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PubMedDate not supplied

Improving preventive care at a medical clinic: how can the patient help?

We developed a comprehensive individualized preventive care reminder system and then tested the hypothesis that directly involving patients in the reminder process would lead to greater use of preventive services than involving physicians only. There were three experimental groups of 350 patients each: in group 1 physicians and patients received the reminder; in group 2 physicians only received the reminder; in group 3 neither physicians nor patients received the reminder. Nine preventive care services were studied: blood pressure measurement; dental exam; ocular pressure measurement; stool exam for occult blood; influenza, pneumococcal, and tetanus vaccinations; mammography; and Papanicolaou smears. Need for these services was determined by telephone interview and chart review. To determine whether services were obtained, charts were reviewed after four to eight months of follow-up. For overall compliance with preventive recommendations and for several individual services (stool exam for occult blood, tetanus vaccination, mammography), group 1 patients received significantly more preventive care than group 2. Likewise, group 2 patients received more preventive care than group 3. These data show that involving patients in reminder efforts is an effective means of raising the level of preventive services.

Adult↗

PubMed1996

Have the most recent Pap smear guidelines affected GP practices?

OBJECTIVE: To assess the attitudes and knowledge of a sample of NSW general practitioners on issues concerning Papanicolaou (Pap) smear tests after the 1991 National Guidelines were established. DESIGN: During January-March 1994, a sample of Sydney general practitioners obtained from a list from the Department of General Practice, Royal North Shore Hospital, were asked to complete a questionnaire based on Pap smear screening. Issues explored included the perceived value of Pap smears, views on recommended screening intervals and the type of patients believed to be at highest risk of developing cervical cancer. SETTING: Northern Sydney metropolitan area. RESULTS: Seventy of 104 general practitioners from the Department of General Practice, Royal North Shore Hospital, returned completed questionnaires. Ninety-five per cent of respondents rated the Pap-smear as an extremely valuable screening test for cervical cancer prevention. The majority of GPs surveyed tended to overscreen younger patients and underscreen both older women and those at highest risk of developing cervical cancer. Seventy-seven per cent of doctors indicated the use of a patient reminder system, in most cases provided by a pathology laboratory but 43% were unaware of the NSW Cancer Council's reminder service. CONCLUSION: Our study suggests that Pap smears are viewed as an important means of cervical cancer prevention. Unfortunately the majority of respondents did not adhere to the recommended guidelines of 2-yearly screening. Possible changes to the current system include improved awareness of the 1991 National Guidelines, greater public awareness of the NSW Cancer Council reminder service, and the establishment of a state cytology registry.

Adolescent↗

PubMed2001

A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980-97.

OBJECTIVES: To appraise findings from studies examining the impact of computers on primary care consultations. DESIGN: Systematic review of world literature from 1980 to 1997. DATA SOURCES: 5475 references were identified from electronic databases (Medline, Science Citation Index, Social Sciences Citation Index, Index of Scientific and Technical Proceedings, Embase, OCLC FirstSearch Proceedings), bibliographies, books, identified articles, and by authors active in the field. 1892 eligible abstracts were independently rated, and 89 studies met the inclusion criteria. MAIN OUTCOME MEASURES: Effect on doctors' performance and patient outcomes; attitudes towards computerisation. RESULTS: 61 studies examined effects of computers on practitioners' performance, 17 evaluated their impact on patient outcome, and 20 studied practitioners' or patients' attitudes. Computer use during consultations lengthened the consultation. Reminder systems for preventive tasks and disease management improved process rates, although some returned to pre-intervention levels when reminders were stopped. Use of computers for issuing prescriptions increased prescribing of generic drugs, and use of computers for test ordering led to cost savings and fewer unnecessary tests. There were no negative effects on those patient outcomes evaluated. Doctors and patients were generally positive about use of computers, but issues of concern included their impact on privacy, the doctor-patient relationship, cost, time, and training needs. CONCLUSIONS: Primary care computing systems can improve practitioner performance, particularly for health promotion interventions. This may be at the expense of patient initiated activities, making many practitioners suspicious of the negative impact on relationships with patients. There remains a dearth of evidence evaluating effects on patient outcomes.

Bibliometrics↗

PubMedDate not supplied

Diagnostic decision support systems.

Diagnostic decision support systems are ready for prime time. We used them in a general medical clinic and found that they could suggest new diagnostic possibilities, focus thinking about clinical problems, and serve as a tool for recertification preparation. In addition, we have found diagnostic decision support systems useful for the novice clinician (fourth-year medical students and interns). These tools serve as a reminder system for learners, suggesting questions to ask the patient, physical exam components to complete, and tests to order. The novice clinician may also use these systems in preparing case presentations. The systems reviewed vary in the ways we described earlier, and there is no one "best buy." Which program is right for you depends on how much detail you want, whether you prefer a CD or internet format, and in what setting you practice. Demos are available from most vendors: Try them out, make a choice, and get on with the business of enhanced diagnostic decision making.

Decision Support Systems, Clinical↗

PubMed1979

Using warning devices to improve pressure-relief training.

A training and monitoring system has been developed to train spinal cord injured patients to relieve pressure intermittently from ischium while sitting in wheelchairs. The system automates the training of wheelchair push-ups based on certain conditioning principles. The system reminds the patient to do a push-up of a specified duration and at specified intervals. The frequency and the duration of the push-ups are monitored providing information about performance of the patients, especially when the alarms to remind the patients are disconnected. A long-term study is in hand to assess the effectiveness of the system.

Adolescent↗

PubMed1995

Breast cancer screening complacency and compliance.

An HMO initiative designed to increase the compliance rate for the preventive service (mammography) is described. By looking at Security Health Plan charge data and sending a letter of notification when women are not up-to-date on their screening mammography, we were able to increase the mammography compliance rate from 47% to 72%. This system is designed to supplement the preferred method of recommendations by the primary care physician aided perhaps by a chart reminder system. Some problems with the methodology are described.

Adult↗

PubMedDate not supplied

Longitudinal assessment of a diabetes care management system in an integrated health network.

OBJECTIVE: To describe the results of longitudinal assessment of the results of a disease management process developed in a large integrated health care system that successfully improved care for patients with diabetes. Outcome measures included rates of testing of hemoglobin A1c (HbA1c) and low-density lipoprotein (LDL), rate of annual eye exams, and LDL and HbA1c values. METHODS: Intermountain Health Care (IHC) initiated the development of a Diabetes Care Management System (DCMS) in early 1998. The DCMS was developed as a comprehensive population-based disease management system. It includes provider education programs; performance feedback to physicians; clinical quality performance incentives for physicians; patient education programs; patient incentive, reminder systems to encourage compliance with best care process models; and tracking of physician behavior change and patient compliance with diabetes therapy. A multifaceted intervention and education approach was chosen because of the complexity of the diabetes treatment process. RESULTS: The percentage of patients with at least one annual HbA1c test increased from 78.5% in 1998 to 90.5% in 2002. During the same time period, the percentage of patients whose most recent HbA1c was less than 7.0 increased from 33.5% to 52.8%, average HbA1c decreased from 8.1 to 7.3, and the percentage of patients whose most recent HbA1c was greater than 9.5 decreased from 34.6% to 21.4%. The percentage of patients who had an LDL cholesterol screening test within the prior 2 years increased from 65.9% in 1998 to 91.7% in 2002. During the same time period, the percentage of patients whose most recent LDL cholesterol was less than 130 mg/dL increased from 39.9% to 69.8%. The percentage of diabetes patients who had an annual eye exam increased from 52% in 1998 to 62% in 2002. CONCLUSION: A multifaceted approach to improving diabetes management has led to improved performance in clinical measures related to diabetes care that have been shown to reduce the risk of patients with diabetes developing diabetes- related complications. All components of the diabetes management continuum of care, including primary care physicians, specialists, office staff, patients, diabetes educators, and others, were involved in the care improvement activities.

Delivery of Health Care, Integrated↗

PubMed2002

An XML-based system for the flexible classification and retrieval of clinical practice guidelines.

Beneficial effects of clinical practice guidelines (CPGs) have not yet reached expectations due to limited routine adoption. Electronic distribution and reminder systems have the potential to overcome implementation barriers. Existing electronic CPG repositories like the National Guideline Clearinghouse (NGC) provide individual access but lack standardized computer-readable interfaces necessary for automated guideline retrieval. The aim of this paper was to facilitate automated context-based selection and presentation of CPGs. Using attributes from the NGC classification scheme, an XML-based metadata repository was successfully implemented, providing document storage, classification and retrieval functionality. Semi-automated extraction of attributes was implemented for the import of XML guideline documents using XPath. A hospital information system interface was exemplarily implemented for diagnosis-based guideline invocation. Limitations of the implemented system are discussed and possible future work is outlined. Integration of standardized computer-readable search interfaces into existing CPG repositories is proposed.

Information Systems↗

PubMed2005

Development of a Web-based diabetes patient management tool.

A Web-based programmed lipid management reminder system has been developed to evaluate physician compliance with the National Cholesterol Education Program's Third Report of the Adult Treatment Panel Guidelines in primary care clinics. The system builds a knowledge-based database from an EMR database first, then generates quarterly profiles of providers and sends the profiles with a reminder letter to each participated physicians by email every quarter to help primary care providers to improve the quality of their care.

Diabetes Mellitus↗

PubMed2005

Development of a Web-based quarterly profile of providers in ATP III study.

Adult↗

PubMed2002

[Quality management in health care: error prevention and managing errors in medicine].

BACKGROUND: About 3.7% of in-house-treated patients in Switzerland, the USA and Australia are victims of treatment-related health problems which probably are related to avoidable "adverse events" in more than 50% of the occurrences. Reasons are primarily systematic incidents, e.g., organizational deficiencies in the health system and only secondarly individual mistakes. As there are no systematic studies available, it is not proven if those figures can be transferred to the German Health Care System. Here, experts anticipate up to 12.000 proven treatment errors per year. PREVENTION OF AND DEALING WITH ADVERSE EVENTS: Dedicated programs for identification and prevention of adverse events should be implemented--besides systematic quality improvement--to improve professional handling and prevention of adverse events. This consists of a) assessment of the existing problem using existing data bases and/or implementation of mandatory documentation and information routines as well as reporting systems, b) development of sanction-free reporting routines within the legal framework, c) dissemination of behavior-oriented training systems for recognition and prevention of adverse events as well as incentives for the participation in such training systems, d) implementation of automatic routines for prevention of adverse events (e.g., computer-based monitoring of ADE or computer-based reminder systems based on clinical guidelines).

Forecasting↗

PubMed1998

Compliance with depot medroxyprogesterone acetate: a randomized, controlled trial of intensive reminders.

We enrolled women in a prospective, randomized study to determine whether an intensive reminder system would improve compliance in women receiving depot medroxyprogesterone injections. Women selecting this treatment were assigned to a group that received both mail and telephone reminders or to a second group that received only a scheduled appointment at the time of the previous injection. The rate of continuation and the rate of on-time injections did not differ between groups. Women who had prolonged bleeding were more likely to discontinue depot medroxyprogesterone injections.

Adult↗

PubMedDate not supplied

A controlled trial to improve delivery of preventive care: physician or patient reminders?

OBJECTIVE: To improve the delivery of preventive care in a medical clinic, a controlled trial was conducted of two interventions that were expected to influence delivery of preventive services differently, depending on level of initiative required of the physician or patient to complete a service. DESIGN: A prospective, controlled trial of five-months' duration. SETTING: A university hospital-based, general medical clinic. PARTICIPANTS: Thirty-nine junior and senior medical residents who saw patients in stable clinic teams throughout the study. INTERVENTION: A computerized reminder system for physicians and a patient questionnaire and educational hand-out on preventive care. MEASUREMENTS AND MAIN RESULTS: Delivery of five of six audited preventive services improved significantly after the interventions were introduced. The computerized reminder alone increased completion rates of services that relied primarily on physician initiative; the questionnaire alone increased completion rate of the service that depended more on patient compliance as well as on some physician-dependent services. Both interventions used together were slightly less effective in improving performance of physician-dependent services than the computerized reminder used alone. CONCLUSIONS: These interventions can improve the delivery of preventive care but they differ in their impacts on physician and patient behaviors. Overall, the computer reminder was the more effective intervention.

Ambulatory Care Information Systems↗

PubMed1993

Monitoring free-text data using medical language processing.

In this paper, we describe a software system for automated monitoring of free-text data in a medical information system that we call RadTRAC (Radiology Text Report Analyzer and Classifier). RadTRAC uses a medical language processing tool and rules derived from statistical analysis of a database to process free-text chest X-ray (CXR) reports and identify reports that describe new or expanding neoplasms for the purpose of monitoring the follow-up of these patients. To evaluate the RadTRAC system, we examined a set of 470 consecutive radiology reports at the Veterans Administration Medical Center, Palo Alto, CA. We compared RadTRAC classification of CXR reports with retrospective expert classification of the reports and with clinical classification from CXR films as recorded in a logbook while the films were being read. The RadTRAC system had a sensitivity of 90% and a specificity of 82% using the logbook as the gold standard. This was similar to the performance of expert radiologists (sensitivity, 92%; specificity, 90%). We then reviewed the charts, appointment schedule, and subsequent X-ray reports of cases either in the logbook or that were identified by RadTRAC as needing follow-up. Two cases in the logbook could have potentially benefited from an automatic monitoring system to ensure follow-up. RadTRAC identified six confirmed new tumors or new metastatic lesions that were not in the logbook. Six other cases were identified by the RadTRAC system with suspicious X-ray findings that had either no follow-up or no further mention of the X-ray lesion in medical records. This suggests that a reminder system based on the RadTRAC technology would be potentially useful.

Abstracting and Indexing↗

PubMed1971

Computerized entry into medical care. Its impact on doctor-patient relationships.

A large proportion of cannery workers see a doctor only as a last resort, in time of crisis. The Cannery Workers Multiphasic Screening Program identified workers in need of physician evaluation, and referred each to a physician of his choice, for examination by appointment, while the worker was not acutely ill. In many instances the screening program generated the first encounters between patient and physician. It conducted a follow-up system for workers unaccustomed to methodical health care. The program financed pretesting education of the persons to be tested, multiphasic testing, physician evaluation of abnormal findings, and the follow-up reminder system. Each physician, in advance of the appointment for evaluation, was sent a computerized report calling attention to findings that exceeded limits considered normal. The report included a form facilitating the physician's report and billing. In counties having foundations for medical care, the foundations reviewed the form for adequacy of follow-up and appropriateness of charges. The effort to bridge the gap between findings, diagnosis and therapy, for a population group newly introduced to modern medical care delivery, was made possible by the use of the computer as a tool for the attainment of specific, preanalyzed components of the total objective.

Computers↗

PubMed2000

Mining association rules from a pediatric primary care decision support system.

The purpose of this study was to apply an unsupervised data mining algorithm to a database containing data collected at the point of care for clinical decision support. The data set was taken from the Child Health Improvement Program (CHIP), a preventive services tracking and reminder system in use at the University of North Carolina. The database contains over 30,000 visits. We used a previously described pattern discovery algorithm to extract 2nd and 3rd order association rules from the data and reviewed the literature two see if the associations had been described before. The algorithm discovered 16 2nd order associations and 103 3rd order associations. The 3rd order associations contained no new information. The 2nd order associations demonstrated a covariance among a range of health risk behaviors. Additionally, the algorithm discovered that both tobacco smoke exposure and chronic cardiopulmonary disease are associated with failure on developmental screens. These relationships have been described before and have been attributed to underlying poverty. The work demonstrates the ability of unsupervised data mining by rule association on sparse clinical data to discover clinically important associations. However, many associations may be previously known or explained by confounding variables.

Algorithms↗

PubMedDate not supplied

Opportunistic electronic reminders. Improving performance of preventive care in general practice.

BACKGROUND: Preventive care is an important role for general practitioners, yet opportunities for prevention are often missed. METHOD: We provided an automatic electronic record preventive care reminder system for 12 preventive care activities for one 10 doctor practice. All patients who attended were randomised by the terminal digit of their record number. RESULTS: The control uptake of opportunistic prevention was low; ranging from 1.5% (tetanus immunisation) to 27% (influenza immunisation). The reminders increased this by significant but small amounts for four out of 12 activities (immunisation for tetanus and pneumococcus and recording of allergies and weight), insignificant increases for four (mumps, measles and rubella immunisation, recording of smoking, and taking of cervical smears and of blood pressure), and insignificantly decreased influenza immunisation, and screening for diabetes and hyperlipidaemia. DISCUSSION: Opportunistic electronic reminders have the potential to increase preventive care in general practice.

Adolescent↗

PubMed1999

[Computerization in a community health service provider].

As the second largest health service provider organization in Israel, we have been progressively computerized. The process was begun in 1988, focusing on improving administrative and financial processes. Today there is a single centralized database for 6,000 users. The system monitors member eligibility, accounting procedures and clinical processes, including diagnoses, laboratory tests, imaging procedures and drug-prescribing. The potential of the computer for physician support is now being realized through integration of clinical guidelines and reminder systems into the computerized clinical record. In addition, the centralized database is used for quality improvement, facilitating cost-effective drug-prescribing and efficient use of technology. The establishment of a computerized working environment for 2,000 physicians and 4,000 other healthcare workers serving 1.3 million patients is a unique model for the development of community health services. Data regarding demographics, disease patterns, drug-prescribing, use of new technology and costs are now readily available to all, from senior management to the individual physician in independent practice. The computer revolution has also presented a new set of problems such patient-record confidentiality and the effect of the computer on the physician-patient encounter.

Community Health Services↗