Chronic Disease Outpatients Research Articles

Effects of traditional Thai folk dance combined with cognitive stimulation program on behavior and cognition among older adults with cognitive decline: A randomized controlled trial.

Older adults with mild behavioral impairment (MBI) are at the higher risk of developing dementia compared to those without MBI, leading to decreased quality of life (QoL). Addressing MBI in older adults provides valuable opportunities to prevent dementia. This study aimed to determine the effects of traditional Thai folk dance combined with a cognitive stimulation program on MBI, QoL, subjective cognitive decline (SCD), and cognitive functioning in older Thai adults. Single-blinded, two-armed, randomized controlled trial, with a three-month follow-up period. Outpatient chronic disease clinics at two districts in Suphan Buri province, Thailand. One-hundred twenty-eight older adults with MBI were randomly assigned to either the experimental (n = 64) and cognitive education control group (n = 64). The 14-session, 7-week traditional Thai folk-dance program combined with cognitive stimulation focused on enhanced moderate intensity physical activity and cognitive stimulation engagement to improve MBI of older adults. The primary outcome was MBI assessed using Mild Behavioral Impairment Checklist. Secondary outcomes were QoL, SCD, and cognitive tests of memory and executive functions. Compared to the control group, participants in the experimental group demonstrated significantly reduced MBI (p <.01), improved QoL (p <.01), decreased SCD (p <.01), and enhanced cognitive functioning (p <.01) after the 7-week intervention and at the 12-week follow-up. The traditional Thai folk dance combined with cognitive stimulation improved outcomes related to early signs of dementia and enhanced the overall QoL of older adults.

Impact of post-COVID-19 changes in outpatient chronic patients’ healthcare-seeking behaviors on medical utilization and health outcomes

IntroductionThis study comprehensively investigates the changes in healthcare utilization among chronic patients with regular outpatient visits to hospitals after the occurrence of Covid-19. The research examines whether patients altered their originally regular medical attendance frequencies due to the pandemic and explores potential negative impacts on the health conditions of those irregular attendees post-pandemic.MethodsData for this study were sourced from a database at a medical center in Taiwan. The subjects were chronic patients with regular hospital outpatient visits before the Covid-19 outbreak. The study tracked medical utilization patterns from 2017 to 2022 for different patient characteristics and outpatient behaviors, employing statistical methods such as Repeated Measures ANOVA and Generalized Estimating Equation to analyze changes in healthcare utilization and health status during the post-pandemic period.ResultsThe results reveal that, compared to the regular group, chronic patients with irregular outpatient visits during the post-pandemic period exhibited a decrease of 5.85 annual outpatient visits, a reduction of NT$20,290.1 in annual medical expenses, and a significantly higher abnormality rate in average biochemical test results by 0.9%.ConclusionsThe findings contribute to understanding the impact of the Covid-19 pandemic on healthcare utilization and health conditions among outpatient chronic disease populations. In response to the new medical landscape in the post-pandemic era, proactive suggestions are made, including providing telemedicine outpatient services and referral-based medical care to meet the needs of the target population, ensuring a continuous and reassuring healthcare model for chronic patients, and mitigating the operational impacts of public health emergencies on hospitals.

The Pain Intervention & Digital Research Program: an operational report on combining digital research with outpatient chronic disease management.

Chronic pain affects up to 28% of U.S. adults, costing ∼$560 billion each year. Chronic pain is an instantiation of the perennial complexity of how to best assess and treat chronic diseases over time, especially in populations where age, medical comorbidities, and socioeconomic barriers may limit access to care. Chronic disease management poses a particular challenge for the healthcare system's transition from fee-for-service to value and risk-based reimbursement models. Remote, passive real-time data from smartphones could enable more timely interventions and simultaneously manage risk and promote better patient outcomes through predicting and preventing costly adverse outcomes; however, there is limited evidence whether remote monitoring is feasible, especially in the case of older patients with chronic pain. Here, we introduce the Pain Intervention and Digital Research (Pain-IDR) Program as a pilot initiative launched in 2022 that combines outpatient clinical care and digital health research. The Pain-IDR seeks to test whether functional status can be assessed passively, through a smartphone application, in older patients with chronic pain. We discuss two perspectives-a narrative approach that describes the clinical settings and rationale behind changes to the operational design, and a quantitative approach that measures patient recruitment, patient experience, and HERMES data characteristics. Since launch, we have had 77 participants with a mean age of 55.52, of which n = 38 have fully completed the 6 months of data collection necessitated to be considered in the study, with an active data collection rate of 51% and passive data rate of 78%. We further present preliminary operational strategies that we have adopted as we have learned to adapt the Pain-IDR to a productive clinical service. Overall, the Pain-IDR has successfully engaged older patients with chronic pain and presents useful insights for others seeking to implement digital phenotyping in other chronic disease settings.

Palliative Approach Remains Lacking in Terminal Hospital Admissions for Chronic Disease Across Rural Settings: Multisite Retrospective Medical Record Audit

Introduction/AimDespite clear benefit from palliative care in end-stage chronic diseases, access is often limited, and rural access largely undescribed. This study sought to determine if a palliative approach is provided to people with chronic disease in their terminal hospital admission. MethodsMultisite, retrospective medical record audit, of decedents with a primary diagnosis of chronic lung, heart, or renal failure, or multimorbidity of these conditions over 2019. ResultsOf 241 decedents, across five clinical sites, 143 (59.3%) were men, with mean age 80.47 years (SD 11.509), and diagnoses of chronic lung (n = 56, 23.2%), heart (n = 56, 23.2%), renal (n = 24, 10.0%) or multimorbidity disease (n = 105, 43.6%), and had 2.88 (3.04SD) admissions within 12 months. Outpatient chronic disease care was evident (n = 171, 73.7%), however, contact with a private physician (n = 91, 37.8%), chronic disease program (n = 61, 25.3%), or specialist nurse (n = 17, 7.1%) were less apparent. “Not-for-resuscitation” orders were common (n = 139, 57.7%), however, advance care planning (n = 71, 29.5%), preferred place of death (n = 18, 7.9%), and spiritual support (n = 18, 7.5%) were rarely documented. Referral to and input from palliative services were low (n = 74, 30.7% and n = 49, 20.3%), as was review of nonessential medications or blood tests (n = 86, 35.7%, and n = 78, 32.4%). Opioids were prescribed in 45.2% (n = 109). Hospital site and diagnosis were significantly associated with outpatient care and palliative approach (P<0.001). ConclusionsEnd-of-life planning and specialist palliative care involvement occurred infrequently for people with chronic disease who died in rural hospitals. Targeted strategies are necessary to improve care for these prevalent and high needs rural populations.

Decentralized Heart Failure Management in Neno, Malawi.

Cardiovascular disease (CVD) is a major cause of death in Malawi. In rural districts, heart failure (HF) care is limited and provided by non-physicians. The causes and patient outcomes of HF in rural Africa are largely unknown. In our study, non-physician providers performed focused cardiac ultrasound (FOCUS) for HF diagnosis and longitudinal clinical follow-up in Neno, Malawi. We described the clinical characteristics, HF categories, and outcomes of patients presenting with HF in chronic care clinics in Neno, Malawi. Between November 2018 and March 2021, non-physician providers performed FOCUS for diagnosis and longitudinal follow-up in an outpatient chronic disease clinic in rural Malawi. A retrospective chart review was performed for HF diagnostic categories, change in clinical status between enrollment and follow-up, and clinical outcomes. For study purposes, cardiologists reviewed all available ultrasound images. There were 178 patients with HF, a median age of 67 years (IQR 44 - 75), and 103 (58%) women. During the study period, patients were enrolled for a mean of 11.5 months (IQR 5.1-16.5), after which 139 (78%) were alive and in care. The most common diagnostic categories by cardiac ultrasound were hypertensive heart disease (36%), cardiomyopathy (26%), and rheumatic, valvular or congenital heart disease (12.3%).At follow-up, the proportion of New York Heart Association (NYHA) class I patients increased from 24% to 50% (p < 0.001; 95% CI: 31.5 - 16.4), and symptoms of orthopnea, edema, fatigue, hypervolemia, and bibasilar crackles all decreased (p < 0.05). Hypertensive heart disease and cardiomyopathy are the predominant causes of HF in this elderly cohort in rural Malawi. Trained non-physician providers can successfully manage HF to improve symptoms and clinical outcomes in limited resource areas. Similar care models could improve healthcare access in other rural African settings.

Impact of China\u2019s zero mark-up drug policy on drug cost of NCDs\u2019 outpatients: an interrupted time series analysis

BackgroundChina proposed the Zero Markup Drug Policy (ZMDP), which popularized in tertiary hospitals across the country in 2017, to control drug expenditures’ rapid growth further and reduce the public’s medical burden. This study aims to evaluate the impact of ZMDP on the drug cost of chronic disease outpatients in the tertiary hospital in Chongqing.MethodsWe collected and described the drug-cost data for outpatients with chronic diseases in a Chongqing’s tertiary hospital from 2015 to 2019. The instantaneous and long-term changes of the outpatient volume and average drug cost after the ZMDP were evaluated using interrupted time series (ITS). We also analyzed the policy’s impact under the stratification of gender, age, and basic medical insurance types.ResultsA total of 350,848 outpatients were collected from January 2015 to February 2019. After the ZMDP, the outpatient volume for diabetes, hypertension, and coronary heart disease (CHD) all showed a downward trend, with a decrease of 53.04 (P = 0.012), 142.19 (P < 0.01) and 12.16 (P < 0.001) per month. Simultaneously, the average drug cost decreased by 4.44 yuan (P = 0.029), 5.87 yuan (P < 0.001) and 10.23 yuan (P = 0.036) per month, respectively. By gender, the average drug cost of diabetes in males had the most considerable instantaneous change, reducing by 51.21 yuan (P = 0.017); the decline of CHD in women is the most obvious, with an average monthly decrease of 12.51 yuan (P < 0.001). By age, the instantaneous change of CHD was the greatest for those older than 65 years old, with a decrease of 102.61 yuan (P = 0.030). CHD in 46–65 years old showed the most significant reduction, with an average monthly decline of 11.70 yuan (P < 0.01). BMIUE’s hypertension had the most considerable instantaneous change, which decreased 59.63 yuan (P = 0.010). BMIUE’s CHD showed the most apparent downward trend, with an average monthly decrease of 10.02 yuan (P = 0.010).ConclusionThe ITS analysis is an effective method of health policy evaluation. The implementation of the ZMDP can reduce the drug cost for chronic disease outpatients in the tertiary hospital and their economic burden. Follow-up policies still require targeted price adjustments in the health service system to adjust the drug cost-effectively.

Patient related barriers to adequate blood pressure control among adult hypertensive patients seen at Kiambu County Hospital, Kenya

Introduction: Hypertension is a key precursor to cardiovascular and renal disease globally. According to WHO, Prevalence of hypertension was about 40 % globally in 2015 and 45% in Sub Saharan Africa in 2015. Despite much emphasis on treatment of the syndrome, the related blood pressure control remains poor or inadequate.&#x0D; Objective: The study sought to establish the patient related barriers to adequate blood pressure control among adult hypertensive patients in Kiambu Count Hospital in Kenya.&#x0D; Methods: A cross -sectional descriptive study method approach was used to examine sample of 330 patients selected through consecutive sampling technique in the medical outpatient chronic disease clinic. Multivariate logistic regression analysis was used to determine variables associated with inadequate or poorly controlled hypertension among adult patients.&#x0D; Results: Most of the patients were females (71.5%). However, the presence of inadequate blood pressure control was significantly higher among males (P-value= 0.009). Regularly taking of hypertension drugs for the last 6 months was significantly associated with adequate blood pressure control (p-value=0.033). The other barriers including single status, inadequate knowledge, employment and time duration since diagnosis of hypertension did not significantly affect blood pressure control status.&#x0D; Discussion: Males were 54% more likely to have inadequate blood pressure control compared to females (AOR=0.543; 95%CI=0.323-0.914). Patients with low adherence to treatment were 11% more likely to have inadequate blood pressure control than those with high adherence rate (AOR=1.093; 95%CI=0.224-5.332) though the association was not significant (p-value=0.912).&#x0D; Conclusion: Male gender was a major barrier to adequate blood pressure control. Patients who well adhered to treatment scheme for a duration of six months preceding the study had their blood pressure better controlled than those who did not. Male hypertensive patients need to be followed up to ensure they adhere to drug treatment in order to reduce the rates of inadequate blood pressure control and other related complications.

Priorities Wizard: Multisite Web-Based Primary Care Clinical Decision Support Improved Chronic Care Outcomes with High Use Rates and High Clinician Satisfaction Rates.

Introduction:Priorities Wizard is an electronic health record-linked, web-based clinical decision support (CDS) system designed and implemented at multiple Health Care Systems Research Network (HCSRN) sites to support high quality outpatient chronic disease and preventive care. The CDS system (a) identifies patients who could substantially benefit from evidence-based actions; (b) presents prioritized evidence-based treatment options to both patient and clinician at the point of care; and (c) facilitates efficient ordering of recommended medications, referrals or procedures.Methods:The CDS system extracts relevant data from electronic health records (EHRs), processes the data using Web-based clinical decision support algorithms, and displays the CDS output seamlessly on the EHR screen for use by the clinician and patient. Through a series of National Institutes of Health-funded projects led by HealthPartners Institute and the HealthPartners Center for Chronic Care Innovation and HCSRN partners, Priorities Wizard has been evaluated in cluster-randomized trials and expanded to include over 20 clinical domains.Results:Cluster-randomized trials show that this CDS system significantly improved glucose and blood pressure control in diabetes patients, reduced 10-year cardiovascular (CV) risk in high-CV risk adults without diabetes, improved management of smoking in dental patients, and improved high blood pressure identification and management in adolescents. CDS output was used at 71–77 percent of targeted visits, 85–98 percent of clinicians were satisfied with the CDS system, and 94 percent reported they would recommend it to colleagues.Conclusions:Recently developed EHR-linked, Web-based CDS systems have significantly improved chronic disease care outcomes and have high use rates and primary care clinician satisfaction.

New antihypertensive medications and clinical implications.

Hypertension remains a global public health issue and is a leading preventable risk factor for many causes of mortality and morbidity. Although it is generally managed as an outpatient chronic disease, anaesthetists will inevitably encounter patients with hypertension, ranging from undiagnosed asymptomatic to chronic forms with end-organ damage(s). An understanding of perioperative management of anti-hypertensive pharmacotherapy is crucial. Although many drugs are familiar, new drug groups that have relevance for blood pressure control and perioperative care have evolved in recent years. This article also describes new antihypertensive agents currently available or under development that could impact perioperative management.

Identification of Potential Drug Interaction with Complementary and Alternative Medicines among Chronic Disease Outpatients

Chronic diseases such as congestive heart failure (CHF) and chronic kidney disease (CKD) are related with multiple drug prescription which can lead to drug interaction. The high usage of complementary and alternative medicines (CAM) in Indonesians can also increase the risk for drug interaction. The objective of this study is to describe CAMs use and identify potential drug interaction with CAMs in CHF and CKD outpatients. The study is a cross sectional study. Data of prescribed drugs and CAMs consumed by the patients was collected by using medication reconciliation process. Data of routine CAMs and prescribed medicines were compared to identify potential drug interactions which were then classified based on their mechanism and significance. The result showed that 6,90 % of CHF patients and 25 % of CKD patients consumed CAMs. Potential drug interaction between the CAMs and the prescribed drugs was identified in 2.74% of patients consuming CAMs. Based on the mechanism, interaction was dominated by pharmacodynamics interaction (69.2%) while interaction significancy was various. It can be concluded that CAMs usage was more familiar in CKD patients compared to CHF patients. Potential drug interaction with CAMs was able to be identified through medication reconciliation process and should be taken into awareness by the healthcare team.

System-Wide and Group-Specific Health Service Improvements: Cross-Sectional Survey of Outpatient Improvement Preferences and Associations with Demographic Characteristics.

Efficient patient-centred quality improvement requires an understanding of the system-wide areas of dissatisfaction along with evidence to identify the programs which can be strategically targeted according to specific patient characteristics and preferences. This cross-sectional study reports the proportion of chronic disease outpatients selecting 23 patient-centred improvement initiatives. Using univariate tests and multivariable logistic regressions, this multi-site study also identifies initiatives differentially selected by outpatients according to clinical and demographic characteristics. A total of 475 outpatients participated (49% response). Commonly selected initiatives included: reducing wait-times (22.3%); convenient appointment scheduling (16.0%); and receiving up-to-date treatment information (16.0%). Within univariate tests, preferences for information and service accessibility initiatives were not significantly associated with specific subgroups. However, seven initiatives were preferred according to age, gender, diagnosis status, and chronic disease type within multivariate models. For example, neurology outpatients were more likely to select assistance to manage psychological symptoms when compared to oncology outpatients (OR: 2.89). Study findings suggest that system-wide programs to enhance information provision are strategic approaches to improve experiences across patient characteristics. Furthermore, a few initiatives can be targeted to specific groups and emphasized the importance of detailed scoping analyses and tailored implementation plans when designing patient-centred quality improvement programs.

Primary Care Physician Volume and Quality of Diabetes Care: A Population-Based Cohort Study.

A relationship between higher patient volume and both better quality of care and better outcomes has been shown for many acute care conditions. Whether a volume-quality relationship exists for the outpatient management of chronic diseases is uncertain. To explore the association between primary care physician volume and quality of diabetes care. Cohort study. The study was conducted using linked population-based health care administrative data in Ontario, Canada. 1018647 adults with diabetes in 2011 who received care from 9014 primary care physicians. Two measures of volume were ascertained for each physician: overall ambulatory volume (representing time available to devote to chronic disease management during patient encounters) and diabetes-specific volume (representing disease-specific expertise). Quality of care was measured over a 2-year period using 6 indicators: disease monitoring (eye examination, hemoglobin A1c testing, and low-density lipoprotein cholesterol testing), prescribing appropriate medications (angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers and statins), and adverse clinical outcomes (emergency department visits for hypoglycemia or hyperglycemia). Higher overall ambulatory volume was associated with lower rates of appropriate disease monitoring and medication prescription. In contrast, higher diabetes-specific volume was associated with better quality of care across all 6 indicators. Only a select set of quality indicators and potential confounders could be ascertained from available data. Primary care physicians with busier ambulatory patient practices delivered lower-quality diabetes care, but those with greater diabetes-specific experience delivered higher-quality care. These findings show that relationships between physician volume and quality can be extended from acute care to outpatient chronic disease care. Health policies or programs to support physicians with a low volume of patients with diabetes may improve care. Canadian Institutes of Health Research.

Design Features of Successful Outpatient Chronic Disease Care Clinical Decision Support Systems

Background/Aims: To identify key design features of point-of-care diabetes clinical decision support (CDS) that have high use rates and high provider satisfaction rates, and that have improved control of major cardiovascular risk factors.

Advanced Disease, Diuretic Use, and Marital Status Predict Hospital Admissions in an Ambulatory Cirrhosis Cohort

Hospital admissions in cirrhotic patients are a source of significant health care expenditure. Most studies to date have focused on readmissions in patients with decompensated cirrhosis. We sought to describe predictors of hospital admissions in an ambulatory cirrhosis cohort consisting of both compensated and decompensated patients to identify patients who could benefit from intensified outpatient chronic disease management. We performed a retrospective cohort study of 395 cirrhotic patients followed at an academic medical center liver clinic. Inclusion criteria were documented cirrhosis and longitudinal care at our center during 2006-2008. Patients were followed until December 2011, death, or liver transplantation. The primary outcomes were non-elective cirrhosis-related hospital admissions within 1 year and time to admission. The secondary outcome was 2-year cirrhosis-related mortality. The study was approved by the Partners Human Research Committee (protocol 2012P001912). Seventy-eight patients (19.7 %) had at least one cirrhosis-related hospital admission within 1 year. The following were significant predictors in the multivariable model: model for end-stage liver disease score ≥15 [OR 2.22, 95 % CI (1.21-4.07), p = 0.01], diagnosis of hepatocellular carcinoma [3.64 (1.42-9.35), 0.007], diuretic use [2.27 (1.23-4.17), 0.008], at least one cirrhosis-related admission during the baseline year [2.17 (1.21-3.89), 0.01], and being unmarried [1.92 (1.10-3.35), 0.02]. Advanced disease, diuretic use, and marital status were associated with cirrhosis-related hospital admissions in patients followed at an academic medical center liver clinic. Our findings suggest that patients with inadequately or overzealously treated ascites, as well as those with limited social supports, could benefit from intensified outpatient management.

Benefit packages for chronic disease outpatients in the New Rural Cooperative Medical Scheme in 32 Chinese counties

Introduction: Chronic disease has become a major problem affecting the health of the Chinese population. In response to this situation, the New Rural Cooperative Medical Scheme (NRCMS) has begun to provide health cover for outpatients with chronic disease expenses, made possible by the increased risk pool of previous years. We compare the differences between Benefit Packages for Chronic Diseases Outpatients (BPCDO) in order to produce a reference for policy makers. Methods: Information on the various BPCDO was located by searching the official NRCMS website in Chinese, using certain criteria to select the ideal BPCDO. Population coverage, service coverage and cost of coverage were chosen to form the analytical framework for this paper. The diseases were classified according to the World Health Organisation's (WHO) International Classification of Diseases (ICD-10). Results: To avoid “moral hazard”, complex processes have been created. This has resulted in chronic disease patients finding it very difficult to become beneficiaries. Forty-one types of chronic diseases were listed in 32 different BPCDO. We found that different counties have different co-payment rates, deductible lines, ceilings, coverage of drugs and tests, appointed hospitals and reimbursement frequencies. Conclusion: High mortality diseases and diseases with a heavier cost burden should be the priority on the list of reimbursement. The BPCDO scheme should be introduced urgently at the national level. It should include twenty-one types of disease and eight essential factors.

PHP116 Equity in the New Rural Cooperative Medical Scheme: Comparison of Benefit Packages for Chronic Disease Outpatients in 32 Counties in China

PHP116 Equity in the New Rural Cooperative Medical Scheme: Comparison of Benefit Packages for Chronic Disease Outpatients in 32 Counties in China

Length of delay in seeking medical care by patients with heart failure symptoms and the role of symptom‐related factors: a narrative review

The delay in seeking timely medical care by patients with acute coronary syndrome and stroke is well established. Less is known about the delay in patients with heart failure (HF). Reducing the delay in seeking care and the early initiation of treatment is associated with improved outcomes in patients with HF. The purpose of this narrative review was to describe the length of the delay in seeking care for HF symptoms and identify symptom-related factors that contribute to the delay in seeking medical care. A literature search was conducted to identify English language studies that (i) describe the length of care-seeking delay for HF symptoms and/or (ii) identify symptom-related factors that contribute to delay in seeking medical care. The results of this review demonstrate that upon hospital admission patients report wide variations in median symptom time course from 2 h to 7 days from the onset of symptoms to hospital admission. The ability of patients to recognize, interpret, and appraise HF symptoms has been demonstrated to be limited. Symptom characteristics such as dyspnoea, oedema, orthopnoea, higher somatic awareness, higher symptom distress, nocturnal symptom onset, and the pattern of symptom onset were related to longer delay in care-seeking for HF symptoms. Furthermore, cognitive responses to HF may also play an important role in symptom appraisal. Delays in seeking care for HF symptoms have been shown to range from hours to days from symptom onset to hospital admission. Healthcare professionals should therefore be more vigilant in identifying high-risk individuals and educating them about the warning signs of HF. Moreover, access to outpatient chronic disease management programmes may have the potential to reduce these delays.

Training Internal Medicine Residents in Outpatient HIV Care: A Survey of Program Directors

The care of patients with HIV is increasingly focused on outpatient chronic disease management. It is not known to what extent internal medicine residents in the US are currently being trained in or encouraged to provide primary care for this population of patients. To survey internal medicine residency program directors about their attitudes regarding training in outpatient HIV care and current program practices. Program directors were surveyed first by email. Non-responding programs were mailed up to two copies of the survey. All internal medicine residency program directors in the US. Program director attitudes and residency descriptions. Of the 372 program directors surveyed, 230 responded (61.8 %). Forty-two percent of program directors agreed that it is important to train residents to be primary care providers for patients with HIV. Teaching outpatient-based HIV curricula was a priority for 45.1%, and 56.5% reported that exposing residents to outpatient HIV clinical care was a high priority. Only 46.5% of programs offer a dedicated rotation in outpatient HIV care, and 50.5% of programs have curricula in place to teach about outpatient HIV care. Only 18.8% of program directors believed their graduates had the skills to be primary providers for patients with HIV, and 70.6% reported that residents interested in providing care for patients with HIV pursued ID fellowships. The strongest reasons cited for limited HIV training during residency were beliefs that patients with HIV prefer to be seen and receive better care in ID clinics compared to general medicine clinics. With a looming HIV workforce shortage, we believe that internal medicine programs should create educational experiences that will provide their residents with the skills and knowledge necessary to meet the healthcare needs of this population.

Using Electronic Health Records to Improve Outpatient Diabetes Care

Early versions of electronic health records (EHRs) were developed in the 1980s. The potential to use such technology to improve care—especially preventive care and outpatient chronic disease care—has been widely assumed since the publication of two landmark Institute of Medicine reports in 1992 and 1994.1,2 However, nearly two decades later, the potential for EHR technology to improve chronic disease care—in particular, care of adults with type 2 diabetes—remains unrealized. The unfulfilled potential is partially related to low levels of outpatient EHR use. As recently as 2008, only ~ 13% of primary care physicians (PCPs) used basic EHR systems, and only 4% reported using fully functional systems.3 Recent federal policies provide incentives for and subsidize the use of outpatient EHRs and are likely to accelerate the use of such systems in the near future. However, other concerns remain.4 Patients appear positively disposed to their providers' use of EHRs,5 but provider reactions have been less enthusiastic. Many early adopters of EHRs reported decreased practice revenue, disrupted clinic workflows, and transient deterioration in the office environment.6,7 Improvement of quality of care, a much anticipated result of the substantial financial investments needed to impel EHR use, has been slow to materialize. Some early reports even noted deterioration in care after EHR implementation.8–11 More recent reports reiterate that the effect of EHR systems on quality is marginal and assert that use of specific features of EHRs may be a better predictor of improved quality than simple implementation of basic systems.12,13 What about diabetes care specifically? What evidence do we have that EHR use or …

Designing and Implementing E-health Applications in the UK's National Health Service

ABSTRACT Telemedicine/e-health applications have the potential to play an important role in Britain's National Health Service (NHS), including the NHS in Scotland. The Scottish Telemedicine Action Forum (STAF) was established by the Scottish Executive Department of Health in 1999 to take a range of applications, targeted on national priorities, into routine service. In the process it has provided insights into how advanced information and communication technologies (ICTs) can be moved from the research stage into routine service. In this article four of the projects are described and analysed focusing on the key issues that have emerged as critical for carrying projects successfully through to implementation in service as follows: 1. A multisite videoconferencing network linking 15 minor injury units to the main accident and emergency (A&E) centre. 2. A single-site neonatal intensive care “cotside” laptop system to assist communication between parents and clinical staff. 3. A single-site outpatient chronic disease management system. 4. A multisite software audit tool to support the care of cleft lip and palate patients from birth onward.