Functional Trajectories Associated With Hospitalization in Older Adults

For older adults, acute-care hospital stays can result in functional decline that leads to increased risk of hospitalization, nursing home admission, or mortality. This study describes functional trajectories in hospitalized older adults and identifies risk factors associated with those trajectories. Respondents ( N = 45) exhibited five of six possible functional trajectory patterns. The largest change in functional status was a decline in activities of daily living (ADL) from baseline at 2 weeks before admission to the time of admission; ADL did not return to baseline during the first 4 days in the hospital. Depression scores were significantly higher in respondents who reported experiencing ADL decline before admission. Respondents whose ADL scores declined during hospitalization (regardless of baseline status) were more likely than others to die within 3 months of discharge. Functional trajectory in hospitalized elderly patients is an important and underappreciated prognostic concept requiring further attention.

A 10-Rights Framework for Patient Care Quality and Safety

Recent reports in the lay and professional press document the failings of our patient care systems and have led to a multitude of suggestions for patient care quality and safety improvement initiatives. Given the complexity and range of services being offered, hospitals are launching numerous improvement initiatives in nearly all clinical care and support areas. This article describes a quality improvement framework, the "10 Rights," designed to help leaders better understand, organize, and prioritize patient care quality and safety issues and approaches. In addition to describing the framework, each Right is linked to 3 current national efforts at enhancing patient care quality and safety: the Joint Commission on Accreditation of Healthcare Organizations' National Patient Safety Goals, the National Quality Forum 30 Safe Practices, and the Centers for Medicare and Medicaid Services Hospital Quality Measures.

Nurse and patient communication via low- and high-bandwidth home telecare systems

We examined nurse-patient communication on two videoconferencing systems: a video-phone (PSTN video) and a PC-based system (IP video). The former used data transmission via a modem at 33.6 kbit/s and the latter via a local-area network at up to 512 kbit/s. Twenty-six nurses and 18 volunteers (simulated patients) participated. On each video system nurse-patient dyads completed scripted interactions; they then completed questionnaires to assess communication. Of the participants, 84% ( n=37) preferred IP video and 14% ( n=6) preferred PSTN video (one expressed no preference). IP video was rated significantly higher in all communication quality areas except self-consciousness/embarrassment. Although participants' overall ratings were higher for the IP video system, two important advantages of the PSTN video system were identified by both nurses and patients: first, it provided superior visualization of the medication bottle, insulin syringe and the patient's skin; and second, it was easier to use. Video quality and audio quality are important determinants of patient and provider perceptions, but ease of use, clinical appropriateness, and the need for training and support must not be forgotten.

A trial of nebulised heparin to limit lung injury following cardiac surgery

Cardiac surgery with cardiopulmonary bypass triggers an acute inflammatory response in the lungs. This response gives rise to fibrin deposition in the microvasculature and alveoli of the lungs. Fibrin deposition in the microvasculature increases alveolar dead space, while fibrin deposition in alveoli causes shunting. We investigated whether prophylactic nebulised heparin could limit this form of lung injury. We undertook a single-centre double-blind randomised trial. Forty patients undergoing elective cardiac surgery with cardiopulmonary bypass were randomised to prophylactic nebulised heparin (50,000 U) or placebo. The primary endpoint was the change in arterial oxygen levels over the operative period. Secondary endpoints included end-tidal CO₂, the alveolar dead space fraction and bleeding complications. We found nebulised heparin did not improve arterial oxygen levels. Nebulised heparin was, however, associated with a lower alveolar dead space fraction (P <0.05) and lower tidal volumes at the end of surgery (P <0.01). Nebulised heparin was not associated with bleeding complications. In conclusion, prophylactic nebulised heparin did not improve oxygenation, but was associated with evidence of better alveolar perfusion and CO₂elimination at the end of surgery.

Individual patient data meta-analysis of self-monitoring of blood pressure (BP-SMART): a protocol

INTRODUCTION

Self-monitoring of blood pressure is effective in reducing blood pressure in hypertension. However previous meta-analyses have shown a considerable amount of heterogeneity between studies, only part of which can be accounted for by meta-regression. This may be due to differences in design, recruited populations, intervention components or results among patient subgroups. To further investigate these differences, an individual patient data (IPD) meta-analysis of self-monitoring of blood pressure will be performed.

METHODS AND ANALYSIS

We will identify randomised trials that have compared patients with hypertension who are self-monitoring blood pressure with those who are not and invite trialists to provide IPD including clinic and/or ambulatory systolic and diastolic blood pressure at baseline and all follow-up points where both intervention and control groups were measured. Other data requested will include measurement methodology, length of follow-up, cointerventions, baseline demographic (age, gender) and psychosocial factors (deprivation, quality of life), setting, intensity of self-monitoring, self-monitored blood pressure, comorbidities, lifestyle factors (weight, smoking) and presence or not of antihypertensive treatment. Data on all available patients will be included in order to take an intention-to-treat approach. A two-stage procedure for IPD meta-analysis, stratified by trial and taking into account age, sex, diabetes and baseline systolic BP will be used. Exploratory subgroup analyses will further investigate non-linear relationships between the prespecified variables. Sensitivity analyses will assess the impact of trials which have and have not provided IPD.

ETHICS AND DISSEMINATION

This study does not include identifiable data. Results will be disseminated in a peer-reviewed publication and by international conference presentations.

CONCLUSIONS

IPD analysis should help the understanding of which self-monitoring interventions for which patient groups are most effective in the control of blood pressure.

Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people

BACKGROUND

There is evidence that water-loss dehydration is common in older people and associated with many causes of morbidity and mortality. However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well-being are compromised.

OBJECTIVES

To determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screening tests for detecting water-loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water-loss dehydration was defined primarily as including everyone with either impending or current water-loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated).

SEARCH METHODS

Structured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTA databases (The Cochrane Library), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studies and identified relevant reviews were checked. Authors of included studies were contacted for details of further studies.

SELECTION CRITERIA

Titles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables.

DATA COLLECTION AND ANALYSIS

Diagnostic accuracy of each test was assessed against the best available reference standard for water-loss dehydration (serum or plasma osmolality cut-off ≥ 295 mOsm/kg, serum osmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water-loss dehydration (including either impending or current water-loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water-loss dehydration, but restricted to current dehydration in the final review.We conducted bivariate random-effects meta-analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre-specified cut-off points investigated.Pre-set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre-specifying three cut-offs for each continuous test may have led to missing a cut-off with useful sensitivity and specificity, we conducted post-hoc exploratory analyses to create receiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut-off missed by the original three. These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability.

MAIN RESULTS

There were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests to be used as screening tests for detecting water-loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years.We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. We assessed 67 tests (at three cut-offs for each continuous outcome) for diagnostic accuracy of water-loss dehydration (primary target condition) and of current dehydration (secondary target condition).Only three tests showed any ability to diagnose water-loss dehydration (including both impending and current water-loss dehydration) as stand-alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post-hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study.Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95% CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97).There was sufficient evidence to suggest that several stand-alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people.No tests were found consistently useful in diagnosing current water-loss dehydration.

AUTHORS' CONCLUSIONS

There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water-loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated.Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy.

Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics

INTRODUCTION

Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care.

MATERIAL AND METHODS

We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity.

RESULTS

4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (β=32, P<0.0001) and history of change in the clinic (β=18, P=0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (β=0.16-0.34, P=<0.0001), and lower improvements in patient-centered care (β=-0.19, P=0.001).

CONCLUSIONS

Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures.

IMPLICATIONS

Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics.

Barriers and facilitators to managing multiple chronic conditions: a systematic literature review

The prevalence of multiple chronic conditions (MCC) is increasing, creating challenges for patients, families, and the health care system. A systematic literature search was conducted to locate studies describing patient's perceptions of facilitators and barriers to management of MCC. Thirteen articles met study inclusion criteria. Patients reported nine categories of barriers including financial constraints, logistical challenges, physical limitations, lifestyle changes, emotional impact, inadequate family and social support, and the complexity of managing multiple conditions, medications, and communicating with health care providers. Four facilitators were found, including health system support, individualized care education and knowledge, informal support from family and social systems, and having personal mental and emotional strength. Existing research on management of MCC from the patient's perspective is limited. Interventions are needed to improve management practices with particular attention to the knowledge and skills required by this unique population.

Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees

BACKGROUND

A high proportion of the US primary care workforce reports burnout, which is associated with negative consequences for clinicians and patients. Many protective factors from burnout are characteristics of patient-centered medical home (PCMH) models, though even positive organizational transformation is often stressful. The existing literature on the effects of PCMH on burnout is limited, with most findings based on small-scale demonstration projects with data collected only among physicians, and the results are mixed.

OBJECTIVE

To determine if components of PCMH related to team-based care were associated with lower burnout among primary care team members participating in a national medical home transformation, the VA Patient Aligned Care Team (PACT).

DESIGN

Web-based, cross-sectional survey and administrative data from May 2012.

PARTICIPANTS

A total of 4,539 VA primary care personnel from 588 VA primary care clinics.

MAIN MEASURES

The dependent variable was burnout, and the independent variables were measures of team-based care: team functioning, time spent in huddles, team staffing, delegation of clinical responsibilities, working to top of competency, and collective self-efficacy. We also included administrative measures of workload and patient comorbidity.

KEY RESULTS

Overall, 39 % of respondents reported burnout. Participatory decision making (OR 0.65, 95 % CI 0.57, 0.74) and having a fully staffed PACT (OR 0.79, 95 % CI 0.68, 0.93) were associated with lower burnout, while being assigned to a PACT (OR 1.46, 95 % CI 1.11, 1.93), spending time on work someone with less training could do (OR 1.29, 95 % CI 1.07, 1.57) and a stressful, fast-moving work environment (OR 4.33, 95 % CI 3.78, 4.96) were associated with higher burnout. Longer tenure and occupation were also correlated with burnout.

CONCLUSIONS

Lower burnout may be achieved by medical home models that are appropriately staffed, emphasize participatory decision making, and increase the proportion of time team members spend working to the top of their competency level.

A usability evaluation exploring the design of American Nurses Association state web sites

National leaders are calling for opportunities to facilitate the Future of Nursing. Opportunities can be encouraged through state nurses association Web sites, which are part of the American Nurses Association, that are well designed, with appropriate content, and in a language professional nurses understand. The American Nurses Association and constituent state nurses associations provide information about nursing practice, ethics, credentialing, and health on Web sites. We conducted usability evaluations to determine compliance with heuristic and ethical principles for Web site design. We purposefully sampled 27 nursing association Web sites and used 68 heuristic and ethical criteria to perform systematic usability assessments of nurse association Web sites. Web site analysis included seven double experts who were all RNs trained in usability analysis. The extent to which heuristic and ethical criteria were met ranged widely from one state that met 0% of the criteria for "help and documentation" to states that met greater than 92% of criteria for "visibility of system status" and "aesthetic and minimalist design." Suggested improvements are simple yet make an impact on a first-time visitor's impression of the Web site. For example, adding internal navigation and tracking features and providing more details about the application process through help and frequently asked question documentation would facilitate better use. Improved usability will improve effectiveness, efficiency, and consumer satisfaction with these Web sites.

Effect of home telemonitoring on glycemic and blood pressure control in primary care clinic patients with diabetes

OBJECTIVE

Patient self-management support may be augmented by using home-based technologies that generate data points that providers can potentially use to make more timely changes in the patients' care. The purpose of this study was to evaluate the effectiveness of short-term targeted use of remote data transmission on treatment outcomes in patients with diabetes who had either out-of-range hemoglobin A1c (A1c) and/or blood pressure (BP) measurements.

MATERIALS AND METHODS

A single-center randomized controlled clinical trial design compared in-home monitoring (n=55) and usual care (n=53) in patients with type 2 diabetes and hypertension being treated in primary care clinics. Primary outcomes were A1c and systolic BP after a 12-week intervention.

RESULTS

There were no significant differences between the intervention and control groups on either A1c or systolic BP following the intervention.

CONCLUSIONS

The addition of technology alone is unlikely to lead to improvements in outcomes. Practices need to be selective in their use of telemonitoring with patients, limiting it to patients who have motivation or a significant change in care, such as starting insulin. Attention to the need for effective and responsive clinic processes to optimize the use of the additional data is also important when implementing these types of technology.

Implementing home blood glucose and blood pressure telemonitoring in primary care practices for patients with diabetes: lessons learned

BACKGROUND

Prior telemonitoring trials of blood pressure and blood glucose have shown improvements in blood pressure and glycemic targets. However, implementation of telemonitoring in primary care practices may not yield the same results as research trials with extra resources and rigid protocols. In this study we examined the process of implementing home telemonitoring of blood glucose and blood pressure for patients with diabetes in six primary care practices.

MATERIALS AND METHODS

Grounded theory qualitative analysis was conducted in parallel with a randomized controlled effectiveness trial of home telemonitoring. Data included semistructured interviews with 6 nurse care coordinators and 12 physicians in six participating practices and field notes from exit interviews with 93 of 108 randomized patients.

RESULTS

The three stakeholder groups (patients, nurse care coordinators, and physicians) exhibited some shared themes and some unique to the particular stakeholder group. Major themes were that practices should (1) understand the capabilities and limitations of the technology and the willingness of patient and physician stakeholders to use it, (2) understand the workflow, flow of information, and human factors needed to optimize use of the technology, (3) engage and prepare the physicians, and (4) involve the patient in the process. Although there was enthusiasm for a patient-centered medical home model that included between-visit telemonitoring, there was concern about the support and resources needed to provide this service to patients.

CONCLUSIONS

As with many technology interventions, careful consideration of workflow and information flow will help enable effective implementations.

Patient portal implementation: resident and attending physician attitudes

BACKGROUND AND OBJECTIVES

Electronic patient portals are increasingly common, but there is little information regarding attitudes of faculty and residents at academic medical centers toward them.

METHODS

The primary objective was to investigate attitudes toward electronic patient portals among primary care residents and faculty and changes in faculty attitudes after implementation. The study design included a pre-implementation survey of 39 general internal medicine and family medicine residents and 43 generalist faculty addressing attitudes and expectations of a planned patient portal and also a pre- and post-implementation survey of general internal medicine and family medicine faculty physicians. The survey also addressed email communication with patients.

RESULTS

Prior to portal implementation, residents reported receiving much less e-mail from patients than faculty physicians; 68% and 9% of residents and faculty, respectively, reported no email exchange in a typical month. Residents were less likely to agree with allowing patients to view selected parts of their medical record on-line than faculty physicians (57% and 81%, respectively). Physicians who participated in the portal's pilot implementation had expected workload to increase (64% agreed), but after implementation, 87% of those responding were neutral or disagreed that workload had increased. After implementation, only 33% believed quality of care had improved compared to 55% who had expected it to improve prior to implementation.

CONCLUSIONS

Residents and faculty physicians need to be prepared for a changing environment of electronic communication with patients. Some positive and negative expectations of physicians toward enhanced electronic access by patients were not borne out by experience.

Nursing interventions in a telemonitoring program

BACKGROUND

The use of telemonitoring of patients with chronic illness in their homes is growing. Current literature does not describe what types of patient problems are addressed by nurses in these programs and what actions are taken in response to identified problems. This study defined and analyzed patient problems and nursing actions delivered in a telemonitoring program focused on chronic disease management.

SUBJECTS AND METHODS

Data were drawn from a clinical trial that evaluated telemonitoring in patients with comorbid diabetes and hypertension. Using study patient records, patient problems and nursing actions were coded using an inductive approach.

RESULTS

In total, 2,336 actions were coded for 68 and 65 participants in two intervention groups. The most frequent reasons for contact were reporting information to the primary care provider and lifestyle information related to diabetes and hypertension (e.g., diet, smoking cessation, foot care, and social contacts). The most frequent mode of contact was the study sending a letter to a participant.

CONCLUSIONS

Detailed descriptions of interventions delivered facilitate analysis of the unique contributions of nurses in the expanding market of telemonitoring, enable identification of the appropriate number and combination of interventions needed to improve outcomes, and make possible more systematic translation of findings to practice. Furthermore, this information can inform calculation of appropriate panel sizes for care managers and the competencies needed to provide this care.

It’s Always Something

The purpose of this qualitative study was to describe the process by which hospital staff nurses keep patients safe within their hospital safety culture. Findings from this study culminated in a grounded theory of Managing Risk, the process by which nurses keep their patients safe from harm. Participants perceived that their patients were always at risk ( it’s always something), thus keeping patients safe was a continual, repetitive process of managing risk to prevent harm to patients. Stages of this process included risk assessment, risk recognition, prioritization, and protective interventions. Practicing nurses can use this theory to understand and articulate their critical role in keeping patients safe in hospitals. Further examination of this process is necessary for targeted assessment of a safety culture’s impact on bedside nursing practice, thus providing a basis for specific interventions to improve patient safety.

Outcomes of a home telehealth intervention for patients with diabetes and hypertension

BACKGROUND

Home telehealth programs often focus on a single disease, yet many patients who need monitoring have multiple conditions. This study evaluated secondary outcomes from a clinical trial evaluating the efficacy of home telehealth to improve outcomes of patients with co-morbid diabetes and hypertension.

SUBJECTS AND METHODS

A single-center randomized controlled clinical trial compared two remote monitoring intensity levels (low and high) and usual care in patients with type 2 diabetes and hypertension being treated in primary care. Secondary outcomes assessed were knowledge (diabetes, hypertension, medications), self-efficacy, adherence (diabetes, medications), and patient perceptions of the intervention mode.

RESULTS

Knowledge scores improved in the high-intensity intervention group participants, but upon further analysis, we found the intervention effect was not mediated by gain in knowledge. No significant differences were found across the groups in self-efficacy, adherence, or patient perceptions of the intervention mode.

CONCLUSIONS

Home telehealth can enhance detection of key clinical symptoms that occur between regular physician visits. While our intervention improved glycemic and blood pressure control, the mechanism of the effect for this improvement was not clear.

Internet use by primary care patients: where is the digital divide?

BACKGROUND AND OBJECTIVES

Internet-based technologies such as personal health records and patient portals are increasingly viewed as essential for enhancing patient-provider communication and patient-centered care. We examined how primary care patients use the Internet, particularly patient characteristics associated with Internet use.

METHODS

We surveyed patients in five primary care clinic waiting rooms. Patients who had used email or the Internet in the past month (Internet users) were asked how often they used a computer for a variety of tasks. Participants who reported not using the Internet were asked about several potential barriers to Internet use.

RESULTS

We approached 713 patients, and 638 (89.6%) completed questionnaires; 499 (78%) were Internet users and 139 (22%) were non-users. Lack of computer access and not knowing how to use email or the Internet were the most common barriers to Internet use. Younger age, higher education and income, better health, and absence of a chronic illness were associated with Internet use. After controlling for age and other variables, chronic illness was no longer associated with Internet use.

CONCLUSIONS

Internet use was high among our primary care patients. The major factor associated with Internet use among patients with chronic conditions was their age. If older adults with chronic illness are to reap the benefits of health information technology, their Internet access will need to be improved. Institutions that are planning to offer consumer health information technology should be aware of groups with lower Internet access.

Consistency of patient preferences about a secure Internet-based patient communications portal: contemplating, enrolling, and using

Internet-based secure communication portals (portal) have the potential to enhance patient care via improved patient-provider communications. This study examines differences among primary care patients' perceptions when contemplating using, enrolling to use, and using a portal for health care purposes. A total of 3 groups of patients from 1 Midwestern academic medical center were surveyed at different points in time: (1) Waiting Room survey asking about hypothetical interest in using a portal to communicate with their physicians; (2) patient portal Enrollment survey; and (3) Follow-up postenrollment experience survey. Those who enroll and use a patient portal have different demographic characteristics and interest levels in selected portal functions (eg, e-mailing providers, viewing medical records online, making appointments) and initially perceive only limited improvements in care because of the portal. These differences have potential market implications and provide insight into selecting and maintaining portal functions of greater interest to patients who use the portal.

A review of verbal order policies in acute care hospitals

BACKGROUND

Although verbal and telephone orders (VOs) are commonly used in the patient care process, there has been little examination of the strategies and tactics used to ensure their appropriate use or how to ensure that they are accurately communicated, correctly understood, initially documented, and subsequently transcribed into the medical record and ultimately carried out as intended. A systematic review was conducted of hospital verbal and telephone order policies in acute care settings.

METHODS

A stratified random sample of hospital verbal and telephone order policy documents were abstracted from critical access, rural, rural referral, and urban hospitals located in Iowa and Missouri and from academic medical centers from across the United States.

FINDINGS

Substantial differences were found across 40 acute care settings in terms of who is authorized to give (including nonlicensed personnel) and take VOs and in terms of time allowed for the prescriber to cosign the VO. When a nonphysician or other licensed prescriber was allowed to communicate VOs, there was no discussion of the process to review the VO before it was communicated in turn to the hospital personnel receiving the order. Policies within several of the same hospitals were inconsistent in terms of the periods specified for prescriber cosignature. Few hospitals required authentication of the identity of the person making telephone VOs, nor the use of practices to improve communication reliability.

CONCLUSION

Careful review and updating of hospital VO policies is necessary to ensure that they are internally consistent and optimize patient safety. The implementation of computerized medical records and ordering systems can reduce but not eliminate the need for VOs.

Transfer of information from personal health records: a survey of veterans using My HealtheVet

OBJECTIVE

Personal health records provide patients with ownership of their health information and allow them to share information with multiple healthcare providers. However, the usefulness of these records relies on patients understanding and using their records appropriately. My HealtheVet is a Web-based patient portal containing a personal health record administered by the Veterans Health Administration. The goal of this study was to explore veterans' interest and use of My HealtheVet to transfer and share information as well as to identify opportunities to increase veteran use of the My HealtheVet functions.

MATERIALS AND METHODS

Two waves of data were collected in 2010 through an American Customer Satisfaction Index Web-based survey. A random sample of veterans using My HealtheVet was invited to participate in the survey conducted on the My HealtheVet portal through a Web-based pop-up browser window.

RESULTS

Wave One results (n=25,898) found that 41% of veterans reported printing information, 21% reported saving information electronically, and only 4% ever sent information from My HealtheVet to another person. In Wave Two (n=18,471), 30% reported self-entering medication information, with 18% sharing this information with their Veterans Affairs (VA) provider and 9.6% sharing with their non-VA provider.

CONCLUSION

Although veterans are transferring important medical information from their personal health records, increased education and awareness are needed to increase use. Personal health records have the potential to improve continuity of care. However, more research is needed on both the barriers to adoption as well as the actual impact on patient health outcomes and well-being.