Assessment of left ventricular (LV) function with echocardiography is mandatory in patients with suspected heart failure (HF).
To investigate if GPs were able to evaluate the LV function in patients at risk of developing or with established HF by using pocket-sized ultrasound (pUS).
Feasibility study in general practice, seven GPs in three different Norwegian primary care centres participated. Ninety-two patients with reduced or at risk of developing reduced LV function were examined by their own GP using pUS. The scan (
Use of specialist healthcare services is increasing.
To evaluate whether alternative healthcare services could reduce the need for admissions to specialist care hospitals.
Prospective observational study of emergency referrals for admission to specialist care.
A single out-of-hours primary care centre (OPCC) in Norway.
Out-of-hours physicians registered their referrals for hospital admission and stated whether the admission could have been avoided given the availability of six other healthcare services.
Of 1083 registered encounters at the OPCC, 152 (14%) were referred for specialist care hospital admission. According to the referring physician, 32 (21%) of these referrals could have been avoided. The most eligible alternatives to such referrals were next-day appointments at a specialist outpatient clinic (11 of 32 referrals), or admission to a community hospital (21 of 32 referrals), or a nursing home (nine of 32 referrals). Respiratory (eight of 32 referrals) and gastrointestinal problems (12 of 32 referrals) were the most common among avoidable admissions.
The use of specialist care hospital admission can be reduced if appropriate alternatives are available.
Information deficits contribute to medical errors. Hence several efforts to develop electronic communication systems to facilitate a flow of information between health care providers have been attempted, including initiatives to develop regional or national electronic patient summaries.
To study information access and information needs in inpatient emergency departments, and how clinicians in these departments handle deficits in available information.
We conducted an observational study of consecutive unplanned inpatient admissions using a structured form to register a set of predefined parameters and free-text notes, including a post-examination interview with the examining emergency department doctors and nurses.
We observed 177 patient admissions, excluding any patients under 18 years of age and planned admissions. One in four patients arrived without any referral. Nearly all referrals described the presenting complaint with a tentative diagnosis. One third of the referrals lacked medication record and medical history. Only one in ten referrals contained information about contraindications. If the patient had previously been admitted to the hospital, the emergency department doctors used the existing electronic patient record and seemed to favor previous discharge letters as an information source. Information on current medications was often copied from earlier admissions. In half of the cases the patients also provided supplementary information in other ways not available, though one in five patients was not in a cognitive state to be properly interviewed. The examining doctors reported a lack of crucial information in 10% of the observed referrals.
Overall, information about medications and previous history was described in most referrals, but was still the information most frequently inquired or searched for. Qualitative assessments revealed that insufficient information put a significant stress on both patients and staff, and in turn caused additional workload and risky work-arounds. In our assessment, these information deficits could be effectively mitigated by an up to date easy-access patient summary.
Different models for care pathways involving both specialist and primary care have been developed to ensure adequate follow-up after discharge. These care pathways have mainly been developed and run by specialist care and have been disease-based. In this study, primary care providers took the initiative to develop a model for integrated care pathways across care levels for older patients in need of home care services after discharge. Initially, the objective was to develop pathways for patients diagnosed with heart failure, COPD and stroke. The aim of this paper is to investigate the process and the experiences of the participants in this developmental work. The participants were drawn from three hospitals, six municipalities and patient organizations in Central Norway.
This qualitative study used focus group interviews, written material and observations. Representatives from the hospitals, municipalities and patient organizations taking part in the development process were chosen as informants.
The development process was very challenging because of the differing perspectives on care and different organizational structures in specialist care and primary care. In this study, the disease perspective, being dominant in specialist care, was not found to be suitable for use in primary health care because of the need to cover a broader perspective including the patient's functioning, social situation and his or her preferences. Furthermore, managing several different disease-based care pathways was found to be unsuitable in home care services, as well as unsuitable for a population characterized by a substantial degree of comorbidity. The outcome of the development process was a consensus that outlined a single, common patient-centred care pathway for transition from hospital to follow-up in primary care. The pathway was suitable for most common diseases and included functional and social aspects as well as disease follow-up, thus merging the differing perspectives. The disease-based care pathways were kept for use within the hospitals.
Disease-based care pathways for older patients were found to be neither feasible nor sustainable in primary care. A common patient-centred care pathway that could meet the needs of multi- morbid patients was recommended.
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User participation is important for developing a functional requirements specification for electronic communication. General practitioners and practising specialists, however, often work in small practices without the resources to develop and present their requirements. It was necessary to find a method that could engage practising doctors in order to promote their needs related to electronic communication.
Qualitative research methods were used, starting a process to develop and study documents and collect data from meetings in project groups. Triangulation was used, in that the participants were organised into a panel of experts, a user group, a supplier group and an editorial committee.
The panel of experts created a list of functional requirements for electronic communication in health care, consisting of 197 requirements, in addition to 67 requirements selected from an existing Norwegian standard for electronic patient records (EPRs). Elimination of paper copies sent in parallel with electronic messages, optimal workflow, a common electronic 'envelope' with directory services for units and end-users, and defined requirements for content with the possibility of decision support were the most important requirements.
The results indicate that we have found a method of developing functional requirements which provides valid results both for practising doctors and for suppliers of EPR systems.
To study early experiences with multidose drug dispensing (MDD) among different groups of health personnel.
Qualitative study based on focus-group interviews.
Primary health care, Trondheim, Norway.
The importance of trust in the technology and in collaborating partners is actualized in the early implementation of MDD.
GPs, home-care nurses, pharmacists, and medical secretaries trusted the new MDD technology. The quality of the GPs' medication records improved. However, health personnel, including the GPs themselves, would not always trust the medication records of the GPs. Checking the multidose bags arriving from the pharmacy was considered unnecessary in the written routines dealing with MDD. However, home-care nurses experienced errors and continued to manually check the bags. Nurses in the home-care service felt a loss of knowledge with regard to the patients' medications and in turn experienced reduced ability to give medical information to patients and to observe the effects of the drugs. The home-care services' routines for drug handling were not always trusted by the other groups of health personnel involved.
Health personnel faced some challenges during the implementation of the MDD system, but most of them remained confident in the new system. Building trust has to be a process that runs in parallel with the introduction of new technology and the establishment of new routines for improving the quality in handling of medicines and to facilitate better cooperation and communication.
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The Directorate for Health and Social Affairs commissioned a project to evaluate the distribution and use of a Norwegian electronic medical handbook (NEL).
NEL uses multimedia techniques and is distributed on a CD twice a year. A questionnaire about the use of NEL was given to 91 medical students. Health professionals at two hospitals and 12 health centres were interviewed.
The use of the electronic handbook differed more within than between groups of professionals. NEL is applied for three main purposes: decision support, quality assurance and as a source for information pamphlets designed for patients. The professionals believed that NEL has contributed to patients' receiving more information and more uniform treatment. Criticism was made about the price and for the lack of integration with the electronic patient record.
The study has revealed some barriers to implementation and use of electronic information sources. Under certain circumstances an electronic handbook might be suitable way for authorities and others to distribute professional guidelines.
Department of Community Medicine and General Practice, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Medisinsk Teknisk Forskningssenter (MTFS), N-7489 Trondheim, Norway. email@example.com
Although primary care physicians are satisfied users of electronic patient records (EPRs) in Norway today, EPR systems may not have reached their full potential. We studied primary care physicians' needs and experiences in relation to EPRs and analysed potential improvements for today's EPR systems. RESPONDENTS AND METHODS: This is a triangulated study that compares qualitative and quantitative data from focus groups, observations of primary care encounters and a questionnaire survey.
General practioners (GPs) were not satisfied with the level of availability of information within EPR systems. They were especially concerned about follow-up for chronic disease and dealing with patients with multiple conditions. Many expressed a desire for reminders and easier access to clinical guidelines under normal working conditions, as well as the possibility of consultations with specialists from their EPR systems. GPs placed importance on the ability to communicate electronically with patients.
Progress toward a problem-oriented EPR system based on episodes of care that includes decision support is necessary to satisfy the needs expressed by GPs. Further research could solve the problem of integration of functionality for consultation with specialists and integration with patient held records. Results from this study could contribute to further development of the next generation of EPRs in primary care, as well as inspire the application of EPRs in other parts of the health sector.
Improved discharge arrangements and targeted post-discharge follow-up can reduce the risk of adverse events after hospital discharge for elderly patients. Although more care is to shift from specialist to primary care, there are few studies on post-discharge interventions run by primary care. A generic care pathway, Patient Trajectory for Home-dwelling elders (PaTH) including discharge arrangements and follow-up by primary care, was developed and introduced in Central Norway Region in 2009, applying checklists at defined stages in the patient trajectory. In a previous paper, we found that PaTH had potential of improving follow-up in primary care. The aim of this study was to establish the effect of PaTH-compared to usual care-for elderly in need of home care services after discharge from hospital.
We did an unblinded, cluster randomised controlled trial with 12 home care clusters. Outcomes were measured at the patient level during a 12-month follow-up period for the individual patient and analysed applying linear and logistic mixed models. Primary outcomes were readmissions within 30 days and functional level assessed by Nottingham extended ADL scale. Secondary outcomes were number and length of inpatient hospital care and nursing home care, days at home, consultations with the general practitioners (GPs), mortality and health related quality of life (SF-36).
One-hundred and sixty-three patients were included in the PaTH group (six clusters), and 141 patients received care as usual (six clusters). We found no statistically significant differences between the groups for primary and secondary outcomes except for more consultations with the GPs in PaTH group (p?=?0.04). Adherence to the intervention was insufficient as only 36% of the patients in the intervention group were assessed by at least three of the four main checklists in PaTH, but this improved over time.
Lack of adherence to PaTH rendered the study inconclusive regarding the elderly's functional level, number of readmissions after hospital discharge, and health care utilisation except for more consultations with the GPs. A targeted exploration of prerequisites for implementation is recommended in the pre-trial phase of complex intervention studies.