The influence of a professional physician network on clinical decision making

Developing Implementation Strategies to Support the Uptake of a Risk Tool to Aid Physicians in the Clinical Management of Patients With Syncope: Systematic Theoretical and User-Centered Design Approach

BACKGROUND

The Canadian Syncope Risk Score (CSRS) was developed to improve syncope management in emergency department settings. Evidence-based tools often fail to have the intended impact because of suboptimal uptake or poor implementation.

OBJECTIVE

In this paper, we aimed to describe the process of developing evidence-based implementation strategies to support the deployment and use of the CSRS in real-world emergency department settings to improve syncope management among physicians.

METHODS

We followed a systematic approach for intervention development, including identifying who needs to do what differently, identifying the barriers and enablers to be addressed, and identifying the intervention components and modes of delivery to overcome the identified barriers. We used the Behaviour Change Wheel to guide the selection of implementation strategies. We engaged CSRS end users (ie, emergency medicine physicians) in a user-centered design approach to generate and refine strategies. This was achieved over a series of 3 qualitative user-centered design workshops lasting 90 minutes each with 3 groups of emergency medicine physicians.

RESULTS

A total of 14 physicians participated in the workshops. The themes were organized according to the following intervention development steps: theme 1-identifying and refining barriers and theme 2-identifying the intervention components and modes of delivery. Theme 2 was subdivided into two subthemes: (1) generating high-level strategies and developing strategies prototypes and (2) refining and testing strategies. The main strategies identified to overcome barriers included education in the format of meetings, videos, journal clubs, and posters (to address uncertainty around when and how to apply the CSRS); the development of a web-based calculator and integration into the electronic medical record (to address uncertainty in how to apply the CSRS); a local champion (to address the lack of team buy-in); and the dissemination of evidence summaries and feedback through email communications (to address a lack of evidence about impact).

CONCLUSIONS

The ability of the CSRS to effectively improve patient safety and syncope management relies on broad buy-in and uptake across physicians. To ensure that the CSRS is well positioned for impact, a comprehensive suite of strategies was identified to address known barriers.

The decision-making and learning roles of a professional social network: The case of a family physicians' network

PURPOSE

This research was aimed at studying the evolution and roles of the Israeli physicians' professional social network as perceived by the members of the network.

METHODOLOGY

The research examined a case study of RAMBAM/KEHILA professional networks, applying both qualitative and quantitative methods for establishing a grounded theory.

FINDINGS

Physicians want to be part of their professional community and consider the network as a place where the "wisdom of the crowd" exists. They seek approval for their initial line of reasoning regarding their clinical cases but will consider other approaches if such are suggested by persons of professional repute or if answers are based on evidence-based medicine. The evolved network constitutes an a-political space which has gained the trust of the community and enables physicians of various ranks to share experiences and thoughts. Moreover, the network fosters learning opportunities and the network dynamics have impact on physicians' professional development.

DISCUSSION

This unique ten-year longitudinal research examined the evolution of a professional social network. The research findings have practical and social implications. Practically, the study shows the values of professional network as an instrument for clinicians' lifelong learning and professional development. Socially, the study presents the professional network social role in facilitating social interactions when the network participants are involved in determining its roles and gain trust by avoiding any political or commercial interference.

Usage Pattern Differences and Similarities of Mobile Electronic Medical Records Among Health Care Providers

BACKGROUND

Recently, many hospitals have introduced mobile electronic medical records (mEMRs). Although numerous studies have been published on the usability or usage patterns of mEMRs through user surveys, investigations based on the real data usage are lacking.

OBJECTIVE

Asan Medical Center, a tertiary hospital in Seoul, Korea, implemented an mEMR program in 2010. On the basis of the mEMR usage log data collected over a period of 4.5 years, we aimed to identify a usage pattern and trends in accordance with user occupation and to disseminate the factors that make the mEMR more effective and efficient.

METHODS

The mEMR log data were collected from March 2012 to August 2016. Descriptive analyses were completed according to user occupation, access time, services, and wireless network type. Specifically, analyses targeted were as follows: (1) the status of the mEMR usage and distribution of users, (2) trends in the number of users and usage amount, (3) 24-hour usage patterns, and (4) trends in service usage based on user occupations. Linear regressions were performed to model the relationship between the time, access frequency, and the number of users. The differences between the user occupations were examined using Student t tests for categorical variables.

RESULTS

Approximately two-thirds of the doctors and nurses used the mEMR. The number of logs studied was 7,144,459. Among 3859 users, 2333 (60.46%) users were nurses and 1102 (28.56%) users were doctors. On average, the mEMR was used 1044 times by 438 users per day. The number of users and amount of access logs have significantly increased since 2012 (P<.001). Nurses used the mEMR 3 times more often than doctors. The use of mEMR by nurses increased by an annual average of 51.5%, but use by doctors decreased by an annual average of 7.7%. For doctors, the peak usage periods were observed during 08:00 to 09:00 and 17:00 to 18:00, which were coincident with the beginning of ward rounds. Conversely, the peak usage periods for the nurses were observed during 05:00 to 06:00, 12:00 to 13:00, and 20:00 to 21:00, which effectively occurred 1 or 2 hours before handover. In more than 80% of all cases, the mEMR was accessed via a nonhospital wireless network.

CONCLUSIONS

The usage patterns of the mEMR differed between doctors and nurses according to their different workflows. In both occupations, mEMR was highly used when personal computer access was limited and the need for patient information was high, such as during ward rounds or handover periods.

Real time medical learning using the WhatsApp cellular network: a cross sectional study following the experience of a division's medical officers in the Israel Defense Forces

Background

Primary care medical officers (MOs) are expected to maintain self-education while serving in their units in order to maintain professional standards. With the rise of smartphone use in the Israel Defense Forces (IDF), the WhatsApp application can facilitate medical learning. To date, there has been no description of the use of this tool by MOs in a military setting. This paper aims to describe the pattern of use of a WhatsApp application group by IDF’s MOs.

Methods

We collected all the information (textual and visual) uploaded to a WhatsApp group called “The Division’s Physicians”, originally established two years earlier, during a randomly selected sample month. We analyzed the pattern of its use and explored the association between the number of questions and responses uploaded to the group and the duration of service of their senders.

Results

In December 2014, the “The Division’s Physicians” WhatsApp group had 41 participants. We identified 478 messages classified as questions and 531 messages classified as responses. The number of questions asked by MOs in their first 2 months of service in the battalion (median = 14.5) and the number of questions asked by MOs with more than one year of their first assignment (median = 10.5) were significantly higher than the number of questions (median = 1.0) asked by MOs in their second assignment or later (p values for comparisons were 0.008 and 0.012 respectively). We also found that both the number of responses provided by MOs with more than one year of service in the battalion (median = 21) and the number of responses provided by MOs in their second assignment or later (median = 5) were significantly higher than the number of responses (median = 1) provided by MOs within their first 2 months of service in the battalion (p value for comparisons were 0.024 and 0.039 respectively).

Conclusion

We conclude from our preliminary study that a WhatsApp group can facilitate the transfer of knowledge from more experienced MOs to those with less experience.

Social networking in an academic conference context: insights from a case study

Purpose

– The purpose of this paper is to propose a conference-based online social network (OSN) for academics’ knowledge sharing and collaboration around and beyond a conference, while exploring the entanglement of the social and technical aspects of the system.

Design/methodology/approach

– Following an exploratory study, an OSN prototype was developed and implemented in ECIS 2014. The usage of the OSN platform was monitored and in-depth interviews were conducted with seven of its active users.

Findings

– Academic researchers have positive attitudes toward using conference-based OSN. However, there is a gap between academics’ perceptions and their actual behavior. Several barriers for engagement were identified, leading to technical and social recommendations, including the following needs: integrating the OSN platform with other conference information systems; addressing privacy concerns; allowing on-going collaboration; increasing OSN vitality; using the wisdom of the crowd; and promotion and its timing.

Research limitations/implications

– The case study highlighted existing benefits, and identified potential future benefits from implementing a conference-based OSN. Future research is required to generalize the findings and evaluate the proposed strategies for enhancing user engagement.

Practical implications

– This study revealed the set of considerations that should be taken upon launching a new academic OSN, which are beyond the technical issues per se.

Social implications

– The paper presents the expected benefits from, and existing barriers to using a conference-based OSN, and suggests recommendations for encouraging academics to engage in such OSN, in order to enhance long-term social interactions, knowledge sharing and collaboration among conference participants.

Originality/value

– This is a first study to examine a conference-based OSN.

Rehabilitation living lab in the mall community of practice: learning together to improve rehabilitation, participation and social inclusion for people living with disabilities

Communities of practice (CoP) can facilitate collaboration between people who share a common interest, but do not usually work together. A CoP was initiated and developed including stakeholders from clinical, research, community and governmental backgrounds involved in a large multidisciplinary and multi-sectorial project: the Rehabilitation Living Lab in a Mall (RehabMaLL). This study aimed to evaluate the structure, process and outcomes of this CoP. A single case-study, using mixed-methods, evaluated the RehabMaLL CoP initiative after one year, based on Donabedian's conceptual evaluation model. Forty-three participants took part in the RehabMaLL CoP with 60.5% (n = 26) participating at least once on the online platform where 234 comments were posted. Four in-person meetings were held. Members expressed satisfaction regarding the opportunity to share knowledge with people from diverse backgrounds and the usefulness of the CoP for the RehabMaLL project. Collaboration led to concrete outcomes, such as a sensitization activity and a research project. Common challenges included lack of time and difficulty finding common objectives. A CoP can be a useful strategy to facilitate knowledge sharing on disability issues. Future research is necessary to determine strategies of increasing knowledge creation between members.

What to give the patient who has everything? A qualitative study of prescribing for multimorbidity in primary care

BACKGROUND

Using clinical guidelines in the management of patients with multimorbidity can lead to the prescription of multiple and sometimes conflicting medications.

AIM

To explore how GPs make decisions when prescribing for multimorbid patients, with a view to informing intervention design.

DESIGN AND SETTING

In-depth qualitative interviews incorporating chart-stimulated recall with purposively sampled GPs in the Republic of Ireland.

METHOD

Grounded theory analysis with iterative theory development.

RESULTS

Twenty GPs were interviewed about 51 multimorbid cases. In these cases, GPs integrated information from multiple sources including the patient, specialists, and evidence-based medicine. Difficulties arose when recommendations or preferences conflicted, to which GPs responded by 'satisficing': accepting care that they deemed satisfactory and sufficient for a particular patient. Satisficing was manifest as relaxing targets for disease control, negotiating compromise with the patient, or making 'best guesses' about the most appropriate course of action to take. In multimorbid patients perceived as stable, GPs preferred to 'maintain the status quo' rather than rationalise medications, even in cases with significant polypharmacy. Proactive changes in medications were facilitated by continuity of care, sufficient consultation time, and open lines of communication with the patient, other healthcare professionals, and other GPs.

CONCLUSION

GPs respond to conflicts in the management of multimorbid patients by making compromises between patient-centred and evidence-based care. These findings will be used to inform interventions that aim to care in multimorbidity.

Why do medical tourists travel to where they do? The role of networks in determining medical travel

Evidence on medical tourism, including patient motivation, is increasing. Existing studies have focused on identifying push and pull factors across different types of treatment, for example cosmetic or bariatric surgery, or on groups, such as diaspora patients returning 'home' for treatment. Less attention has been on why individuals travel to specific locations or providers and on how this decision is made. The paper focused on the role of networks, defined as linkages - formal and informal - between individual providers, patients and facilitators to explain why and where patients travel. Findings are based on a recently completed, two year research project, which examined the effects of medical tourism on the UK NHS. Research included in-depth interviews with 77 returning medical tourists and over sixty managers, medical travel facilitators, clinicians and providers of medical tourism in recipient countries to understand the medical tourism industry. Interviews were conducted between 2011 and 2012, recorded and transcribed, or documented through note taking. Authors undertook a thematic analysis of interviews to identify treatment pathways by patients, and professional linkages between clinicians and facilitators to understand choice of treatment destination. The results highlight that across a large sample of patients travelling for a variety of conditions from dental treatment, cosmetic and bariatric surgery, through to specialist care the role of networks is critical to understand choice of treatment, provider and destination. While distance, costs, expertise and availability of treatment all were factors influencing patients' decision to travel, choice of destination and provider was largely the result of informal networks, including web fora, personal recommendations and support groups. Where patients were referred by UK clinicians or facilitators these followed informal networks. In conclusion, investigating medical travel through focus on networks of patients and providers opens up novel conception of medical tourism, deepening understanding of patterns of travel by combining investigation of industry with patient motivation.