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Integrating depression Care: The Time Has Come

JOURNAL OF GENERAL INTERNAL MEdICINE 2013年第3期28卷 333-335页

作者： Kroenke, Kurt Roudebush VA Med Ctr VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN USA Indiana Univ Dept Med Indianapolis IN USA Regenstrief Inst Inc Indianapolis IN USA

The Veterans Health Administration (VHA) has been an excellent health care system in which to implement and evaluate new models of integrating depression care. A single payer providing comprehensive medical and mental health services for eligible beneficiaries, a commitment to the parity of mental with medical disorders, an investment in mental health resources, and a nationwide electronic medical record all reduce some of the barriers that commonly exist in other practice settings. Also, primary care has received extra attention, including routine depression screening (97 % of eligible patients received depression screening in 2010) and the funding of additional mental health resources embedded in primary care. This issue of JGIM includes two reports on the VHA track record of integrating depression care.

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Investigating the Role of Ischemia vs. Elevated Hydrostatic Pressure Associated with Acute Obstructive Uropathy

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ANNALS OF BIOMEdICAL ENGINEERING 2009年第7期37卷 1415-1424页

作者： Russ, Alissa L. dadarlat, Iunia A. Haberstroh, Karen M. Rundell, Ann E. Purdue Univ Weldon Sch Biomed Engn W Lafayette IN 47907 USA Roudebush VAMC VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN USA Brown Univ Div Engn Providence RI 02912 USA

Obstructive uropathy can cause irreversible renal damage. It has been hypothesized that elevated hydrostatic pressure within renal tubules and/or renal ischemia contributes to cellular injury following obstruction. However, these assaults are essentially impossible to isolate in vivo. Therefore, we developed a novel pressure system to evaluate the isolated and coordinated effects of elevated hydrostatic pressure and ischemic insults on renal cells in vitro. Cells were subjected to: (1) elevated hydrostatic pressure (80 cm H2O);(2) ischemic insults (hypoxia (0% O-2), hypercapnia (20% CO2), and 0 mM glucose media);and (3) elevated pressure + ischemic insults. Cellular responses including cell density, lactate dehydrogenase (LdH) release, and intracellular LdH (LdHi), were recorded after 24 h of insult and following recovery. data were analyzed to assess the primary effects of ischemic insults and elevated pressure. Unlike pressure, ischemic insults exerted a primary effect on nearly all response measurements. We also evaluated the data for insult interactions and identified significant interactions between ischemic insults and pressure. Altogether, findings indicate that pressure may sub-lethally effect cells and alter cellular metabolism (LdHi) and membrane properties. Results suggest that renal ischemia may be the primary, but not the sole, cause of cellular injury induced by obstructive uropathy.

关键词： Kidney tubules proximal LLC-PK1 cells Pressure system In vitro

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On Improving Provider decision Making with Enhanced Computerized Clinical Reminders

On Improving Provider Decision Making with Enhanced Computer...

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2nd International Conference on digital Human Modeling held at the HCI International 2009

作者： Wu, Sze-jung Lehto, Mark Yih, Yuehwern Saleem, Jason J. doebbeling, Bradley Purdue Univ Sch Ind Engn W Lafayette IN 47906 USA Richard L Roudebush Vet Affairs Med Ctr VA HSR&D Ctr Implementing Evidence based Practice Indianapolis IN 46202 USA

ISBN: (纸本)9783642028083

A computerized clinical reminder (CCR) system is a type of decision support tool to remind healthcare providers of recommended actions. In our prior Study, we found a linear correlation between resolution time and adherence rate. This correlation implies a potentially biased clinical decision making. This study aimed to redesign the Veterans Affairs (va) CCR system in order to improve providers' situation awareness and decision quality. The CCR redesign incorporated a knowledge-based risk factor repository and a prioritization mechanism. Both CCR designs were prototyped and tested by 16 physicians in a controlled lab in the Indianapolis va Medical center. The results showed that 80% of the subjects changed their prioritization decisions after being introduced to the modified design. Moreover, with the modified design, the correlation between resolution time and adherence rate was no longer found. The redesign improved the subjects' situation awareness and assisted them in making more informed decisions.

关键词： Computerized clinical reminders decision Support system situation awareness

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The Patient-Provider Relationship in Chronic Pain Management: Where do We Go From Here?

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PAIN MEdICINE 2010年第12期11卷 1747-1749页

作者： Matthias, Marianne S. Bair, Matthew J. Richard L Roudebush Vet Affairs Med Ctr VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN 46202 USA Indiana Univ Purdue Univ Indianapolis Dept Commun Studies Indianapolis IN USA Indiana Univ Dept Med Bloomington IN 47405 USA

The authors reflect on the study concerning the views of the patients for management and primary care of chronic pain. The authors mention that the study heightens the knowledge of the patients on the troubles associated to chronic pain care. The authors state that the primary care patients determined the negative as well as positive prospects of their relations with the primary care providers. Moreover, the authors say that the study exhibits the problems in patient-provider communication.

关键词： PAIN management CHRONIC pain PRIMARY care (Medicine) MEdICAL care

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Recovery Orientation in Hospital and Community Settings

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JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH 2010年第3期37卷 385-399页

作者： Tsai, Jack Salyers, Michelle P. Indiana Univ Purdue Univ Dept Psychol Indianapolis IN 46202 USA Roudebush VA Med Ctr ACT Ctr Indiana Indianapolis IN USA Roudebush VA Med Ctr Regenstrief Inst Inc Roudebush VAMC & IU Ctr Hlth Serv & Outcomes Res VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN USA

There has been an increasing emphasis on community integration, consumer involvement, and recovery-focused treatment;but the extent to which these recovery-oriented principles have been adopted in state hospitals is unknown. This study surveyed 1,150 staff at three state hospitals and 230 staff at four community mental health centers on personal optimism, consumer optimism, and agency recovery orientation. Responses were obtained from 729 (63.4%) hospital staff and 181 (78.7%) community staff. Staff at state hospitals scored significantly lower on all three recovery measures even after controlling for background differences. Treatment setting may be an important factor in the dissemination of recovery-oriented care principles.

关键词： state hospital recovery optimism community mental health centers

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A Novel Tool to Track and Analyze Qualitative Usability data: Lessons Learned from the va's Personal Health Record

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Proceedings of the Human Factors and Ergonomics Society Annual Meeting 2010年第16期54卷 1264 - 1268页

作者： Scott A. Russell Jason J. Saleem david A. Haggstrom Alissa L. Russ Neale R. Chumbler VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis IN VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis INIndiana University (IU) Center for Health Services & Outcomes Research Regenstrief Institute Inc. VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis INIndiana University (IU) Center for Health Services & Outcomes Research Regenstrief Institute Inc.Department of Medicine IU School of Medicine Indianapolis IN VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis INDepartment of Sociology IU School of Liberal Arts Indianapolis IN.

We developed a User-Testing database to be able to process a greater amount of user data, from multiple sources of data, at a much finer level of granularity, and to be able to aid in a more sophisticated analysis, including specific queries of usability data than a typical “manual”-based usability analysis. In this paper, we demonstrate our User-Testing database as applied to a usability assessment of the Veterans Affairs (va) My HealtheVet personal health record. The usability test included 24 Veterans who completed a series of scenarios in the usability lab at a Midwest Veterans Affairs Medical center (vaMC). The User-Testing database facilitated reduction of data gathered from video review, facilitator notes, and debrief notes into 1160 observations that were sorted into conceptual bins and summarized for the designers of the personal health record. From creation of the database to completion of the reports took four months and did not require extensive knowledge of qualitative analysis techniques. We argue a User-Testing database can allow other usability studies to increase the number of participants and the granularity of the data without prohibitively increasing the amount of time and experience required to process the data gathered.

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The Workflow of Computerized Medication Ordering in Primary Care is Not Prescriptive

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Proceedings of the Human Factors and Ergonomics Society Annual Meeting 2010年第12期54卷 840 - 844页

作者： Alissa L. Russ Jason J. Saleem M. Sue McManus Richard M. Frankel Alan J. Zillich VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis INIndiana University (IU) Center for Health Services & Outcomes Research Indianapolis IN VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis INDepartment of Electrical & Computer Engineering IUPUI Indianapolis IN Department of Nephrology Roudebush VAMC Indianapolis IN VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis INIndiana University (IU) Center for Health Services & Outcomes Research Indianapolis INDepartment of Medicine IU School of Medicine Indianapolis IN VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis INIndiana University (IU) Center for Health Services & Outcomes Research Indianapolis INPurdue University School of Pharmacy Department of Pharmacy Practice West Lafayette IN.

While the potential benefits of computerized provider order entry (CPOE) are well recognized, little is known about how prescribers have integrated electronic medication ordering into other aspects of patient care. As part of a larger investigation of computerized medication alerts, we observed and opportunistically interviewed 20 primary care prescribers at a major Veterans Affairs Medical center (vaMC). Participants were recruited from each of the vaMC's 5 primary care clinics and included physicians, nurse practitioners, and clinical pharmacists. Prescribers were observed as they ordered mediations via the CPOE system during routine patient care. In total, observations included 91 routine patient encounters across 66.5 hrs of observation. This paper provides illustrative case examples of how prescribers have integrated CPOE into medication decision-making processes and other patient care tasks. Results demonstrate that CPOE workflow varies widely among prescribers. In addition, results indicate that there are trade-offs associated with using CPOE with the patient in the exam room versus outside of the exam room. Findings may have implications for provider-patient relationships, workflow efficiency, and medication safety, and may ultimately enhance the effectiveness of CPOE in primary care.

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Paper Use with the Electronic Medical Record: An Important Supplement or Negative Circumvention?

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Proceedings of the Human Factors and Ergonomics Society Annual Meeting 2008年第12期52卷 773 - 777页

作者： Jason J. Saleem Alissa L. Russ Connie F. Justice Heather Hagg Peter A. Woodbridge Bradley N. doebbeling VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis IN；Department of Electrical & Computer Engineering IUPUI 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.； 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.；Department of Computer Information Technology IUPUI Indianapolis IN； VA HSR&D Center on Implementing Evidence-Based Practice 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.；Department of Medicine IU School of Medicine Indianapolis IN.

Healthcare organizations are increasingly implementing electronic medical records (EMRs) and other related health information technology (IT). Even in institutions which have long adopted these computerized systems, there are still instances where employees rely on paper to complete their work. The use of paper suggests that parts of the EMR may not be sufficiently designed to support clinicians and their work processes. To understand the use of paper-based alternatives, we conducted 14 key-informant interviews in a large Veterans Affairs Medical center (vaMC), with a fully implemented EMR. We found nine distinct categories of paper-based workarounds to the use of the EMR. In several cases, paper served as an important tool and assisted healthcare employees in their work. In other cases, paper use circumvented the intended EMR design, introduced potential gaps in documentation, and generated possible paths to medical error. We discuss implications of these findings for EMR design and implementation.

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Paper persistence, workarounds, and communication breakdowns in computerized consultation management

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INTERNATIONAL JOURNAL OF MEdICAL INFORMATICS 2011年第7期80卷 466-479页

作者： Saleem, Jason J. Russ, Alissa L. Neddo, Adam Blades, Paul T. doebbeling, Bradley N. Foresman, Brian H. Roudebush VA Med Ctr VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN USA Regenstrief Inst Inc Indianapolis IN USA Indiana Univ Ctr Hlth Serv & Outcomes Res Indianapolis IN 46204 USA IUPUI Dept Elect & Comp Engn Indianapolis IN USA Purdue Univ Coll Pharm Dept Pharm Practice W Lafayette IN 47907 USA Roudebush VA Med Ctr Sleep Med Program Indianapolis IN USA IU Sch Med Dept Med Indianapolis IN USA

Objective: The consultation request process between primary care and specialty services often contains paper-based components that may be inefficient and difficult to track. Other barriers may include workarounds and communication breakdowns with the potential to adversely impact delivery of quality medical care. We investigated current challenges to the electronic outpatient consult management process in the United States Veterans Health Administration (VHA). design: We conducted ethnographic observation and semi-structured interviews in nine different specialty clinics and three primary care clinics in a large, tertiary Veterans Affairs Medical center (vaMC). We also performed a national-level query of 'electronic error and enhancement requests' (E3Rs) related to the consult package in the va's electronic health record (EHR) submitted over a 5-year period (2005-2009). Measurements: Two researchers recorded the observable interactions and interview responses of 16 healthcare workers related to their work with consultations. Two separate coding schemes were applied to both the observational and the interview data. E3Rs from the national query were reviewed and categorized based on the nature of the enhancement requests. Results: We identified several examples of paper persistence, as well as workarounds, communication breakdowns, and redundancies in computerized consult management. An analysis of enhancement requests for the consults also revealed three broad needs related to reporting, configuration or customization, and user interface enhancements. Conclusion: Understanding these challenges to the current consult management process is important to help design enhanced informatics tools integrated into workflow to support coordination of care and tracking of consults requests. Published by Elsevier Ireland Ltd

关键词： Workarounds Electronic health records [MeSH] Computerized medical record [MeSH] Consultation and referral [MeSH] Human information processing [MeSH]

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"There's More to This Pain Than Just Pain": How Patients' Understanding of Pain Evolved during a Randomized Controlled Trial for Chronic Pain

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JOURNAL OF PAIN 2012年第6期13卷 571-578页

作者： Matthias, Marianne S. Miech, Edward J. Myers, Laura J. Sargent, Christy Bair, Matthew J. Roudebush VA Med Ctr VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN USA Regenstrief Inst Inc Indianapolis IN USA Indiana Univ Purdue Univ Dept Commun Studies Indianapolis IN 46202 USA Indiana Univ Sch Med Dept Emergency Med Indianapolis IN USA Indiana Univ Sch Med Dept Med Indianapolis IN USA

Chronic pain is prevalent, is costly, and exerts an emotional toll on patients and providers. Little is known about chronic pain in veterans of the recent military conflicts in Afghanistan and Iraq (OEF/OIF/ONd [Operation Enduring Freedom/Operation Iraqi Freedom/Operation New dawn] veterans). This study's objective was to ascertain veterans' perceptions of a multicomponent intervention tested in a randomized controlled trial for OEF/OIF/ONd veterans with chronic musculoskeletal pain (ESCAPE: Evaluation of Stepped Care for Chronic Pain). Qualitative interviews were conducted with patients in the intervention arm of ESCAPE. Questions related to veterans' experiences with trial components, overall perceptions of the intervention, strengths, and suggestions for improvement. Twenty-six veterans (21% of total intervention patients) participated. Patients were purposefully sampled to include treatment responders (defined as >= 30% reduction in pain-related disability or pain severity) and non-responders. Non-completers (completed <50% of the trial) were also sampled. Qualitative analysis was guided by grounded theory, using constant comparative methodology. Both responders and non-responders spoke about their evolving understanding of their pain experience during the trial, and how this new understanding helped them to manage their pain more effectively. This evolution is reported under 2 themes: 1) learning to recognize physical and psychosocial factors related to pain;and 2) learning to manage pain through actions and thoughts. Perspective: Responders and non-responders both described making connections between their pain and other factors in their lives, and how these connections positively influenced how they managed their pain. Traditional quantitative measures of response to pain interventions may not capture the full benefits that patients report experiencing. Published by Elsevier Inc. on behalf of the American Pain Society

关键词： Chronic pain self-management qualitative research veterans randomized controlled trial

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