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PubMed2004

The challenge of promoting integration: conceptualization, implementation, and assessment of a pilot care delivery model for patients with type 2 diabetes.

BACKGROUND: The Côte-des-Neiges diabetes pilot project strove to conceptualize, implement, and assess an integrated health care system for Type 2 diabetes. Using a disease management and population-based approach, a multidisciplinary team sought to (1). organize health care in an integrative framework, (2). promote behavior changes in patients to foster self-care, (3). introduce tools to allow family physicians to modify their practices, and (4). encourage local community action to support patients and providers. METHODS: Information from a needs assessment helped guide the development of the care model, which was implemented over a 1-year period. A preliminary assessment was undertaken using qualitative methods. Data were collected through in-depth interviews, focus groups, participant observation, and document analysis. RESULTS: (1). Physicians and patients appreciated having access to a multidisciplinary team and related services, and personalized communication was preferred to computerized links. (2). Patients also perceived the benefit of individualized assessment and self-care educational sessions allowing them to participate in their illness management. (3). A diabetes care flow sheet altered the management strategies of physicians. (4). Limited time prevented full development of networking efforts to promote community mobilization. CONCLUSIONS: Approaches to chronic diseases such as diabetes require integrative health care strategies to support patients and providers in their community. In spite of time constraints, patients perceived the value of education with increasing involvement in their illness, physicians reported changes in their practice, and steps were initiated to mobilize community resources.

Adult↗

PubMed2004

From eminence-based practice to evidence-based practice: a paradigm shift.

Evidence-based medicine differs from the traditional approach to health care in that in addition to relying on clinical experience, expert opinion, and knowledge of pathophysiology for clinical decision-making, clinicians identify important knowledge gaps and information needs, formulate answerable questions, identify potentially relevant research, assess the validity of evidence and results, and apply research evidence to individual patients in a way that takes into account the patients' particular experiences, expectations, and values. It is becoming increasingly important that physicians learn the concepts of EBM because many EBM-related concepts have become a part of daily clinical practice. This article uses examples from orthopedics to outline EBM principles and methods and the advantages of EBM over traditional approaches. It also discusses challenges in implementing EBM and suggests EBM-related resources for physicians.

Clinical Competence↗

PubMed2004

Gels and more gels: probing toxicity.

Two-dimensional electrophoresis (2-DE) remains an important technology in the study of protein expression. In many applications, 2-DE has been supplanted by liquid chromatographic and mass spectrometric approaches that overcome some of its limitations and labor intensiveness. Nevertheless, 2-DE has exceptional relevance in toxicology and, despite the challenges, its implementation continues to support toxicologists in understanding the biological effects of chemical exposures in living systems. This review will address the use of 2-DE-based proteomics in toxicology and recent developments in this strategy, considering the unique nature of toxicity testing and the issues of dynamic range and reproducibility that have previously limited the overall utility of 2-DE in this field.

Animals↗

PubMed2005

You've led the horse to water, now how do you get him to drink: managing change and increasing utilization of computerized provider order entry.

Community hospitals served by predominately private-practice physicians face difficult challenges in implementing computerized provider order entry (CPOE), but there are techniques and incentives that can be employed to change physician behavior Various techniques were used to increase CPOE utilization at Lehigh Valley Hospital, a three-campus, 750-bed tertiary community hospital in eastern Pennsylvania. Those techniques included presenting studies supporting CPOE as a way to improve patient care, recognizing support with small trinkets, providing individual access to computers, adding clinical decision support, and bringing peer pressure to bear Ultimately, financial compensation for the educational time required to learn to use and become proficient with the system was employed and had the greatest impact on behavior Measuring utilization of the CPOE system with data extracted from the hospital's clinical information system, CPOE utilization by physicians increased to 57 percent from 35 percent after a financial compensation program was initiated. Utilization declined to 42 percent several months after completing the first phase of the program and increased to 54 percent after a second phase was initiated.

Attitude to Computers↗

PubMedDate not supplied

Seeds of change: using peacemaking circles to build a village for every child.

Roca, Inc., a grassroots human development and community organization, has adopted the peacemaking circle as a tool in its relationship building with youth, communities, and formal systems. Circles are a method of communication derived from aboriginal and native traditions. In Massachusetts, the Department of Social Services and the Department of Youth Services are exploring the application of the circle in programming with youth and families. By providing a consistent structure for open, democratic communication, peacemaking circles enhance the formation of positive relationships in families, communities, and systems. The outcome is a stronger community with greater unity across truly diverse participants. This article presents the theory and practice of peacemaking circles, the lessons and challenges of implementing circles in formal organizations, and the potential of the circle to support a strengths-based and community-based approach to child welfare.

Child↗

PubMed2004

Home based E-health applications.

Home based e-health applications use telecommunication and videoconferencing technologies to enable a healthcare provider at the clinical site to conmunicate with patients at their home. Such an interaction is called a 'virtual visit'. Numerous applications are utilizing commercially available monitoring devices and the Internet to enable home based disease management and monitoring. The aim to meet older adults' desire to remain independent at home while controlling home health care costs has also led to the development of "smart home" technologies. A smart home is a residence equipped with technology that enhances safety of patients at home and monitors their health conditions. Therefore, the devices and sensors chosen to be installed and maintained in the older adults' residences need to address functional limitations and social and health care needs. This paper provides an overview of home based e-health applications and discusses the challenges of implementing and evaluating e-health applications.

Home Care Services↗

PubMed2005

Controversies around gestational diabetes. Practical information for family doctors.

OBJECTIVE: To summarize some of the issues facing primary care physicians who are seeing increasing numbers of patients with gestational diabetes mellitus (GDM) and to explore new developments in use of oral hypoglycemics during pregnancy. QUALITY OF EVIDENCE: All the literature on screening for GDM offers level III evidence. Much of the literature on treatment is also level III, but newer studies offer level I evidence and are more useful for daily practice. Existing research leaves many important questions unanswered; research findings are inconsistent among studies, and treatment strategies are challenging to implement. MAIN MESSAGE: Recent studies have clarified that rates of neonatal mortality and congenital malformations are not higher among the offspring of mothers with GDM. Treatment might affect birth weight, but whether treatment is associated with reductions in rates of shoulder dystocia and cesarean section is unclear. Several level I studies conclude that the oral hypoglycemic glyburide can be used safely and effectively during the second and third trimesters of pregnancy. CONCLUSION: Management of GDM remains a controversial area in obstetric care. It is a growing area of research, and new developments that might clarify risk and simplify treatment are expected in the coming years.

Congenital Abnormalities↗

PubMed2005

Putting prevention into practice: counseling patients to prevent and decrease obesity.

The number of obese and overweight Oklahomans and Americans has grown both steadily and rapidly in the last few decades. Along with this increase in weight, doctors now see a higher proportion of chronic, degenerative diseases such as cardiovascular disease, diabetes, cancer, and osteoarthritis. Poor diet, sedentary lifestyle, and poor stress and time management contribute to weight problems and illness. Lifestyle changes have no side effects or risks, other than the perceived challenge of implementing and maintaining them. Healthier habits offer multiple organ system benefits including weight control, less anxiety and depression, improved energy, better sleep, and lower rates of gastrointestinal problems, such as reflux, gallstones, and fatty liver. By providing accurate and comprehensible information, doctors can motivate and support patients to better safeguard their health and manage their weight. This article will suggest specific phrases to use in the framework of motivational interviewing, as discussed in the first article, Part I, in this 3-part series.

Counseling↗

PubMed2005

Challenges of preparing allied health professionals for interdisciplinary practice in rural areas.

Meeting the health needs of individuals in rural communities involves addressing the challenges of complex multifaceted health problems, limited local health resources and services, isolation, and distance. Interdisciplinary collaboration can create solutions to health care problems that transcend conventional, discipline-specific methods, procedures, and techniques. This paper reports on the four-pronged approach of the Western Maryland Area Health Education Center used to prepare allied health students to be interdisciplinary team members in rural areas. It describes the development of four interdisciplinary instructional team member training venues (in-class instruction, Web-based modules, service-learning programs, and faculty development workshops) that integrate opportunities to develop and practice interdisciplinary health promotion skills in rural communities. Challenges to implementing the model are described, including developing faculty and student training participation, integrating training venues into existing programs at participating institutions, and designing a unified program evaluation.

Allied Health Personnel↗

PubMed2005

Identifying best practices for WISEWOMAN programs using a mixed-methods evaluation.

INTRODUCTION: Recommendations on best practices typically are drawn from unique settings; these practices are challenging to implement in programs already in operation. We describe an evaluation that identifies best practices in implementing lifestyle interventions in the Center for Disease Control and Prevention's WISEWOMAN program and discuss our lessons learned in using the approach. METHODS: We used a mixed-methods evaluation that integrated quantitative and qualitative inquiry. Five state or tribal WISEWOMAN projects were included in the study. The projects were selected on the basis of availability of quantitative program performance data, which were used to identify two high-performing and one low-performing site within each project. We collected qualitative data through interviews, observation, and focus groups so we could understand the practices and strategies used to select and implement the interventions. Data were analyzed in a multistep process that included summarization, identification of themes and practices of interest, and application of an algorithm. RESULTS: Pilot testing data collection methods allowed for critical revisions. Conducting preliminary interviews allowed for more in-depth interviews while on site. Observing the lifestyle intervention being administered was key to understanding the program. Conducting focus groups with participants helped to validate information from other sources and offered a more complete picture of the program. CONCLUSION: Using a mixed-methods evaluation minimized the weaknesses inherent in each method and improved the completeness and quality of data collected. A mixed-methods evaluation permits triangulation of data and is a promising strategy for identifying best practices.

Adult↗

PubMed2005

Identifying and overcoming obstacles to point-of-care data collection for eye care professionals.

Supporting data entry by clinicians is considered one of the greatest challenges in implementing electronic health records. In this paper we describe a formative evaluation study using three different methodologies through which we identified obstacles to point-of-care data entry for eye care and then used the formative process to develop and test solutions to overcome these obstacles. The greatest obstacles were supporting free text annotation of clinical observations and accommodating the creation of detailed diagrams in multiple colors. To support free text entry, we arrived at an approach that captures an image of a free text note and associates this image with related data elements in an encounter note. The detailed diagrams included a color pallet that allowed changing pen color with a single stroke and also captured the diagrams as an image associated with related data elements. During observed sessions with simulated patients, these approaches satisfied the clinicians' documentation needs by capturing the full range of clinical complexity that arises in practice.

Attitude to Computers↗

PubMed2005

Overcoming obstacles to collecting narrative data from eye care professionals at the point-of-care.

Capturing the nuances of clinical observations in an electronic format has been a major challenge in implementing electronic health records. In a formative evaluation study using three different methodologies, we identified that the greatest obstacle to point-of-care data entry for eye care was supporting free text annotation of clinical observations. To overcome this obstacle, we developed an approach that captures an image of a free text entry and associates this image with related data elements in an encounter note. Through simulated patient studies, we observed that this approach successfully supported complex documentation at the point of care by clinicians.

Attitude to Computers↗

PubMed2006

[Simulation training of laparoscopic skills in gynaecology].

Laparoscopic techniques are increasingly being applied in gynaecology in Denmark. Despite this, the training and assessment of basic skills are still not managed with a valid, reliable and systematic approach. Laparoscopic simulators might be the innovative answer to this challenge, but implementation needs to be evidence-based This paper discusses the latest metaanalysis of the evidence of simulator systems for evaluation and transfer of technical surgical skills, and the paper also points out areas that need further investigation before implementation of simulators in the gynaecological surgical curriculum.

Clinical Competence↗

PubMed2006

Quality improvement in New Zealand healthcare. Part 6: keeping the patient front and centre to improve healthcare quality.

Patient-centred care is arguably the most important of the dimensions of quality as it is likely that a healthcare system which is patient-centred will also perform well against the other dimensions--safety as well as timely, accessible, effective, and efficient care. What does it mean to be patient-centred and how can it be achieved? This article explores several definitions of patient-centred care and discusses two interpretations--the expert patient and shared decision-making. Being sick is inherently a vulnerable position to be in and our current healthcare system does little to recognise and alleviate this vulnerability. But the patient-centred approach is about more than making the journey for patients less tortuous, it has actually been shown to improve outcomes. The evidence of benefit for a patient-centred approach is reviewed, along with some of the challenges in implementing the concept in practice.

Evidence-Based Medicine↗

PubMed2006

[How to change physicians' practice--health services research with the knowledge-performance gap on focus].

How can the knowledge-performance gap be bridged? The discrepancy between our scientific knowledge on the one hand and its inadequate application in everyday practice on the other remains a major challenge for implementation research. Looking back on ten years of Health Services Research and acknowledging the achievements of educational research we have gained access to a variety of research findings and tools describing how physicians'--and other health professionals'--behavior and performance in medical care may be influenced. The time has come for testing and evaluating them.

Delivery of Health Care↗

PubMed1990

Development of a judicial response to substance abuse.

The American juvenile justice system continues to be an arena in which a myriad of varying values and practices come under constant challenge and close scrutiny, not only from those outside the system, but particularly by those within the system, those on the firing-line--the judges, court administrators, prosecutors, defenders, police, social workers and probation officers who are responsible for the operation of the system. Every juvenile court and the personnel who work with it are faced with the difficult process of evaluating and adapting to multiple "standards" and the challenges of implementing effective change within the perimeters of varying systems and statutes. The National Council of Juvenile and Family Court Judges recognizes that the responsibility for further improvement, for effective and long-lasting change, in a juvenile justice system that operates in a vastly complex society will rest even more heavily in the future where it has been in the past--on the individual judge and practitioner.

Adolescent↗

PubMedDate not supplied

Ways of assessing practice performance.

Management of a dental practice is challenging. The implementation of a management control system will improve practice performance. This system consists of planning practice goals and objectives, gathering information about the practice activity related to the planned goals and objectives, and taking corrective actions to remedy deviations from the practice plan. Three types of control, preventive, concurrent, and feedback, are presented with an application to the dental practice. Within each type of control a variety of administrative functions are discussed, such as financial analysis, employee supervision, and quality assurance.

Financial Management↗

PubMed2024

The use of next-generation sequencing in personalized medicine.

The revolutionary progress in development of next-generation sequencing (NGS) technologies has made it possible to deliver accurate genomic information in a timely manner. Over the past several years, NGS has transformed biomedical and clinical research and found its application in the field of personalized medicine. Here we discuss the rise of personalized medicine and the history of NGS. We discuss current applications and uses of NGS in medicine, including infectious diseases, oncology, genomic medicine, and dermatology. We provide a brief discussion of selected studies where NGS was used to respond to wide variety of questions in biomedical research and clinical medicine. Finally, we discuss the challenges of implementing NGS into routine clinical use.

High-throughput sequencing↗