Scott M. Strayer

Assessing medical residents’ usage and perceived needs for personal digital assistants

Health care professionals need information delivery tools for accessing information at the point of patient care. Personal digital assistants (PDAs), or hand-held devices demonstrate great promise as point of care information devices. An earlier study [The Constellation Project: experience and evaluation of personal digital assistants in the clinical environment, in: Proceedings of the 19th Annual Symposium on Computer Applications in Medical Care, 1995, 678] on the use of PDAs at the point of care found that hardware constraints, such as memory capability limited their usefulness, however, they were used frequently for accessing medical references and drug information [The Constellation Project: experience and evaluation of personal digital assistants in the clinical environment, in: Proceedings of the 19th Annual Symposium on Computer Applications in Medical Care, 1995, 678]. Since this study was completed in 1995, hand-held computer technology has advanced rapidly, and between 26 and 50% of physicians currently use PDAs [Physicians use of hand-helds increases from 15% in 1999 to 26% in 2001: Harris interactive poll results, Harris Poll. 8-24-2002 (electronic citation); ACP-ASIM survey finds nearly half of U.S. members use hand-held computers: ACP-ASIM press release, American College of Physicians, 9-3-2002 (electronic citation)]. This use appears higher among residents, with one recent study finding that over two-thirds of family practice residencies use hand-held computers in their training programs [J. Am. Med. Inform. Assoc. 9 (1) (2002) 80]. In this study, we systematically evaluate PDA usage by residents in our institution using quantitative and qualitative methods. Our evaluation included a brief on-line survey of 88 residents in seven residency programs including primary care and specialty practices. The surveys were completed between 26 October 2001 and 30 April 2002. Follow-up interviews with 15 of the surveyed residents were then conducted between 24 April 2002 and 13 May 2002. The original contributions of this study are the evaluation of residents in primary and specialty programs and evaluation of both medical application software and the conventional personal organizational software (such as calendars and to-do lists). This evaluation was also conducted using significantly advanced hardware and software compared with previous studies [The Constellation Project: experience and evaluation of personal digital assistants in the clinical environment, in: Proceedings of the 19th Annual Symposium on Computer Applications in Medical Care, 1995, 678]. Results of our survey and follow-up interviews of residents showed most residents use PDAs daily, regardless of practice or whether their program encourages PDAs. Uses include commercial medical references and personal organization software, such as calendars and address books. Concerns and drawbacks mentioned by these residents included physical size of the PDA and the potential for catastrophic data loss. Another issue raised by our results suggests that security and Health Information Portability and Accountability Act (HIPAA) compliance need to be addressed, in part by resident education about securing patient data on PDAs. Overall, PDAs may become even more widely used if two issues can be addressed: (a) providing secure clinical data for the current patients of a given resident, and (b) allaying concerns of catastrophic data loss from their PDAs (e.g. by educating residents about procedures to recover information from PDA backup files).

Screening Colonoscopies by Primary Care Physicians: A Meta-Analysis

PURPOSE There is currently too few endoscopists to enact a national colorectal cancer screening program with colonoscopy. Primary care physicians could play an important role in filling this shortage by offering screening colonoscopy in their practice. The purpose of this study was to examine the safety and effectiveness of colonoscopies performed by primary care physicians. METHODS We identified relevant articles through searches of MEDLINE and EMBASE bibliographic databases to December 2007 and through manual searches of bibliographies of each citation. We found 590 articles, 12 of which met inclusion criteria. Two authors independently abstracted data on study and patient characteristics. Descriptive statistics were performed. For each outcome measure, a random effects model was used to determine estimated means and confidence intervals. RESULTS We analyzed 12 studies of colonoscopies performed by primary care physicians, which included 18,292 patients (mean age 59 years, 50.5% women). The mean estimated adenoma and adenocarcinoma detection rates were 28.9% (95% confidence interval [CI], 20.4%–39.3%) and 1.7% (95% CI, 0.9%–3.0%), respectively. The mean estimated reach-the-cecum rate was 89.2% (95% CI, 80.1%–94.4%). The major complication rate was 0.04% (95% CI, 0.01%–0.07%); no deaths were reported. CONCLUSIONS Colonoscopies performed by primary care physicians have quality, safety, and efficacy indicators that are comparable to those recommended by the American Society of Gastrointestinal Endoscopy, the American College of Gastroenterology, and the Society of American Gastrointestinal Endoscopic Surgeons. Based on these results, colonoscopy screening by primary care physicians appears to be safe and effective.

Development and evaluation of an instrument for assessing brief behavioral change interventions

OBJECTIVE To develop an observational coding instrument for evaluating the fidelity and quality of brief behavioral change interventions based on the behavioral theories of the 5 As, Stages of Change and Motivational Interviewing. METHODS Content and face validity were assessed prior to an intervention where psychometric properties were evaluated with a prospective cohort of 116 medical students. Properties assessed included the inter-rater reliability of the instrument, internal consistency of the full scale and sub-scales and descriptive statistics of the instrument. Construct validity was assessed based on students scores. RESULTS Inter-rater reliability for the instrument was 0.82 (intraclass correlation). Internal consistency for the full scale was 0.70 (KR20). Internal consistencies for the sub-scales were as follows: MI intervention component (KR20=.7); stage-appropriate MI-based intervention (KR20=.55); MI spirit (KR20=.5); appropriate assessment (KR20=.45) and appropriate assisting (KR20=.56). CONCLUSIONS The instrument demonstrated good inter-rater reliability and moderate overall internal consistency when used to assess performing brief behavioral change interventions by medical students. PRACTICE IMPLICATIONS This practical instrument can be used with minimal training and demonstrates promising psychometric properties when evaluated with medical students counseling standardized patients. Further testing is required to evaluate its usefulness in clinical settings.

Updating clinical knowledge: an evaluation of current information alerting services.

PURPOSE Clinicians are overwhelmed by the sheer magnitude of new clinical information that is available on a daily basis. Despite the availability of information tools for finding this information and for updating clinical knowledge, no study has examined the quality of current information alerting services. METHODS We developed a 7-item checklist based on the principles of evidence-based medicine and assessed content validity with experts and face validity with practicing clinicians and clinician researchers. A list of clinical information updating tools (push tools) was generated in a systematic fashion and the checklist was used to rate the quality of these tools by two independent raters. Prior to rating all instruments, the raters were trained to achieve good agreement (>80%) by applying the checklist to two sets of three randomly selected tools. Descriptive statistics were used to describe the quality of the identified tools and inter-rater reliability was assessed using Intraclass Correlation (ICC). RESULTS Eighteen tools were identified using our systematic search. The average quality of these tools was 2.72 (range 0-7). Only two tools met all suggested criteria for quality. Inter-rater reliability for the 7-item checklist was .82 (ICC). CONCLUSIONS We developed a checklist that can be used to reliably assess the quality of clinical information updating tools. We found many shortcomings in currently available clinical knowledge updating tools. Ideally, these tools will evolve in the direction of applying basic evidence-based medicine principles to new medical information in order to increase their usefulness to clinicians.

Physician Advice for e-Cigarette Use

Purpose: To determine characteristics of smokers discussing e-cigarette use with their physician and receiving recommendations from their physician to use e-cigarettes for smoking cessation. Methods: US adult smokers who had visited a physician in the previous 12 months (n = 2671) were surveyed. Logistic generalized estimating equation models were used to assess the characteristics of smokers who (1) talked to a physician about e-cigarettes, and (2) received physician advice to use e-cigarettes for smoking cessation. Results: 15% (n = 406) of smokers who visited a physician talked with their physician about e-cigarettes. Among those asked whether their physician recommend e-cigarettes for smoking cessation (n = 257), 61% responded affirmatively. Current e-cigarette users were more likely to talk to their physicians about e-cigarettes (nondaily users vs never users: OR, 2.70; 95% CI, 1.79–4.05; daily users vs never users: OR, 4.29; 95% CI, 2.34–7.84) and have their physician recommend e-cigarettes for smoking cessation (daily users vs never users: OR, 9.40; 95% CI, 2.54–34.71). Conclusions: The majority of smokers who talk to their physician about e-cigarettes report that they received advice to use e-cigarettes to quit smoking, despite limited evidence for their efficacy. More studies are needed to better understand e-cigarette recommendations in clinical settings.

Evaluation of a Screening and Counseling Tool for Alcohol Misuse: A Virginia Practice Support and Research Network (VaPSRN) Trial

Background: Surveys reveal limited screening and counseling for alcohol misuse by primary care physicians despite evidence-based recommendations. We developed and evaluated an alcohol screening and misuse counseling tool designed to assist clinicians at the point of care (POC). Methods: This was a mixed methods, prospective cohort study conducted with licensed clinicians in a practice-based research network. A software tool was designed to guide clinicians through evidence-based alcohol misuse assessment and interventions. Results: Participants (N = 12) used the tool an average of 3 sessions and 71% were satisfied with the tool. Participants increased their ability to differentiate between patients who are “at risk” drinkers versus those with alcohol use disorders including dependence/abuse (21%; t = 2.4; P = .04). Thematic analysis of interviews suggests that barriers to overall use included perceptions of alcohol use; clinical need to intervene; time; and issues with use of technology, most often at the POC. However, the tool added confidence and a valuable framework for interventions and was valued as an educational tool. Users felt that increased training and practice could increase comfort and impact future POC use. Increased POC usability also may be achieved through simplification of the tool and additional flexibility in options for POC use. Conclusions: A computer-assisted counseling tool for alcohol misuse and abuse can be implemented in primary care settings and shows promise for improving physician screening and interventions for alcohol misuse. To enhance utility in daily clinical practice we recommend design enhancements and strategies to enhance usage as described in this research.

Institutional support for handheld computing: clinical and educational lessons learned.

Handheld computing devices, or personal digital assistants (PDAs), are used often in the health care setting. They provide a convenient way to store and carry either personal or reference information and can be used to accomplish other tasks associated with patient care. This article reports clinical and educational lessons learned from a longitudinal institutional initiative designed to provide medical students with PDAs to facilitate patient care and assist with clinical learning.

Disseminating drug prescribing information: the cox-2 inhibitors withdrawals.

This case study examined the recent withdrawal of valdecoxib to determine the timeliness of updates in commonly used information sources used by healthcare professionals. The method included assembling a purposive sample of 15 drug reference and warning systems that were then systematically monitored for several months after the withdrawal of valdecoxib to determine the time to update this information. These information sources were classified and described qualitatively. A time to diffusion curve was plotted and the average number of days to report the drug withdrawal or update reference databases was calculated. Only 2 of 15 information systems reported the drug withdrawal on the actual date of the FDA announcement. Institutional electronic textbooks took an average of 109.8 days (+/-14 days) to report the withdrawal. In addition, one pharma-sponsored dissemination source (Peerview Press) had not updated their information as of this publication.

Software for Other Healthcare Professionals: Hey, What About Me?

If you’re not a physician or nurse in the healthcare field, you might be asking at this point . . . “Hey, what about me?” Although many of the programs we have described so far can be used by different healthcare professionals, it certainly has been written from our doctor-centric perspective—we just don’t know anything else! So we asked a speech pathologist, a physician assistant, and the CEO of a home health nursing agency to write about other uses of handheld computers in the healthcare industry. Just as there are a plethora of different types of handheld computers in every shape, size, and color, there are an infinite number of uses for them in health care, and that’s what this chapter is all about. We were pleasantly surprised by the creative uses that different healthcare professionals find for their trusty handheld companions.

Getting Software from Cyberspace to the Palm of Your Hand: Downloading and Installing Software on Your Palm OS or Pocket PC Handheld

retail outlet, and taken the plunge to buy your first handheld computer. Trust me, you won’t be disappointed. The fun is just about to begin! In this chapter we detail the process of downloading and installing all the great medical software from the Internet that is described in Section II. I personally struggled with downloading and installing software for 2 weeks until a generous fellow handheld user explained the process to me. It really isn’t that hard, so long as you stick to the basics of file management on your PC or Mac computer and follow these simple step-by-step instructions. One of the great things you will learn about handheld software is that it usually comes as a very small file (normally less than 1MB). Even better, most of the software programmers must have learned a thing or two from drug reps, because many programs are free, and even the commercial versions usually have a free 30-day demo. Thus, you can stock your handheld with excellent medical software at no cost, and you can trial just about any other software available through the Internet. On the other hand, as with the information from drug reps, there is sometimes a catch with the free software. Creating high-quality software, keeping it up-to-date, and responding to the needs of users is a full-time job, so don’t hesitate to part with a little green to support your local computer programmer! Getting all these great medical resources from cyberspace into the palm of your hand really involves three simple steps. First, you have to identify the software you want, which we cover in detail in the next section of the book. Second, you have to download and sometimes “uncompress” the software package. Finally, you have to install it to your Palm OS or Pocket PC handheld computer. 3