OBJECTIVE To explore whether a home-based intermediate care program in a large Canadian city lowe... more OBJECTIVE To explore whether a home-based intermediate care program in a large Canadian city lowers the cost of care and to look at whether such home-based programs could be a solution to the increasing demands on Canadian hospitals. DESIGN Single-arm study with historical controls. SETTING Department of Family Medicine at the Ottawa Hospital (Civic campus) in Ontario. PARTICIPANTS Patients requiring hospitalization for acute care. Participants were matched with historical controls based on case-mix, most responsible diagnosis, and level of complexity. INTERVENTIONS Placement in the home-based intermediate care program. Daily home visits from the nurse practitioner and 24-hour access to care by telephone. MAIN OUTCOME MEASURES Multivariate regression models were used to estimate the effect of the program on 5 outcomes: length of stay in hospital, cost of care substituted for hospitalization (Canadian dollars), readmission for a related diagnosis, readmission for any diagnosis, and c...
Canadian family physician Medecin de famille canadien, 2020
Electronic health records (EHRs) are becoming increasingly popular and their potential value is r... more Electronic health records (EHRs) are becoming increasingly popular and their potential value is recognized internationally.[1][1] In a recent survey of 788 family physicians across all Canadian provinces, 97.5% of the respondents reported using computers in their practices, and 67.5% reported using
ABSTRACT Context: Electronic Health Records (EHRs) are critical in the provision and documentatio... more ABSTRACT Context: Electronic Health Records (EHRs) are critical in the provision and documentation of primary health care. However, many care providers complain about the usability of the EHR software. Poor usability can often lead to poor quality of care and degraded patient safety. Objective: Empirically test the usability of EHR by observing physicians use it during patient encounter. Design and setting: An empirical usability test detects issues in a product by having real users interact with it in a realistic context (i.e. simulated doctor-patient interactions). Common practices with the EHR were assessed in four scenarios including interactions between the test participants and a simulated patient. All sessions were conducted between Spring 2012 and January 2013 in a regular clinic exam room of a large family medicine “paperless” teaching clinic with an EHR installed in 2007. There were eight participants, each of whom was a practicing and experienced physician in that clinic. Throughout each one hour session they were asked to “think aloud” and report what they were doing or trying to do and bring to attention any problems or concerns they were having. Results: Preliminary findings include: 1. Insufficient support for effective and efficient navigation and workflow in the system; 2. Difficulty in following and reaching some previous patient encounters; 3. Poor support in managing medications effectively; 4. Lengthy learning process; 5. Overall inefficient use (e.g., too many clicks to do something); 6. Inadequate means or mechanisms to support communication and collaboration between physicians; and 7. Insufficient automation allowing the physician to interact more with the patient. Conclusions: The poor usability of the system makes it harder for the physician to interact adequately with the patient while using the system. Redesign of key features in the EHR can improve encounter effectiveness and efficiency, and contribute to quality and safety of primary health care.
ABSTRACT Context: Family medicine in Canada is undergoing major change as a result of the College... more ABSTRACT Context: Family medicine in Canada is undergoing major change as a result of the College Family Physicians of Canada having initiated a competency-based, triple-C curriculum with new accreditation standards for the post graduate training programs. The Department of Family Medicine of University of Ottawa (DFM) has responded by developing a new “In Training Evaluation Report” (ITER) for assessing residents in our core family medicine rotation. The assessment is based on using a series of observable benchmarks to determine the progress in acquiring competencies. The process of determining the benchmarks to be used, developing consensus, as well as determining an “action-oriented” assessment scale is described. The following steps then required translation of the concepts into a usable form and both piloting and implementing it. Design: We have taken a conceptual approach to validating the ITER under one overarching framework of construct validity which has been used in the field of education measurement. Throughout the development and field testing of the ITER we have been systematic in collecting validity evidence from a number of sources. Results to Date: 1) Three DFM retreats from May 2012, seeking feedback from educational leaders and residents; 2) Informal discussion with the resident population; 3) On-site curriculum and evaluation consultation by the leadership team visiting each of the seven units and encompassing 37 full-time faculty as well as separate meeting with 12 community preceptors; 4) Intensive review by both the educational leaders (PG Executive) and Evaluation Advisory groups; 5) Piloting the forms in a select group of community-based, and two small units with an evaluation to commence in April 2013; and 6) Full-scale implementation in July 2013. Future Directions: As this is a work-in-progress, this poster describes the process of determining and validating the benchmarks through to the results of the forthcoming pilot of the evaluation. Results of the pilot will be shared in November.
ABSTRACT Context or setting: The uOttawa Department of Family Medicine (DFM) postgraduate program... more ABSTRACT Context or setting: The uOttawa Department of Family Medicine (DFM) postgraduate program has constructed a “Field Note” for documenting a preceptor’s feedback to a resident and categorizing in reference to curriculum domains, CanMEDS roles and other frameworks. The notes can be aggregated to develop a graphical approach to resident educational experience. This poster describes the approach to ensuring face and content validity as well as acceptability of the tool for use by residents and preceptors. Why the innovation was undertaken: The steps taken to ensure validity include: 1) three DFM retreats in 1 year, seeking feedback from educational leaders and some residents; 2) focus groups with 30% of the resident population; 3) preceptor survey assessing feedback behaviour prior to and after implementation of the tool; 4) on-site curriculum and evaluation consultation by the leadership team visiting each unit, encompassing ~85% of full-time faculty and 5) planned quantitative assessment of written feedback forms over a three year window. What was done: Self-reported feedback behaviour of 28 rural and urban preceptors was surveyed prior to implementing a field note. Oral feedback was used over 90% of the time. Completing in-training evaluation reports (ITERs) was supported by written documentation in only 15% of preceptors. Seven urban preceptors were re-surveyed 2-3 months after implementation. All preceptors assessed usefulness and usability of the field note positively and five were providing written feedback more than 50% of the time. All were using written documentation to complete ITERs. Brief evaluation of the innovation and/or its impact: We believe that we have demonstrated behavioural change amongst our faculty and successful implementation and utilization of a field note tool that can be effectively used for documenting preceptor feedback.
ABSTRACT PURPOSE: The title of this pilot project was taken from an article written by Eric Berge... more ABSTRACT PURPOSE: The title of this pilot project was taken from an article written by Eric Berger titled The iPad: Gadget or Medical Godsend? He notes that since the inception of the iPad tablet computer in 2010 a debate has begun about whether the iPad is a high end toy or the, “ vanguard of portable computing that will one day rule the clinical setting” (Berger, 2010, p. 21A). The purpose of this innovative pilot is to explore the use of tablet computers to support and enhance effective teaching and learning in a rural community clinical teaching environment. METHODS: Preceptors and residents were given tablet computers at a half-day workshop with links to the University of Ottawa’s revised family medicine curriculum, resources (including medical and general applications), and evaluation tools. Use of the tablets is being tracked and feedback from the participants is being collected on an ongoing basis. Data are being collected based on observations, field notes (using notes and voice recorder apps), semi-structured interviews, and a pre-test/post-test survey. RESULTS AND CONCLUSIONS: Preliminary findings from pilot will be shared to indicate how preceptors and residents are using their tablets for clinical teaching and learning.
ABSTRACT Family medicine programs have been designed with the appropriate assumption of success a... more ABSTRACT Family medicine programs have been designed with the appropriate assumption of success and all are now evolving to incorporate new Triple C curricula that are based on acquisition of competencies. However, based on personal experience and communications, about 10% of residents fail to achieve adequate competency in one or more domains during training. These residents typically require extension of specific experiences, and often the residency period, with learning plans, remediation, and occasionally probation. Though each challenged resident is unique, the process of managing each, being cautious with precedence-setting, and ensuring fairness and patient safety, is enormously complex and time-consuming. The “unsatisfactory” resident and associated faculty experience a tremendous emotional toll. There are also substantial personal and institutional costs to extending a residency. A survey of the evaluation/assessment policies at all of Canada’s FM programs will be presented and a workshop on designing and ensuring effective mechanisms to support resident success will be discussed
ABSTRACT Purpose The tablet computer has the potential to impact the way physicians practice medi... more ABSTRACT Purpose The tablet computer has the potential to impact the way physicians practice medicine. However, its potential role has not yet been sufficiently assessed. The purpose of this pilot project was twofold. First, was to evaluate the extent to which family medicine and specialist preceptors teaching family medicine residents and their residents at a rural clinical teaching site use tablet computers; and second, to evaluate the extent to which the participants accessed other resources through their iPad in an effort to support and enhance effective teaching and learning. Methods Each participating preceptor and resident was given an iPad pre-loaded with revised Family Medicine curriculum and various selected medical applications (apps). In addition to the introductory workshop the lead evaluator of the pilot and other experienced iPad users met periodically with the participants over an eight month period to provide support and training sessions on the iPad. Formal feedback was received through a validated survey and focus group sessions after 4 and 8 months. Results Five residents and 21 preceptors have participated in the study. The final emerging themes include: curriculum and assessment issues; access and ease of use, portability, useful apps and resources, functionality, security and support. Conclusions It is worthwhile pursuing the tablet as a teaching tool. Therefore, the findings from the pilot will be used to inform future use of tablet computers for clinical teaching within the University of Ottawa, Department of Family Medicine.
ABSTRACT PURPOSE OF STUDY: To identify areas of greatest needs for continuing medical education (... more ABSTRACT PURPOSE OF STUDY: To identify areas of greatest needs for continuing medical education (CME) in primary care by conducting a secondary analysis of 1,889 point-of-care questions asked by primary care practitioners in the context of their clinical practices. The questions were generated by 88 clinicians participating in the Just-in-Time Information (JIT) project, a randomized controlled trial that demonstrated the feasibility of an online medical librarian consultation service to answer point-of-care questions asked by primary care practitioners. Participants asked questions in the course of their daily patient consultations and submitted them using a handheld device (Blackberry™). These questions were answered in less than 15 minutes by a medical librarian consultation service, which enabled the practitioner to use the answer in the patient encounter. METHODS: The study design will be secondary analysis of the JIT database of questions using quantitative content analysis methods. Word frequency analyses will be conducted and will be classified using two classification schemes (question-type-based vs. system-based). Interrater reliability will be assessed by having a sample of questions (n=400) classified by two additional independent reviewers. The two reviewers’ results will be compared and differences resolved by consensus. RESULTS: CME recommendations based on the frequency and content of the questions
ABSTRACT Context: Yearly more than fifty faculty interview more than 500 candidates for the uOtta... more ABSTRACT Context: Yearly more than fifty faculty interview more than 500 candidates for the uOttawa Department of Family Medicine’s 60 residency positions. This year (2013) in an ongoing effort to improve the standardization of the half hour semi-structured interviews entrance interviews the Department changed its scoring system to provide better guidance to faculty. Postgraduate leaders re-defined the competencies sought in candidates, and created new interview questions based on these competencies along with a standardized scoring rubric. We hypothesize that some faculty might be either particularly “hard” or “easy” interviewers, and that changing to standardized scoring tools would normalize the interview scores overall in comparison to previous years. Methods: In this descriptive cross-sectional, retrospective study, previous data were collected from the Department’s 2011-13 de-identified candidate rank lists and interview scores. Possible “hard” and “easy” raters were characterized by determining each faculty interviewers’ mean scores, and determining whether each interviewer differed statistically from the mean of means for all interviewers. Results: Preliminary results show 521 final year candidates were interviewed by 54 faculty members over four days in January and February 2013. Faculty interviewers were coded and de-identified, and mean interview scores (and standard deviations) were determined. Faculty were ranked based on their mean scores. After the instrument change all but four faculty members were within one standard deviation of the mean. Data from 2013 will be compared to the two years prior to the change. Conclusions: It is anticipated that the Department’s standardized interview is a more objective method for evaluating prospective residents. By using a standardized interview, a candidate’s in
OBJECTIVE To explore whether a home-based intermediate care program in a large Canadian city lowe... more OBJECTIVE To explore whether a home-based intermediate care program in a large Canadian city lowers the cost of care and to look at whether such home-based programs could be a solution to the increasing demands on Canadian hospitals. DESIGN Single-arm study with historical controls. SETTING Department of Family Medicine at the Ottawa Hospital (Civic campus) in Ontario. PARTICIPANTS Patients requiring hospitalization for acute care. Participants were matched with historical controls based on case-mix, most responsible diagnosis, and level of complexity. INTERVENTIONS Placement in the home-based intermediate care program. Daily home visits from the nurse practitioner and 24-hour access to care by telephone. MAIN OUTCOME MEASURES Multivariate regression models were used to estimate the effect of the program on 5 outcomes: length of stay in hospital, cost of care substituted for hospitalization (Canadian dollars), readmission for a related diagnosis, readmission for any diagnosis, and c...
Canadian family physician Medecin de famille canadien, 2020
Electronic health records (EHRs) are becoming increasingly popular and their potential value is r... more Electronic health records (EHRs) are becoming increasingly popular and their potential value is recognized internationally.[1][1] In a recent survey of 788 family physicians across all Canadian provinces, 97.5% of the respondents reported using computers in their practices, and 67.5% reported using
ABSTRACT Context: Electronic Health Records (EHRs) are critical in the provision and documentatio... more ABSTRACT Context: Electronic Health Records (EHRs) are critical in the provision and documentation of primary health care. However, many care providers complain about the usability of the EHR software. Poor usability can often lead to poor quality of care and degraded patient safety. Objective: Empirically test the usability of EHR by observing physicians use it during patient encounter. Design and setting: An empirical usability test detects issues in a product by having real users interact with it in a realistic context (i.e. simulated doctor-patient interactions). Common practices with the EHR were assessed in four scenarios including interactions between the test participants and a simulated patient. All sessions were conducted between Spring 2012 and January 2013 in a regular clinic exam room of a large family medicine “paperless” teaching clinic with an EHR installed in 2007. There were eight participants, each of whom was a practicing and experienced physician in that clinic. Throughout each one hour session they were asked to “think aloud” and report what they were doing or trying to do and bring to attention any problems or concerns they were having. Results: Preliminary findings include: 1. Insufficient support for effective and efficient navigation and workflow in the system; 2. Difficulty in following and reaching some previous patient encounters; 3. Poor support in managing medications effectively; 4. Lengthy learning process; 5. Overall inefficient use (e.g., too many clicks to do something); 6. Inadequate means or mechanisms to support communication and collaboration between physicians; and 7. Insufficient automation allowing the physician to interact more with the patient. Conclusions: The poor usability of the system makes it harder for the physician to interact adequately with the patient while using the system. Redesign of key features in the EHR can improve encounter effectiveness and efficiency, and contribute to quality and safety of primary health care.
ABSTRACT Context: Family medicine in Canada is undergoing major change as a result of the College... more ABSTRACT Context: Family medicine in Canada is undergoing major change as a result of the College Family Physicians of Canada having initiated a competency-based, triple-C curriculum with new accreditation standards for the post graduate training programs. The Department of Family Medicine of University of Ottawa (DFM) has responded by developing a new “In Training Evaluation Report” (ITER) for assessing residents in our core family medicine rotation. The assessment is based on using a series of observable benchmarks to determine the progress in acquiring competencies. The process of determining the benchmarks to be used, developing consensus, as well as determining an “action-oriented” assessment scale is described. The following steps then required translation of the concepts into a usable form and both piloting and implementing it. Design: We have taken a conceptual approach to validating the ITER under one overarching framework of construct validity which has been used in the field of education measurement. Throughout the development and field testing of the ITER we have been systematic in collecting validity evidence from a number of sources. Results to Date: 1) Three DFM retreats from May 2012, seeking feedback from educational leaders and residents; 2) Informal discussion with the resident population; 3) On-site curriculum and evaluation consultation by the leadership team visiting each of the seven units and encompassing 37 full-time faculty as well as separate meeting with 12 community preceptors; 4) Intensive review by both the educational leaders (PG Executive) and Evaluation Advisory groups; 5) Piloting the forms in a select group of community-based, and two small units with an evaluation to commence in April 2013; and 6) Full-scale implementation in July 2013. Future Directions: As this is a work-in-progress, this poster describes the process of determining and validating the benchmarks through to the results of the forthcoming pilot of the evaluation. Results of the pilot will be shared in November.
ABSTRACT Context or setting: The uOttawa Department of Family Medicine (DFM) postgraduate program... more ABSTRACT Context or setting: The uOttawa Department of Family Medicine (DFM) postgraduate program has constructed a “Field Note” for documenting a preceptor’s feedback to a resident and categorizing in reference to curriculum domains, CanMEDS roles and other frameworks. The notes can be aggregated to develop a graphical approach to resident educational experience. This poster describes the approach to ensuring face and content validity as well as acceptability of the tool for use by residents and preceptors. Why the innovation was undertaken: The steps taken to ensure validity include: 1) three DFM retreats in 1 year, seeking feedback from educational leaders and some residents; 2) focus groups with 30% of the resident population; 3) preceptor survey assessing feedback behaviour prior to and after implementation of the tool; 4) on-site curriculum and evaluation consultation by the leadership team visiting each unit, encompassing ~85% of full-time faculty and 5) planned quantitative assessment of written feedback forms over a three year window. What was done: Self-reported feedback behaviour of 28 rural and urban preceptors was surveyed prior to implementing a field note. Oral feedback was used over 90% of the time. Completing in-training evaluation reports (ITERs) was supported by written documentation in only 15% of preceptors. Seven urban preceptors were re-surveyed 2-3 months after implementation. All preceptors assessed usefulness and usability of the field note positively and five were providing written feedback more than 50% of the time. All were using written documentation to complete ITERs. Brief evaluation of the innovation and/or its impact: We believe that we have demonstrated behavioural change amongst our faculty and successful implementation and utilization of a field note tool that can be effectively used for documenting preceptor feedback.
ABSTRACT PURPOSE: The title of this pilot project was taken from an article written by Eric Berge... more ABSTRACT PURPOSE: The title of this pilot project was taken from an article written by Eric Berger titled The iPad: Gadget or Medical Godsend? He notes that since the inception of the iPad tablet computer in 2010 a debate has begun about whether the iPad is a high end toy or the, “ vanguard of portable computing that will one day rule the clinical setting” (Berger, 2010, p. 21A). The purpose of this innovative pilot is to explore the use of tablet computers to support and enhance effective teaching and learning in a rural community clinical teaching environment. METHODS: Preceptors and residents were given tablet computers at a half-day workshop with links to the University of Ottawa’s revised family medicine curriculum, resources (including medical and general applications), and evaluation tools. Use of the tablets is being tracked and feedback from the participants is being collected on an ongoing basis. Data are being collected based on observations, field notes (using notes and voice recorder apps), semi-structured interviews, and a pre-test/post-test survey. RESULTS AND CONCLUSIONS: Preliminary findings from pilot will be shared to indicate how preceptors and residents are using their tablets for clinical teaching and learning.
ABSTRACT Family medicine programs have been designed with the appropriate assumption of success a... more ABSTRACT Family medicine programs have been designed with the appropriate assumption of success and all are now evolving to incorporate new Triple C curricula that are based on acquisition of competencies. However, based on personal experience and communications, about 10% of residents fail to achieve adequate competency in one or more domains during training. These residents typically require extension of specific experiences, and often the residency period, with learning plans, remediation, and occasionally probation. Though each challenged resident is unique, the process of managing each, being cautious with precedence-setting, and ensuring fairness and patient safety, is enormously complex and time-consuming. The “unsatisfactory” resident and associated faculty experience a tremendous emotional toll. There are also substantial personal and institutional costs to extending a residency. A survey of the evaluation/assessment policies at all of Canada’s FM programs will be presented and a workshop on designing and ensuring effective mechanisms to support resident success will be discussed
ABSTRACT Purpose The tablet computer has the potential to impact the way physicians practice medi... more ABSTRACT Purpose The tablet computer has the potential to impact the way physicians practice medicine. However, its potential role has not yet been sufficiently assessed. The purpose of this pilot project was twofold. First, was to evaluate the extent to which family medicine and specialist preceptors teaching family medicine residents and their residents at a rural clinical teaching site use tablet computers; and second, to evaluate the extent to which the participants accessed other resources through their iPad in an effort to support and enhance effective teaching and learning. Methods Each participating preceptor and resident was given an iPad pre-loaded with revised Family Medicine curriculum and various selected medical applications (apps). In addition to the introductory workshop the lead evaluator of the pilot and other experienced iPad users met periodically with the participants over an eight month period to provide support and training sessions on the iPad. Formal feedback was received through a validated survey and focus group sessions after 4 and 8 months. Results Five residents and 21 preceptors have participated in the study. The final emerging themes include: curriculum and assessment issues; access and ease of use, portability, useful apps and resources, functionality, security and support. Conclusions It is worthwhile pursuing the tablet as a teaching tool. Therefore, the findings from the pilot will be used to inform future use of tablet computers for clinical teaching within the University of Ottawa, Department of Family Medicine.
ABSTRACT PURPOSE OF STUDY: To identify areas of greatest needs for continuing medical education (... more ABSTRACT PURPOSE OF STUDY: To identify areas of greatest needs for continuing medical education (CME) in primary care by conducting a secondary analysis of 1,889 point-of-care questions asked by primary care practitioners in the context of their clinical practices. The questions were generated by 88 clinicians participating in the Just-in-Time Information (JIT) project, a randomized controlled trial that demonstrated the feasibility of an online medical librarian consultation service to answer point-of-care questions asked by primary care practitioners. Participants asked questions in the course of their daily patient consultations and submitted them using a handheld device (Blackberry™). These questions were answered in less than 15 minutes by a medical librarian consultation service, which enabled the practitioner to use the answer in the patient encounter. METHODS: The study design will be secondary analysis of the JIT database of questions using quantitative content analysis methods. Word frequency analyses will be conducted and will be classified using two classification schemes (question-type-based vs. system-based). Interrater reliability will be assessed by having a sample of questions (n=400) classified by two additional independent reviewers. The two reviewers’ results will be compared and differences resolved by consensus. RESULTS: CME recommendations based on the frequency and content of the questions
ABSTRACT Context: Yearly more than fifty faculty interview more than 500 candidates for the uOtta... more ABSTRACT Context: Yearly more than fifty faculty interview more than 500 candidates for the uOttawa Department of Family Medicine’s 60 residency positions. This year (2013) in an ongoing effort to improve the standardization of the half hour semi-structured interviews entrance interviews the Department changed its scoring system to provide better guidance to faculty. Postgraduate leaders re-defined the competencies sought in candidates, and created new interview questions based on these competencies along with a standardized scoring rubric. We hypothesize that some faculty might be either particularly “hard” or “easy” interviewers, and that changing to standardized scoring tools would normalize the interview scores overall in comparison to previous years. Methods: In this descriptive cross-sectional, retrospective study, previous data were collected from the Department’s 2011-13 de-identified candidate rank lists and interview scores. Possible “hard” and “easy” raters were characterized by determining each faculty interviewers’ mean scores, and determining whether each interviewer differed statistically from the mean of means for all interviewers. Results: Preliminary results show 521 final year candidates were interviewed by 54 faculty members over four days in January and February 2013. Faculty interviewers were coded and de-identified, and mean interview scores (and standard deviations) were determined. Faculty were ranked based on their mean scores. After the instrument change all but four faculty members were within one standard deviation of the mean. Data from 2013 will be compared to the two years prior to the change. Conclusions: It is anticipated that the Department’s standardized interview is a more objective method for evaluating prospective residents. By using a standardized interview, a candidate’s in
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Papers by Gary Viner