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A Pilot to Enhance the Recovery Orientation of Assertive Community Treatment Through Peer-Provided Illness Management and Recovery

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AMERICAN JOURNAL OF PSYCHIATRIC REHABILITATION 2009年第3期12卷 191-204页

作者： Salyers, Michelle P. Hicks, Lia J. McGuire, Alan B. Baumgardner, Heather Ring, Karen Kim, Hea-Won ACT Ctr Indiana Indianapolis IN 46202 USA Regenstrief Inst inc VA HSR&D Ctr Implementing Evidence Based Practice Roudebush VAMC & IU Ctr Hlth Serv & Outcomes Res 1480 W 10th St 11H Indianapolis IN 46202 USA Indiana Univ Purdue Univ Dept Psychol Indianapolis IN 46202 USA ACT Ctr Indiana Adult & Child Mental Hlth Ctr Indianapolis IN 46202 USA Roudebush VAMC VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN 46202 USA Adult & Child Mental Hlth Ctr Indianapolis IN 46227 USA Indiana Univ Sch Social Work Bloomington IN 47405 USA

Assertive community treatment (ACT) is widely regarded as an evidencebased practice (Bond, drake, Mueser, & Latimer, 2001);however, observers have questioned the recovery orientation of the model. As an organizational model of service delivery, the recovery orientation of ACT can be improved through the integration of other, more clinically defined evidence-based practices. We present findings from an uncontrolled, 9-month pilot study in which a peer specialist was trained to provide illness management and recovery (IMR) on a well-established ACT team. This pilot included both quantitative measures of knowledge and recovery beliefs, and a qualitative interview with consumers (N = 14) and providers (N = 16). Consumer perceptions of recovery significantly improved, and there was a trend toward increased knowledge. In interviews, consumers and staff reported many benefits of IMR, including an increase in consumers' trying new things, being involved in more meaningful activities, and greater hope (for consumers and staff). The integration of IMR onto ACT with a peer specialist shows promise as a useful way to improve consumer recovery outcomes and increase the recovery orientation of ACT.

关键词： Assertive community treatment evidence-based practice Illness management and recovery Implementation

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Computerized Medication Alerts and Prescriber Mental Models: Observing Routine Patient Care

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Proceedings of the Human Factors and Ergonomics Society Annual Meeting 2009年第11期53卷 655 - 659页

作者： Alissa L. Russ Jason J. Saleem M. Sue McManus Alan J. Zillich Bradley N. doebbeling VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis IN；Indiana University (IU) Center for Health Services & Outcomes Research； Regenstrief Institute Inc. Indianapolis IN； Department of Nephrology Roudebush VAMC Indianapolis IN； VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis IN；Indiana University (IU) Center for Health Services & Outcomes Research； Regenstrief Institute Inc. Indianapolis IN；Purdue University School of Pharmacy Department of Pharmacy Practice West Lafayette IN； VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis IN；Indiana University (IU) Center for Health Services & Outcomes Research； Regenstrief Institute Inc. Indianapolis IN；Department of Medicine IU School of Medicine Indianapolis IN.

Computerized medication alerts (e.g., drug-drug interactions, drug-allergy interactions), which are intended to protect patient safety, need to match the mental models of medication prescribers in order to aid medication ordering. To maximally protect patient safety, the programmer mental model, system image, and prescriber mental model should work seamlessly together to fully support prescriber decision-making. In this study, we examined prescribing processes in the context of routine patient care to understand how the design of medication alerts can be enhanced for prescribers. We shadowed prescribers, including physicians, pharmacists, and nurse practitioners, across five outpatient primary care clinics at a large Veterans Affairs Medical center (vaMC). In addition, prescribers were opportunistically interviewed as they ordered mediations via a computerized order entry system and resolved any subsequent medication alerts. This investigation is one of the few to examine medication alerts by directly observing prescribers during patient care. Altogether, 191 medication alerts occurred across 63.5 total hrs of observation, 19 prescribers, and 86 patients during routine patient care tasks. Results reveal problematic system images and mismatches between programmer and prescriber mental models. Findings can help inform medication alert redesigns, which may promote safer, more effective prescribing practices.

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Healthcare Workers' Perceptions of Information in the Electronic Health Record

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Proceedings of the Human Factors and Ergonomics Society Annual Meeting 2009年第11期53卷 635 - 639页

作者： Alissa L. Russ Jason J. Saleem Connie F. Justice Heather Hagg Peter A. Woodbridge Bradley N. doebbeling VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis IN；Indiana University (IU) Center for Health Services & Outcomes Research Regenstrief Institute Indianapolis IN； VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis IN；Indiana University (IU) Center for Health Services & Outcomes Research Regenstrief Institute Indianapolis IN；Department of Computer Information Technology IUPUI Indianapolis IN； VA Nebraska Western Iowa Heath Care System Omaha NE；University of Nebraska Medical Center College of Public Health Omaha NE； VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis IN；Indiana University (IU) Center for Health Services & Outcomes Research Regenstrief Institute Indianapolis IN；Department of Medicine IU School of Medicine Indianapolis IN.

Electronic health record (EHR) systems and health information technology (IT) hold unrealized potential for improving the quality, continuity, and safety of medical care; they can also introduce new gaps in care and present unique challenges for healthcare workers. We conducted 14 key informant, semi-structured interviews at a large Veterans Affairs Medical center and asked healthcare employees why paper use persists despite a fully implemented EHR. In this investigation, we performed a secondary analysis on interview data to identify characteristics of information technology (IT) that are important to support healthcare workflow. As a result of this study, 17 distinct information characteristics emerged; in this document, we provide detail on five characteristics that were often cited as desirable for workflow but insufficiently supported by health IT: 1) customizable, 2) prioritized, 3) trendable, 4) locatable, and 5) accessible. Results from this study reveal key electronic information characteristics for healthcare workflow and have implications for patient safety and future health IT designs.

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Evaluation of a Physician Informatics Tool to Improve Patient Handoffs

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JOURNAL OF THE AMERICAN MEdICAL INFORMATICS ASSOCIATION 2009年第4期16卷 509-515页

作者： Flanagan, Mindy E. Patterson, Emily S. Frankel, Richard M. doebbeling, Bradley N. Regenstrief Inst Inc IU Ctr Hlth Serv & Outcomes Res Indianapolis IN 46202 USA Richard L Roudebush VA Med Ctr VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN USA VA GAPS Ctr Cincinnati OH USA Ohio State Univ Columbus OH 43210 USA Purdue Univ Regenstrief Ctr Healthcare Engn W Lafayette IN 47907 USA Indiana Univ Sch Med Dept Med Div Gen Med & Geriatr Indianapolis IN USA

Objective: To facilitate patient handoffs between physicians, the computerized patient handoff tool (PHT) extracts information from the electronic health record to populate a form that is printed and given to the cross-cover physician. Objectives were to: (1) evaluate the rate at which data elements of interest were extracted from the electronic health record into the PHT, (2) assess the frequency for needing information beyond that contained in the PHT and where obtained, (3) assess physician's perceptions of the PHT, (4) identify opportunities for improvement. design: Observational study. Measurements: This multi-method study included content coding of PHT forms, end of shift surveys of cross-cover resident physicians, and semi-structured interviews to identify opportunities for improvement. Thirty-five of 42 internal medicine resident physicians participated. Measures included: 1264 PHT forms coded for type of information, 63 end-of-shift surveys of cross-cover residents (residents could participate 2 times), and 18 semi-structured interviews. Results: For objective 1, patient identifiers and medications were reliably extracted (>98%). Other types of information-allergies and code status-were more variable (<50%). For objective 2, nearly a quarter of respondents required information from physician notes not available in the PHT. For objective 3, respondents found that the PHT Supported handoffs but indicated that it often excluded the assessment and plan. For objective 4, residents suggested including treatment plans. Conclusions: The PHT reliably extracts information from the electronic health record. Respondents found the PHT to be suitable, although opportunities for improvement were identified.

关键词： Medical Informatics

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Innovations and Adaptations of Assertive Community Treatment

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AMERICAN JOURNAL OF PSYCHIATRIC REHABILITATION 2009年第3期12卷 185-190页

作者： Salyers, Michelle P. Bond, Gary R. ACT Ctr Indiana Indianapolis IN 46202 USA Regenstrief Inst Inc VA HSR&D Ctr Implementing Evidence Based Practice Roudebush VAMC & IU Ctr Hlth Serv & Outcomes Res 1481 W 10th St 11H Indianapolis IN 46202 USA Indiana Univ Purdue Univ Dept Psychol Indianapolis IN 46202 USA

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关键词： COMMUNITY-based corrections MENTALLY ill

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Exploring the persistence of paper with the electronic health record

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INTERNATIONAL JOURNAL OF MEdICAL INFORMATICS 2009年第9期78卷 618-628页

作者： Saleem, Jason J. Russ, Alissa L. Justice, Connie F. Hagg, Heather Ebright, Patricia R. Woodbridge, Peter A. doebbeling, Bradley N. Roudebush VAMC VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN USA Indiana Univ Ctr Hlth Serv & Outcomes Res Regenstrief Inst Inc Indianapolis IN 46204 USA Indiana Univ Purdue Univ Dept Elect & Comp Engn Indianapolis IN 46202 USA Indiana Univ Purdue Univ Dept Comp Informat Technol Indianapolis IN 46202 USA IU Sch Nursing Dept Adult Hlth Indianapolis IN USA VA Nebraska Western Iowa Heath Care Syst Omaha NE USA Univ Nebraska Med Ctr Coll Publ Hlth Omaha NE USA IU Sch Med Dept Med Indianapolis IN USA

Objective: Healthcare organizations are increasingly implementing electronic health records (EHRs) and other related health information technology (IT). Even in institutions which have long adopted these computerized systems, employees continue to rely on paper to complete their work. The objective of this study was to explore and understand human-technology integration factors that may be causing employees to rely on paper alternatives to the EHR. Methods: We conducted semi-structured interviews with 20 key-informants in a large Veterans Affairs Medical center (vaMC), with a fully implemented EHR, to understand the use of paper-based alternatives. Participants included clinicians, administrators, and IT specialists across several service areas in the medical center. Results:We found 11 distinct categories of paper-based workarounds to the use of the EHR. Paper use related to the following: (1) efficiency;(2) knowledge/skill/ease of use;(3) memory;(4) sensorimotor preferences;(5) awareness;(6) task specificity;(7) task complexity;(8) data organization;(9) longitudinal data processes;(10) trust;and (11) security. We define each of these and provide examples that demonstrate how these categories promoted paper use in spite of a fully implemented EHR. Conclusions: In several cases, paper served as an important tool and assisted healthcare employees in their work. in other cases, paper use circumvented the intended EHR design, introduced potential gaps in documentation, and generated possible paths to medical error. We discuss implications of these findings for EHR design and implementation. Published by Elsevier Ireland Ltd

关键词： Paper-based workarounds Electronic health record Computerized medical record Human information processing data display

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Can a Nurse Practitioner Serve in the Prescriber Role on an Assertive Community Treatment Team?

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AMERICAN JOURNAL OF PSYCHIATRIC REHABILITATION 2009年第3期12卷 205-224页

作者： Williams, Kara Kukla, Marina Bond, Gary R. McKasson, Mike Salyers, Michelle P. Community Mental Hlth Ctr Lawrenceburg IN 47025 USA Indiana Univ Purdue Univ Dept Psychol 402 N Blackford St Indianapolis IN 46202 USA ACT Ctr Indiana Adult & Child Ctr Indianapolis IN 46202 USA ACT Ctr Indiana Indianapolis IN 46202 USA Regenstrief Inst Inc VA HSR&D Ctr Implementing Evidence Based Practice Roudebush VAMC & IU Ctr Hlth Serv & Outcomes Research Indianapolis IN 46202 USA

Background: In the assertive community treatment (ACT) model, the psychiatrist's role on the team has been considered a critical one. Recently, some observers have suggested that the psychiatrist role as medication prescriber could be filled with a nurse-practitioner. Methods: Using surveys, interviews, and assessments of program fidelity, we examined the relative effectiveness of nurse-practitioner as prescriber, comparing two ACT teams, one employing a psychiatrist and the other a nurse-practitioner. Findings: At the organizational level, the ACT team with a nursepractitioner (ACT-NP) had substantially better fidelity to evidence-based medication management standards than did the ACT team with a psychiatrist (ACT-Md) whereas both teams had low fidelity to medication management standards at the level of the individual prescriber (although similar to average fidelity in a national sample of mental health-center psychiatrists). Prescriber interviews revealed that the psychiatrist and nurse-practitioner had similar views regarding the roles of the prescriber, team, and consumer in medication management. Both teams reported high levels of team cohesion, indicating a positive organizational climate. Consumers served by an ACT-Md reported significantly higher satisfaction with their medication prescriber than did consumers served by an ACT-NP;however, because the nurse-practitioner on the ACT-NP served a dual role as both prescriber and team leader, the ability to draw substantive conclusions from these findings is limited. Conclusions: While this study did not demonstrate a decisive advantage for either team in providing quality services, neither did it reveal any evidence against substituting a nurse-practitioner for a psychiatrist as medication prescriber on ACT teams. We therefore recommend further exploration of the nurse-practitioner option.

关键词： Assertive community treatment Fidelity scales Medication management Nurse practitioner Prescriber privileges

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Computerized Medication Alerts and Prescriber Mental Models: Observing Routine Patient Care

Computerized Medication Alerts and Prescriber Mental Models:...

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53rd Human Factors and Ergonomics Society Annual Meeting 2009, HFES 2009

作者： Russ, Alissa L. Saleem, Jason J. McManus, M. Sue Zillich, Alan J. doebbeling, Bradley N. VA HSR and D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis IN United States Center for Health Services and Outcomes Research Regenstrief Institute Inc. Indianapolis IN United States Department of Electrical and Computer Engineering IUPUI Indianapolis IN United States Department of Nephrology Roudebush VAMC Indianapolis IN United States Purdue University School of Pharmacy Department of Pharmacy Practice West Lafayette IN United States Department of Medicine IU School of Medicine Indianapolis IN United States

ISBN: (纸本)9781615676231

关键词： drug interactions

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Healthcare workers' perceptions of information in the electronic health record

Healthcare workers' perceptions of information in the electr...

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53rd Human Factors and Ergonomics Society Annual Meeting 2009, HFES 2009

作者： Russ, Alissa L. Saleem, Jason J. Justice, Connie F. Hagg, Heather Woodbridge, Peter A. doebbeling, Bradley N. VA HSR and D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis IN United States Center for Health Services and Outcomes Research Regenstrief Institute Indianapolis IN United States Department of Electrical and Computer Engineering IUPUI Indianapolis IN United States Department of Computer Information Technology IUPUI Indianapolis IN United States VA Nebraska Western Iowa Heath Care System Omaha NE United States University of Nebraska Medical Center College of Public Health Omaha NE United States Department of Medicine IU School of Medicine Indianapolis IN United States

ISBN: (纸本)9781615676231

Electronic health record (EHR) systems and health information technology (IT) hold unrealized potential for improving the quality, continuity, and safety of medical care;they can also introduce new gaps in care and present unique challenges for healthcare workers. We conducted 14 key informant, semi-structured interviews at a large Veterans Affairs Medical center and asked healthcare employees why paper use persists despite a fully implemented EHR. In this investigation, we performed a secondary analysis on interview data to identify characteristics of information technology (IT) that are important to support healthcare workflow. As a result of this study, 17 distinct information characteristics emerged;in this document, we provide detail on five characteristics that were often cited as desirable for workflow but insufficiently supported by health IT: 1) customizable, 2) prioritized, 3) trendable, 4) locatable, and 5) accessible. Results from this study reveal key electronic information characteristics for healthcare workflow and have implications for patient safety and future health IT designs.

关键词： Records management

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Barriers and Facilitators in implementing Illness Management and Recovery for Consumers with Severe Mental Illness: Trainee Perspectives

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AdMINISTRATION ANd POLICY IN MENTAL HEALTH ANd MENTAL HEALTH SERVICES RESEARCH 2009年第2期36卷 102-111页

作者： Salyers, Michelle P. Rollins, Angela L. McGuire, Alan B. Gearhart, Tim ACT Ctr Indiana Indianapolis IN USA Roudebush VAMC VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN 46202 USA Indiana Univ Purdue Univ Dept Psychol Indianapolis IN 46205 USA Regenstrief Inst Inc IU Ctr Hlth Serv & Outcomes Res Indianapolis IN 46202 USA

We conducted an on-line survey of clinicians who attended training on illness management and recovery (IMR) to identify the extent of implementation and barriers and facilitators of IMR practice. Of 89 direct service providers, 50.6% reported using the formal IMR curriculum, 25.8% reported using parts of IMR, and 23.6% never used IMR following training. Factor analysis of facilitator items revealed three internally consistent factors: agency leadership support, program level structure, and job-related structural support. Participants who used formal IMR endorsed a greater percentage of overall facilitators, and scored higher on each of the three factors of agency leadership support, program-level structures (e.g., fidelity reports) and job-related structures (e.g., presence of weekly supervision). In addition to training and toolkit materials, attention needs to be given to other elements to support IMR implementation.

关键词： Implementation Recovery Facilitators

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