Patient Centered Outcomes Research
PI: David Mehr
Co-I: Doug Wakefield
Dr. David Mehr, Family and Community Medicine is the PI of the AHRQ
funded grant. This project is building a center for patient‐centered outcomes research (PCOR) at the University of Missouri (MU) with a thematic focus on improving patient care transitions across health care settings or from one phase of care to another. To build long-term sustainability for conducting patient-centered outcomes research the MU Center will: (1) develop MU's capabilities in PCOR by mentoring investigators, supporting pilot studies, providing research training, and new hiring; (2) foster development of skills and capabilities to work with large data sets using advanced analytic methods to study comparative treatment effectiveness; (3) build research expertise on practice-changing interventions to support care transitions; and (4) engage stakeholders through focus groups, a patient advisory panel, and a novel social networking and tailored messaging platform that facilitates information gathering, feedback from participants to investigators, and dissemination. Dr. Wakefield leads the Evaluation Core and serves on the Education Core as well as the Center Executive Committee. CHCQ is also providing database design as well as electronic health record data query support. For more information, please visit this link
In the U.S., it is estimated that social and behavioral factors contribute to more than half of all causes of disease and death, including cancer, heart disease, chronic obstructive pulmonary disease, and type II diabetes. In partnership with Indiana University School of Medicine and a consortium of 18 other medical schools across the county, University of Missouri School of Medicine leaders were awarded a grant through the National Institutes of Health. The University of Missouri School of Medicine will be able to create an institutional environment and culture that actively uses theory and practices from the social and behavior sciences that leads to improved patient care in these areas, and thus promote patient-/relationship-centeredness, physician self-awareness, professional and ethical character, effective communication with patients, optimal systems for patient safety, and cultural competency. This grant will allow the University Of Missouri School Of Medicine to further enhance the medical student experience and support the mission to education physicians to provide effective patient-centered care for the people of Missouri and beyond.
Train-the-Trainer (T3) Inter-professional Faculty Development Training Program
MU PIs: Les Hall / Carla Dyer
The Train-the-Trainer (T3) Inter-professional Faculty Development Program (FDP) is a comprehensive series of interactive learning opportunities with a focus on inter-professional practice and education designed specifically for clinical educators and collaborative practice partners. The grant funded was by The Josiah Macy Jr. Foundation
to establish national centers for training. The three-and-a-half day workshops are hosted at three university sites around the country: the University of Washington (Seattle, WA), the University of Virginia (Charlottesville, VA), and the University of Missouri (Columbia, MO). For more information on the program, please visit T3-FDP Program site
Faculty Development in Inter-professional Team-Based Care
The The Josiah Macy Jr. Foundation
Board provided a grant to support a project titled, “Faculty Development in Inter-professional Team-Based Care”. The grant includes working with six academic health centers and the University of Washington in collaboration to design an inter-professional Faculty Development initiative that will train faculty how to deploy inter-professional training in team-based care.
Basic Disaster Life Support (BDLS) and Advanced Disaster Life Support (ADLS)
The Missouri Department of Health and Senior Services (MDHSS), the University of Missouri-Columbia, and Shelden Clinical Simulation Center
have created a training course for pre-hospital and hospital healthcare providers (trauma or non-trauma) to build capacity for multiple/mass casualty event management. The course focus is to bridge theory and practice between day-to-day trauma practice and trauma care in multiple/mass casualty events. Simulation-based training addresses multiple/mass casualty preparedness and explores day to day trauma practice and trauma care in altered settings and austere environments.
Verbal Order Policies, Occurrence, and Perceptions
Face-to-face verbal and telephone orders (VOs) are commonly used in inpatient care settings. VOs hold substantial potential for miscommunication due to a variety of factors, including fatigue, workload, sound-alike medications, background noise, accents, dialects and different pronunciations. VO prescribers and receivers may also misspeak, miscommunicate, or not understand patient-specific information being exchanged (e.g., indicating the possible need for an order). These inherent dangers have been recognized by The Joint Commission (TJC), the National Quality Forum (NQF) and others. While VOs are commonly used, there has been little systematic study 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, or ultimately carried out as intended.
The research proposed in this study was designed to make a significant contribution to understanding VOs by addressing several gaps in the existing literature. The grant was sponsored by the AHRQ
Linking Health Care Workarounds and Burnout to Patient and Worker Safety
Within the health care setting, workarounds and workforce burnout may be associated with medical errors, occupational injuries and illnesses of nurses. Dr. Jonathon Halbesleben, Assistant Professor in the Department of Management and Marketing at the University of Wisconsin at Eau Claire, was awarded this career development award in order to integrate occupational health concepts with occupational injuries of health care workers and patient safety. By studying nurses in the Veteran’s Health Administration, the study will first seek to better understand the early markers of occupational injuries and illnesses of health services workers through a study of workarounds and burnout as causes of occupational health outcomes. Second, this study could lead to interventions designed to address occupational health of nurses by addressing the manner in which nursing work is designed. Finally, this study aims at improving the measurement of occupational illnesses and injuries among health care workers and the measurement of the workarounds which can lead to high quality future research in these areas. Drs. Doug Wakefield and Gordon Brown will serve as mentors to Dr. Halbesleben.
Bridging the Care Gap Between Rural Primary Care Physicians, Rural Breast Cancer Survivors, and Cancer Specialists: Building a Shared-Care Model
A total of 16 providers were interviewed from 7 mid-Missouri Counties served by the Mid-Missouri Susan G. Komen Breast Cancer Foundation. The major themes identified by the research staff were:
- Rural by choice. Most of the providers were rural by choice. They recognize that making the choice to practice in these areas does present certain challenges. However, there is an appreciation for and understanding of the people that live in these areas. Additionally, they are practicing in a community of which they feel they are an important part.
Role of primary care provider. These providers see themselves as playing very particular roles prior to diagnosis, during treatment and post-treatment. They do not want to do the work that the oncologist does, but want to facilitate them.
Providing patient-centered care. These providers believed in listening to what their patients wanted and doing their best to accommodate those needs. In terms of breast cancer treatment, that means sending patients to providers they want to go to, attempting to keep them close to home, and offering them choices.
Patient challenges. Providers identified several challenges faced by their rural patients - lack of insurance, access to care, traveling, the cost of travel, fear of a large complex health system, the perceived "waste of time" of traveling long distances for certain appointments, and locating counseling for post-treatment patients.
Primary care challenges. These providers faced many challenges before treatment begins (e.g., getting referrals), during treatment (e.g., finding out what is happening to the patient), and post-treatment (e.g., getting follow-up information, feeling that their role is appreciated and respected by oncologists).
Barriers to shared care. A key intention of this project was to determine how a shared-care model could be facilitated. However, these providers identified many barriers: turnover at the University makes it difficult to build long-lasting working relationships; patients are lost to the oncologists during cancer treatment, so the primary care providers often do not see them during treatment, and getting them back during post-treatment may be difficult; patients are referred to other specialists while getting treatment for cancer rather than being referred back to their primary care provider; a perceived belief that some primary care providers are not capable of managing the general health of patients; a perceived belief that rural providers are not as well educated or trained.
- Timely communication. Providers indicated that in many situations, the information they get back on patients after they have been treated for cancer is not timely. So if they happen to see a patient, the primary care provider is unaware of the type of care received, making it difficult to communicate with the patient. It also undermines the patient's trust in the provider if they cannot answer questions.
Care summary. A care summary for breast cancer patients was shown to all providers during the interview. The intention of this summary is to give primary care providers a snapshot of the care received, but more importantly, to delineate which provider is providing certain care - the oncologist or the primary care provider. This summary was well-received. Changes were suggested and have been incorporated into a new draft of the summary.
Collaborative Electronic Health Record (EHR) Implementation to Bridge the Continuum of Care in Rural Iowa
This study provides a unique opportunity to evaluate how implementation of an integrated electronic health record and computerized provider order entry (EHR/CPOE) system using common tools, including decision supports affects patient care in nine, small, rural hospitals and their associated primary care clinics, throughout Mercy Health Network - North Iowa (MMC-NI), and on a regional basis with regard to changes in access to medical specialty, pharmacy, and laboratory consultation services. The proposed implementation process groups the 9 hospitals (and their primary care clinics) into three cohorts. The first cohort consisting of three hospitals will activate the new system in July 2008. A second cohort of four hospitals will activate the new system in September 2008. A third cohort of two hospitals will not activate the new system during the planned grant period. Because the proposed study will run from September 2005 to August 2009 there will be sufficient time for Cohorts 1 and 2 to have a 2-year Build Phase evaluation and a 1-year post-EHR evaluation. Cohort 3 will serve as a quasi-control during the grant period. The evaluation will focus on changes in patient care processes as well as changes in selected patient care quality and safety indicators. More specifically the researchers will evaluate the 9 hospital EHR/CPOE implementation in terms of: 1) The leadership, strategies for hospital security levels used in the EHR/CPOE implementation; 2) How the clinical decision support rules (CDSR) and evidence-based service specific order sets (SSOS) change patient care processes; 3) Changes in staff and physician perceptions of quality and safety, and specific indicators used to assess patient care quality and safety change as a result of the implementation; 4) How access and relationships among the 9 hospitals, MMC-NI, and the visiting consulting clinics are affected; 5) How job satisfaction, work tasks and adverse event and error reporting behaviors are affected; and, 6) How an EHR/CPOE implementation influences organizational learning within individual hospitals and as a multi-hospital network.
The Management of Late Treatment Effects in Breast Cancer Survivors in Rural Areas: An Exploratory Study
Abstract: Due to better screening and more effective treatments, the survival rates for breast cancer have increased to nearly 90%. However, years after treatment, exposure to these same treatments can cause late treatment effects of cancer. The IOM's 2006 report From Cancer Patient to Cancer Survivor noted that for survivors and for their health care providers, care is fragmented, communication between the cancer specialists, primary care providers, and survivors is often poor, and a lack of agreement as to what constitutes survivorship care exists. An absence of information is particularly problematic in rural areas where neither breast cancer survivors nor primary care providers may have regular contact with the cancer specialists or information sources focused on late treatment effects. The purpose of this study is to explore rural breast cancer survivors' and primary care physicians' understanding and management of late treatment effects as well as to develop care summaries for both survivors and primary care physicians in rural areas. There were three specific aims. Aim 1. Assess rural primary care providers' awareness, understanding and knowledge of breast cancer late treatment effects. Aim 2. Assess rural breast cancer survivors' awareness, understanding and knowledge of breast cancer late treatment effects, as well as to assess their health information needs regarding breast cancer survival. Aim 3. Develop and pilot test patient-specific care summaries for both survivors and primary care physicians, detailing the survivors' breast cancer treatment and their implications for late treatment effects for subsequent health problems. The study was conducted in partnership with the Mid-Missouri Susan G. Komen Breast Cancer Foundation.
Findings: The survivors interviewed for this study had a minimal awareness of late treatment effects. They are aware that they may have a recurrence, or develop lymphedema depending on the type of treatment they had. They generally feel that they received an adequate amount of information post-treatment; however, given their lack of knowledge about late treatment effects, as well as their discussions of untreated depression and anxiety, and some family discord, the aftermath of their cancer and its treatment is not being addressed. They typically felt that the care they were receiving post-treatment from their specialists was good; however, they typically do not discuss their breast cancer with their primary care provider. Rather, they see their specialist as being their "primary care provider" of their breast cancer care. It is the primary care provider that may be able to address the other issues addressed above, such as emotional problems and family breakdown. To address some of these issues, a "Thrivership Guide" was developed for the survivors. This details the treatment they received, provides a discussion of what they may expect post-treatment with regard to their physical, emotional, social and spiritual well-being, and lists resources (e.g., books, magazine, national groups, websites) that may be helpful. For the rural providers interviewed, it was found that even for providers connected to a large health system with a shared electronic medical record, barriers exist when it comes to providing optimal care to patients who are breast cancer survivors (e.g., fragmented care, lack of information about optimal post-treatment care, poor communication). To alleviate some of those problems, a patient care summary was created for primary care providers. the summary includes the particular patient's diagnosis, treatment, follow-up plan for the specialist, and the follow-up recommendations for the primary care provider. This summary would be generated by the specialist and sent to the primary care provider. This will initially be a paper summary, but will ultimately be generated through the shared electronic medical record.
Using Health Information Technology (HIT) to Improve Ambulatory Chronic Disease Care
PI: David Mehr
Co-I: Doug Wakefield
While chronic disease care consumes an increasing share of healthcare resources, management of chronic illnesses is often fragmented and ineffective. Patients are increasingly being treated for multiple chronic diseases by many different providers. The resulting fragmented system both decreases the quality of care and increases patient safety concerns, such as interactions between medications prescribed by multiple providers. Wagner's chronic care model provides a framework for improving chronic disease care through care coordination, active follow-up, support for self-management, clinician decision support, and information systems. Despite the potential for health information technology (HIT) to facilitate these processes, research to date has often failed to show clear benefit. To improve patient care quality and safety outcomes, the Family Medicine and General Internal Medicine practices at the University of Missouri-Columbia plan a phased implementation of selected ambulatory care HIT systems and functions. The HIT implementations will use specific strategies to (1) improve providers' access to information, allowing individual providers to compare and improve their clinical performance against standardized performance targets and peers' performance; and (2) enhance patient-provider connectivity and communication to improve clinical decision-making, patient participation in the care process, and ultimately, patient care outcomes. Specific strategies include providing physicians with comparative performance reports in one of three formats, providing patients with access to a web-based, interactive software system that includes secure messaging and in-home reconciliation of all medications, and using in-home "smart" diagnostic devices that send patient data directly to the care team. We propose a multi-method evaluation of HIT innovations designed to enhance the quality of primary care for chronic diseases. We will include qualitative interviews, surveys, and analysis of outcome data in the evaluation. The planned HIT systems for improving chronic disease care at MU will be implemented differently in various practices and with different associated care systems. This variation in care processes provides an extraordinary opportunity to evaluate factors that influence whether HIT innovations will aid in performance-based quality improvement, assist with care coordination, and facilitate patient self-management. Dr. Wakefield is working with the Department of Family and Community Medicine on this project. Dr. David Mehr serves as the PI.