with chronic IBD, simply providing access to electronic medical records has little usefulness on its own. Useful technology for patients with IBD is multifaceted, self-care promoting, and integrated into the patients already existing health and psychosocial support infrastructure. The four identified themes can serve as focal points for the evaluation of information technology designed for patient use, thus providing a patient-centered framework for developers seeking to adapt existing EMR systems to patient access and use for the purposes of improving health care quality and health outcomes. Further studies in other populations are needed to enhance generalizability of the emergent theory.

Effect of Home Blood Pressure Telemonitoring With Self-Care Support on Uncontrolled Systolic Hypertension in Diabetics

Lowering blood pressure reduces cardiovascular risk, yet hypertension is poorly controlled in diabetic patients. In a pilot study we demonstrated that a home blood pressure telemonitoring system, which provided self-care messages on the smartphone of hypertensive diabetic patients immediately after each reading, improved blood pressure control. Messages were based on care paths defined by running averages of transmitted readings. The present study tests the systems effectiveness in a randomized, controlled trial in diabetic patients with uncontrolled systolic hypertension. Of 244 subjects screened for eligibility, 110 (45%) were randomly allocated to the intervention (n=55) or control (n=55) group, and 105 (95.5%) completed the 1-year outcome visit. In the intention-to-treat analysis, mean daytime ambulatory systolic blood pressure, the primary end point, decreased significantly only in the intervention group by 9.1±15.6 mmHg (SD; P<0.0001), and the mean between-group difference was 7.1±2.3 mmHg (SE; P<0.005). Furthermore, 51% of intervention subjects achieved the guideline recommended target of <130/80 mmHg compared with 31% of control subjects (P<0.05). These improvements were obtained without the use of more or different antihypertensive medications or additional clinic visits to physicians. Providing self-care support did not affect anxiety but worsened depression on the Hospital Anxiety and Depression Scale (baseline, 4.1±3.76; exit, 5.2±4.30; P=0.014). This study demonstrated that home blood pressure telemonitoring combined with automated self-care support reduced the blood pressure of diabetic patients with uncontrolled systolic hypertension and improved hypertension control. Home blood pressure monitoring alone had no effect on blood pressure. Promoting patient self-care may have negative psychological effects.

Patient-Perceived Barriers to the Adoption of Nocturnal Home Hemodialysis

BACKGROUND AND OBJECTIVES Nocturnal home hemodialysis (NHHD) has been shown to improve clinical outcomes, although adoption has been limited. Given the known benefits, an understanding of the barriers to adoption is needed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patient-perceived barriers were studied through a cross-sectional survey of prevalent hemodialysis patients using validated instruments, study-specific questions, and ethnographic interviews. Fifty-six of 66 NHHD patients and 153 of 199 conventional hemodialysis (CHD) patients were included in the survey. Twenty interviews were conducted with NHHD, CHD, and predialysis patients. RESULTS Compared with CHD patients, NHHD patients had higher perceived physical health scores (Short Form 12 [SF-12]: 41.47 +/- 10.9 versus 34.73 +/- 10.6, P < 0.0001), but had similar mental health scores (47.30 +/- 11.1[NHHD] versus 45.27 +/- 11.3[CHD]), P = 0.25). Despite having similar measures of education and perceived social support as NHHD patients, CHD patients had a low interest (1.68 [out of 5] +/- 1.26) in adopting NHHD. The major barriers perceived by CHD patients were lack of self-efficacy in performing the therapy, lack of confidence in self-cannulation, and length of time on current therapy. Similar themes emerged from the qualitative analysis as well as: burden on family members and fear of a catastrophic event. CONCLUSIONS Patient-perceived barriers are primarily fears of self-cannulation, a catastrophic event, and the burden on family. These findings should form the basis of screening patients for interest in NHHD and serve to mitigate these concerns.

The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals.

BACKGROUND Effective clinical communication is critical to providing high-quality patient care. Hospitals have used different types of interventions to improve communication between care teams, but there have been few studies of their effectiveness. OBJECTIVES To describe the effects of different communication interventions and their problems. DESIGN Prospective observational case study using a mixed methods approach of quantitative and qualitative methods. SETTING General internal medicine (GIM) inpatient wards at five tertiary care academic teaching hospitals. PARTICIPANTS Clinicians consisting of residents, attending physicians, nurses, and allied health (AH) staff working on the GIM wards. METHODS Ethnographic methods and interviews with clinical staff (doctors, nurses, medical students, and AH professionals) were conducted over a 16-month period from 2009 to 2010. RESULTS We identified four categories that described the intended and unintended consequences of communication interventions: impacts on senders, receivers, interprofessional collaboration, and the use of informal communication processes. The use of alphanumeric pagers, smartphones, and web-based communication systems had positive effects for senders and receivers, but unintended consequences were seen with all interventions in all four categories. CONCLUSIONS Interventions that aimed to improve clinical communications solved some but not all problems, and unintended effects were seen with all systems.

It's not about pager replacement: an in-depth look at the interprofessional nature of communication in healthcare.

BACKGROUND Institutions have tried to replace the use of numeric pagers for clinical communication by implementing health information technology (HIT) solutions. However, failing to account for the sociotechnical aspects of HIT or the interplay of technology with existing clinical workflow, culture, and social interactions may create other unintended consequences. OBJECTIVE To evaluate a Web-based messaging system that allows asynchronous communication between health providers and identify the unintended consequences associated with implementing such technology. DESIGN Intervention-a Web-based messaging system at the University Health Network to replace numeric paging practices in May 2010. The system facilitated clinical communication on the medical wards for coordinating patient care. Study design-pre-post mixed methods utilizing both quantitative and qualitative measures. PARTICIPANTS Five residents, 8 nurses, 2 pharmacists, and 2 social workers were interviewed. Pre-post interruption-15 residents from 5 clinical teams in both periods. MEASUREMENTS The study compared the type of messages sent to physicians before and after implementation of the Web-based messaging system; a constant comparative analysis of semistructured interviews was used to generate key themes related to unintended consequences. RESULTS Interruptions increased 233%, from 3 pages received per resident per day pre-implementation to 10 messages received per resident per day post-implementation. Key themes relating to unintended consequences that emerged from the interviews included increase in interruptions, accountability, and tactics to improve personal productivity. CONCLUSIONS Meaningful improvements in clinical communication can occur but require more than just replacing pagers. Introducing HIT without addressing the sociotechnical aspects of HIT that underlie clinical communication can lead to unintended consequences.

Perception of eye contact in video teleconsultation

During patient consultations by videoconferencing, clinicians often sit as close as 1 m from the videoconferencing units, creating a significant eye gaze angle (i.e. the angle between the eye and the camera, and the eye and the centre of the display). Eye gaze angle may adversely affect the satisfaction with videoconferencing. Four videoconferencing environments were examined: desktop PC, portable telehealth unit, videoconferencing room, and a boardroom equipped with a ceiling-mounted camera and a projection screen. Two still images of each of the three subjects were captured: one at a 7° eye gaze angle and the other at 15°. Each of 53 observers ranked four pairs of images for each of the three subjects. In 87% of cases, the observers perceived better eye contact at an eye gaze angle of 7° than 15°. Also, 92% of observers responded that the difference in the perceived eye contact was important to them as patients. Improved eye contact can be realized by increasing the horizontal distance of participants from the videoconferencing unit.

Frequency and clinical importance of pages sent to the wrong physician.

E ffective communication between health care providers is essential to patient safety and quality of care. A retrospective study of 14 000 admissions found that communication failures were the most common cause of preventable disability or death and were nearly twice as common as those due to inadequate medical skill. A major type of communication failure is sending a page to the wrong physician. Prior studies have described paging problems such as paging the wrong physician, unanswered pages, and delayed responses but do not quantify the extent of the problem. Our primary aim was to quantify the frequency of pages sent to the wrong physician in 2 academic teaching hospitals and to examine the potential clinical importance of these errors.

Accidental Ingestion of 35% Hydrogen Peroxide

Hydrogen peroxide is a commonly used oxidizing agent with a variety of uses depending on its concentration. Ingestion of hydrogen peroxide is not an uncommon source of poisoning, and results in morbidity through three main mechanisms: direct caustic injury, oxygen gas formation and lipid peroxidation. A case of a 39-year-old man who inadvertently ingested 250 mL of unlabelled 35% hydrogen peroxide intended for natural health use is presented. Hydrogen peroxide has purported benefits ranging from HIV treatment to cancer treatment. Its use in the natural health industry represents an emerging source for accidental poisonings.

Improving hospital care and collaborative communications for the 21st century: key recommendations for general internal medicine.

Background Communication and collaboration failures can have negative impacts on the efficiency of both individual clinicians and health care system delivery as well as on the quality of patient care. Recognizing the problems associated with clinical and collaboration communication, health care professionals and organizations alike have begun to look at alternative communication technologies to address some of these inefficiencies and to improve interprofessional collaboration. Objective To develop recommendations that assist health care organizations in improving communication and collaboration in order to develop effective methods for evaluation. Methods An interprofessional meeting was held in a large urban city in Canada with 19 nationally and internationally renowned experts to discuss suitable recommendations for an ideal communication and collaboration system as well as a research framework for general internal medicine (GIM) environments. Results In designing an ideal GIM communication and collaboration system, attendees believed that the new system should possess attributes that aim to: a) improve workflow through prioritization of information and detection of individuals’ contextual situations; b) promote stronger interprofessional relationships with adequate exchange of information; c) enhance patient-centered care by allowing greater patient autonomy over their health care information; d) enable interoperability and scalability between and within institutions; and e) function across different platforms. In terms of evaluating the effects of technology in GIM settings, participants championed the use of rigorous scientific methods that span multiple perspectives and disciplines. Specifically, participants recommended that consistent measures and definitions need to be established so that these impacts can be examined across individual, group, and organizational levels. Conclusions Discussions from our meeting demonstrated the complexities of technological implementations in GIM settings. Recommendations on the design principles and research paradigms for an improved communication system are described.

Real-time automated paging and decision support for critical laboratory abnormalities

Background For patients with critical laboratory abnormalities, timely clinical alerts with decision support could improve management and reduce adverse events. Methods The authors developed a real-time clinical alerting system for critical laboratory abnormalities. The system sent alerts to physicians as text messages to a smartphone or alphanumeric pager. Decision support was available via smartphone or hospital intranet. The authors evaluated the system in a prospective controlled stepped-wedge study with blinded outcome assessment in general internal medicine units at two academic hospitals. The outcomes were the proportion of potential clinical actions that were actually completed in response to the alert, and adverse events (worsening of condition or complications related to treatment of the condition). Results The authors evaluated 498 laboratory conditions on 271 patients. Overall, only 50% of potential clinical actions were carried out, and there were adverse clinical events within 48 h for 36% of the laboratory conditions. The median (IQR) proportion of potential clinical actions that were actually completed was 50% (33–75%) with alerting system on and 50% (33–100%) with alerting system off (p=0.94, Wilcoxon rank sum test). When the alerting system was on (n=164 alerts) there were 67 adverse events within 48 h of the alerts (42%). When the alerting system was off (n=334 alerts), there were 112 adverse events within 48 h (33%; difference: 9% higher with alerting system on, p=0.06). Conclusions The provision of real-time clinical alerts and decision support for critical laboratory abnormalities did not improve clinical management or decrease adverse events.