I share much of Dr Morris' enthusiasm for decision support. While
involved in an evaluation of a decision support targeting vancomycin
ordering practice,[1] I had the opportunity to observe the potential
impact of this approach. However, as a clinician using the same
computerized order entry system in daily practice, I also recognized the
major limitation of this approach: users will not tolerate many...
I share much of Dr Morris' enthusiasm for decision support. While
involved in an evaluation of a decision support targeting vancomycin
ordering practice,[1] I had the opportunity to observe the potential
impact of this approach. However, as a clinician using the same
computerized order entry system in daily practice, I also recognized the
major limitation of this approach: users will not tolerate many such
interventions at any given time.
Too many alarms can contribute to a sense of general noise, so that
they lose their value.[2] Similarly, too many triggers for guidelines, or
even alerts such as potential drug-drug interactions, will result in users
clicking past all such screens, so that in the end, none of the screens
will work. Forcing users to follow a given guideline or respond to a
particular alert runs the risk of adding an intolerable time burden to
frequent users of the system – e.g., interns and residents who write
multiple orders a day.
Consider the admission orders for even a routine medical admission.
Possible guidelines might relate to many medications (e.g., choices of
antibiotics), diagnostic orders ('does this patient really need a KUB –
the yield of plain abdominal radiographs is known to be low in most
clinical situations'[3]), various prophylactic strategies (“do you want to
order DVT prophylaxis?' '...stress ulcer prophylaxis?' etc.)
Elderly patients will trigger even more guidelines - does the patient
need fall precautions? How about a soft matteress or other decubitus ulcer
precautions? Pneumococcal vaccination prior to discharge?[4] Vlu vaccine?
[4] Does the patient have an advanced directive?[5]
The list goes on, and this does not even include guidelines triggered
by specific admitting diagnoses e.g., guidelines for treatment of
community acquired pneumonia, acute coronary syndrome, hip fracture,
gastrointestinal bleeding, stroke, etc. etc, not to mention important
secondary diagnoses – 'This patient has diabetes: do you want to add an
angiotensin converting enzyme inhibitor.' 'This patient has a diagnosis of
congestive heart failure, but there is no record of an echocardiogram or
other assessment of ejection fraction.' 'This patient is on prednisone;
would you like to add a bisphosphonate to protect against osteoporosis?'
Thus, computerized systems offer a greater chance of success for
implementation of a single guideline, it is unlikely that this benefit
will generalize to more than a handful of such protocols at any given
time. Further research will need determine optimal strategies for
harnessing the potential of computerized decision support. Currently,
though, it is unrealistic to think that an institution acquiring an order
entry system could expect to impact practice in more than a few areas
using this approach.
References
(1) Shojania KG, Yokoe D, Platt R, Fiskio J, Ma'luf N, Bates DW.
Reducing vancomycin use utilizing a computer guideline: results of a
randomized controlled trial. J Am Med Inform Assoc 1998;5:554-562.
(2) Cropp AJ, Woods LA, Raney D, Bredle DL. Name that tone. The
proliferation of alarms in the intensive care unit. Chest 1994;105:1217-
1220.
(3) Harpole LH, Khorasani R, Fiskio J, Kuperman GJ, Bates DW.
Automated evidence-based critiquing of orders for abdominal radiographs:
impact on utilization and appropriateness. J Am Med Inform Assoc
1997;4:511-521.
(4) Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald
CJ. A computerized reminder system to increase the use of preventive care
for hospitalized patients. N Engl J Med 2001;345:965-970.
(5) Heffner JE, Barbieri C, Fracica P, Brown LK. Communicating do-not-
resuscitate orders with a computer-based system. Arch Intern Med
1998;158:1090-1095.
As a member of the professional organisation for nurses in Ontario, I
would like to direct nurses and other interested readers to the web page
of the Registered Nurses Association of Ontario, www.rnao.org
This site has a wealth of position statements, policies, submissions
to a variety of health stakeholders and other documents relating to
providing...
As a member of the professional organisation for nurses in Ontario, I
would like to direct nurses and other interested readers to the web page
of the Registered Nurses Association of Ontario, www.rnao.org
This site has a wealth of position statements, policies, submissions
to a variety of health stakeholders and other documents relating to
providing quality health care as well as nursing.
Adding the element of safety to medical education can not be effected
unless the institutions supplement their systems with program of outcomes
assesment.
While all that Dr Stevens describes is of interest, only when it is
established that the medical safety material that has been presented is
absorbed and put into practice will the validity of the suggestions be
established.
Adding the element of safety to medical education can not be effected
unless the institutions supplement their systems with program of outcomes
assesment.
While all that Dr Stevens describes is of interest, only when it is
established that the medical safety material that has been presented is
absorbed and put into practice will the validity of the suggestions be
established.
This requires testing of competence at completion of the program and
evaluation of performance,with remediation as required, thereafter.
I will call the work of giving Medicine to poor countries, a Great English
men do this beautiful things. From a Professor of internal medicine -
Jorge H Jimenez.
This scholarly article has been a fine example of what a fresh
approach and interdisciplinary overview can do.
We work with illness explanatory models of patients from various
outpatient clinics who suffer from biomedically unexplained fatigue and
weakness for six months or more. Also, in private practice of clinical
psychiatry compliance is the pivotal issue. We find that cultural
epide...
This scholarly article has been a fine example of what a fresh
approach and interdisciplinary overview can do.
We work with illness explanatory models of patients from various
outpatient clinics who suffer from biomedically unexplained fatigue and
weakness for six months or more. Also, in private practice of clinical
psychiatry compliance is the pivotal issue. We find that cultural
epidemiology plays a significant role in understanding and managing
patients' compliance and outcome. Either intentional error or violation,
or unintentional slip or lapse, patients do always have subjective
explanation for their behaviour. The antecedents of compliance or non-
compliance can be found:
(1)in patient's illness experience, different
variables of which include stigma of illness or treatment, anticipated
outcome, perceived seriousness of the symptoms, and many other
sociocultural contextual factors;
(2)in subjective meaning of the illness
as exemplified by the perceived causes of the illness and their linkages
among each other; and
(3)his experiences with the help seeking behaviour
and the agencies of help, with their meeting patient's perceived needs.
Patient's explanatory models (emic) and its match or otherwise with
the explanatory models of the professional care giving agencies (etic) is
an important determinant of the patient's compliance toward the prescribed
treatment. Careful attention to the patient's emic is facilitated by
cultural epidemiological approach with the use of Explanatory Model
Interview Catalogue(EMIC), a tool that can be used in research as well as
in clinical practice. It focuses on patient's experience, meaning, and
behaviour while retaining the qualitative as well as the quantitative
aspects. Ratings on predetermined codes facilitate comparison and analysis
apart from crystallizing the salient features of the explanatory model.
Reliability of this effective tool has been documented in studies on
leprosy and depression.
The provision of free access to the electronic versions of journals to
the users in the developing world deserves lots of praise, indeed. Coming
from such a background, I cannot over emphasize the long felt need for the
same.
Internet use, especially for medical education and training in India,
has increased by leaps and bounds over the last five years. In spite of
that, institutional subscr...
The provision of free access to the electronic versions of journals to
the users in the developing world deserves lots of praise, indeed. Coming
from such a background, I cannot over emphasize the long felt need for the
same.
Internet use, especially for medical education and training in India,
has increased by leaps and bounds over the last five years. In spite of
that, institutional subscriptions for journals are poor due to funding
restrictions.
Free access is helping many medical students and trainees far more
than it is probably appreciated. The approach and awareness of doctors in
training has changed in a better direction, in the light of such quick and
comprehensive access to all the recent developments in the medical world.
From my personal experience, the idea has changed medical education in a
very positive way.
It is too good to get this facility free of cost. It could be a bit better
if many of the other publishing houses (both from the United Kingdom and
United States of America) follow the example set by the BMJ group.
Yours sincerely
Dr S Chakrabarti
Senior House Officer
Roberts et al[1] provide a commentary on the Patient Satisfaction
Questionnaire (PSQ) that we have developed and validated.[2][3] Whilst
they accept that the PSQ is a valid and internally reliable tool for
assessing patient satisfaction with primary care services, they suggest
that further work is required before the measure is adopted. In
particular they point to the need to assess the acceptabi...
Roberts et al[1] provide a commentary on the Patient Satisfaction
Questionnaire (PSQ) that we have developed and validated.[2][3] Whilst
they accept that the PSQ is a valid and internally reliable tool for
assessing patient satisfaction with primary care services, they suggest
that further work is required before the measure is adopted. In
particular they point to the need to assess the acceptability of the items
to different patient groups.
In the development of a measure such as the PSQ, continuing
assessment of reliability, validity and acceptability is clearly
worthwhile. Nevertheless we would argue that there already exists
sufficient data on the reliability and validity of the scale[2][3] to
warrant its adoption as means of assessing patient satisfaction with
primary care services.
In relation to the specific points raised by Roberts et al[1]:
First, in relation to the issue that certain items may be
unacceptable and produce low response rates. Analysis of items included in
both the original study where the questionnaire was developed[2] and the
validation study[3] has failed to show any differences in response rates
on individual items. Also, all items originated in interviews and open-ended questionnaires with patients, and we have no reason to believe that
they would be unacceptable to other patients.
Second, in relation to whether particular items may distress or
offend respondents. As all items were originally derived from interviews
with patients, the wording reflects the way in which patients talk about
these services. In reproducing the questionnaire we allow practitioners
the opportunity to judge the potential offensiveness of the items. We have
not received any negative feedback about items from practitioners or
respondents to the questionnaires used in our validation study in terms of
their distressing nature or offensiveness. There is no evidence to
support the suggestion that any of the items in the PSQ will distress or
offend respondents.
Third, in relation to the suggestion that the PSQ as a whole may not
be completed by particular groups: This is not an issue we have
specifically addressed in our research. To do so would require the
assessment of response rates in different groups where we might expect
differences. A further analysis might then compare the numbers of fully
versus partially completed PSQs. In relation to this latter point, from
the data reported in Grogan et al,[3] we were able to make a comparison
of questionnaires that were fully completed versus those that were only
partially completed. This indicated no significant impact of various
demographic groups (eg, age, gender) on completion rates.
In summary, whilst we accept that further work to assess the
reliability, validity, and acceptability of the PSQ is warranted, we
believe that the measure has been sufficiently tested to make it suitable
for adoption by those wishing to assess patient's satisfaction with
primary care services.
Sarah Grogan, PhD (Address for correspondence)
Senior Lecturer
Department of Psychology and Speech Pathology
Manchester Metropolitan University
Elizabeth Gaskell Building
Manchester M13 OJA, UK
Mark Conner, PhD
Senior Lecturer
School of Psychology
University of Leeds
Leeds LS2 9JT, UK
References
(1) Roberts L, Roalfe A, Wilson S. Patient Satisfaction Questionnaire
- Further validation required [Rapid Response]. Qual Health Care 22
December 2000. http://www.qualityhealthcare.com/cgi/eletters/9/4/210#EL1
(2) Grogan S, Conner M, Willits D, Norman P. Development of a
questionnaire to measure patients' satisfaction with general
practitioners' services. British Journal of General Practice 1995;45:525-
29.
(3) Grogan S, Conner M, Norman P, Willits, Porter I. Validation of a
questionnaire measuring patient satisfaction with general practitioner
services. Qual Health Care 2000;9:210-15.
Dear Editor
I share much of Dr Morris' enthusiasm for decision support. While involved in an evaluation of a decision support targeting vancomycin ordering practice,[1] I had the opportunity to observe the potential impact of this approach. However, as a clinician using the same computerized order entry system in daily practice, I also recognized the major limitation of this approach: users will not tolerate many...
Dear Editor
As a member of the professional organisation for nurses in Ontario, I would like to direct nurses and other interested readers to the web page of the Registered Nurses Association of Ontario, www.rnao.org
This site has a wealth of position statements, policies, submissions to a variety of health stakeholders and other documents relating to providing...
Dear Editor
Adding the element of safety to medical education can not be effected unless the institutions supplement their systems with program of outcomes assesment.
While all that Dr Stevens describes is of interest, only when it is established that the medical safety material that has been presented is absorbed and put into practice will the validity of the suggestions be established.
This req...
Dear Editor
I will call the work of giving Medicine to poor countries, a Great English men do this beautiful things. From a Professor of internal medicine - Jorge H Jimenez.
Thanks
Dear Editor
This scholarly article has been a fine example of what a fresh approach and interdisciplinary overview can do.
We work with illness explanatory models of patients from various outpatient clinics who suffer from biomedically unexplained fatigue and weakness for six months or more. Also, in private practice of clinical psychiatry compliance is the pivotal issue. We find that cultural epide...
Dear Editor
The provision of free access to the electronic versions of journals to the users in the developing world deserves lots of praise, indeed. Coming from such a background, I cannot over emphasize the long felt need for the same.
Internet use, especially for medical education and training in India, has increased by leaps and bounds over the last five years. In spite of that, institutional subscr...
Dear Editor,
Roberts et al[1] provide a commentary on the Patient Satisfaction Questionnaire (PSQ) that we have developed and validated.[2][3] Whilst they accept that the PSQ is a valid and internally reliable tool for assessing patient satisfaction with primary care services, they suggest that further work is required before the measure is adopted. In particular they point to the need to assess the acceptabi...
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