Discussion:Improving Communication with Patients and Providers Using Health Information Technology

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Discussion:Improving Communication with Patients and Providers Using Health Information TechnologyORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON  Discussion:Improving Communication with Patients and Providers Using Health Information TechnologyThis week, you will write your theoretical framework. For this section of your paper, you must specifically identify and address two independent theories or conceptual models that relate directly to your change project in addition to the Plan-Do-Study-Act (PDSA) cycle. Keep in mind that your theoretical framework provides the structure for your change project. Think of it as a frame for a new home that is being built. The framework is what guides and directs your change project. Basically, it will help make sense of your change project. Make sure to describe how you will apply these theories and models to your change project. Discussion:Improving Communication with Patients and Providers Using Health Information TechnologyPlease use the documents i am enclosing they are peer reviewed and evidenced based as well as the conceptual models and many in text citations. The title is above and you worked on the previous one, __1_.pdfmhealth_technology_as_a_persua.pdfacceptability_of_mobile_phone_.pdfhealth_literacy_and_the_digita.pdfcell_phone_utilization_among_f.pdfImproving Communication Between Patients and Providers Using Health Information Technology and Other Quality Improvement Strategies: Focus on Asian Americans Medical Care Research and Review Supplement to 67(5) 231S­–245S © The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1077558710375432 http://mcr.sagepub.com Quyen Ngo-Metzger1, Gillian R. Hayes1, Yunan Chen1, Ralph Cygan1, and Craig F. Garfield2 Abstract Disparities in provider–patient communication have been shown to exist among Asian Americans, especially those who are low-income and have limited English proficiency. These disparities have resulted in unmet health care needs and poor quality care. To identify strategies for improving provider–patient communication in this population, we conducted a systematic review of the literature and in-depth interviews with key informants. Little published literature on interventions focused on Asian Americans was found. Most interventions were conducted among White populations and occurred in the waiting room before patients’ visits with their providers. Interventions ranged from a leaflet encouraging patients to ask more questions, to more intensive face-to-face coaching before office visits. Health information technology (health IT) has not been widely used to improve communication, especially among patients with limited English proficiency. More research is needed using new health IT strategies to improve care for Asian Americans and other vulnerable populations. This article, submitted to Medical Care Research and Review on December 14, 2009, was revised and accepted for publication on May 19, 2010. 1 University of California–Irvine, Irvine, CA, USA Northwestern University, Evanston, IL, USA 2 Corresponding Author: Quyen Ngo-Metzger, Health Policy Research Institute, Department of Medicine, University of California, Irvine School of Medicine, 100 Theory, Suite 110, Irvine, CA 92697-5800, USA Email: qhngo@uci.edu 232S Medical Care Research and Review Supplement to 67(5) Keywords health information technology, health IT, HIT, Asian Americans, communication, intervention, quality improvement (QI) The U.S. census (Barnes & Bennett, 2002) has defined Asian Americans as “people having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent.” Discussion:Improving Communication with Patients and Providers Using Health Information TechnologyIn 2006, there were approximately 14.7 million Asians living in the United States, nearly 5% of the total population (Trinh-Shevrin, Islam, & Rey, 2009). By 2050, this diverse population is projected to grow to 37.6 million, exceeding 9% of the total U.S. population (Trinh-Shevrin et al., 2009). Chinese (24%), Filipino (20%), Asian Indian (18%), Vietnamese (11%), Korean (10%), and Japanese (8%) individuals make up the largest subgroups with smaller populations of Cambodians, Laotians, Pakistanis, Hmong, Thai, Indonesians, and Bangladeshis. Asian Americans represent a wide range of languages, cultures, and socioeconomic backgrounds. Within this diverse population, there are large socioeconomic differences by ethnic subgroups determined, in part, by the degree of language proficiency and acculturation. For example, Cambodians and Hmongs have far lower socioeconomic status compared with Japanese Americans, and proportionately more Asian Americans remain in poverty compared with White Americans (Trinh-Shevrin et al., 2009). Additionally, Vietnamese, Korean, and Chinese Americans are more likely to lack medical insurance compared with Whites (Trinh-Shevrin et al., 2009). Analysis of aggregate data hides the heterogeneity within the Asian American population. The myth of Asians being “the model American minority” (universally successful) masks the significant challenges encountered by many Asian American immigrants (Trinh-Shevrin et al., 2009). Effective communication is a core component of the clinical encounter, and is the foundation on which the framework of an effective relationship is built—mutual trust, respect, and partnership.Discussion:Improving Communication with Patients and Providers Using Health Information TechnologyEffective communication includes question asking and information giving, along with other behaviors to help build rapport that include paying attention and validating patients’ health beliefs (Roter, Hall, & Aoki, 2002). Good communication helps establish the mutual trust and respect required for the therapeutic partnership and increases the likelihood that patients will take an active role in decision making and in the management of their illness. However, provider–patient communication problems are reported more frequently among Asian Americans. Health information technology (health IT) has the potential to improve health communication and the quality of health care. However, many have raised concerns that certain disadvantaged populations may be “left behind” in the digital divide (U.S. Department of Commerce, 2000). Asian Americans, particularly those subgroups with lower socioeconomic status and limited English proficiency (LEP), may not receive the potential benefits of health IT unless specific, targeted strategies are used. Ngo-Metzger et al. 233S New Contribution In this article, we first identify the barriers to good provider–patient communication among Asian Americans. Then, through a systematic review of the literature and interviews with key experts, we identify interventions that may be effective in improving provider–patient communication in this population. We discuss how health IT and other strategies may be utilized to reduce barriers in communication. Finally, we recommend future directions in research and implementation. Provider–Patient Communication in Asian American Adults The National Healthcare Disparities Reports have shown disparities in provider–patient communication for Asian Americans (Agency for Healthcare Research and Quality [AHRQ], 2008, 2009). Discussion:Improving Communication with Patients and Providers Using Health Information TechnologyAsian Americans were more likely than White respondents to report that their doctors did not understand their backgrounds and values, listen to them, spend as much time with them, or involve them in decisions about care as much as they wanted (Ngo-Metzger, Legedza, & Phillips, 2004). Asian Americans’ cultural backgrounds affect the way they communicate their health concerns (Kreuter & McClure, 2004). Culturally, Asians are expected to show deference to authority. Thus, even highly educated Asian Americans may be less likely to question medical professionals when they disagree. Asians tend to be less emotionally expressive, which may lead providers to assume that they are satisfied and do not have questions or concerns. They are also more likely to use complementary or alternative medicine (CAM) and are more satisfied when their doctors discuss CAM use with them (Ahn et al., 2006). Language barriers are also an important contributor to provider–patient miscommunication and may result in unmet health needs among Asian Americans with LEP (Ngo-Metzger et al., 2007). In population-based surveys, LEP Asian Americans are less likely to receive mental health care, cancer screening and treatment, and hospice care compared with Whites (De Alba, Ngo-Metzger, Sweningson, & Hubbell, 2005; Goel et al., 2005; Ngo-Metzger, Phillips, & McCarthy, 2008; Sorkin, Tan, Hays, Mangione, & Ngo-Metzger, 2008). Method Literature Review We systematically reviewed the literature to identify studies of intervention shown to be effective in improving provider-patient communication among Asian Americans. We also sought to identify health IT and other quality improvement (QI) strategies that may enhance and aid communication. We searched PubMed (1965-July 2009), CINAHL (1982-July 2009), PsycINFO (1965-July 2009), ACM Portal (1947July 2009), Lecture Notes in Computer Science (1973-July 2009), and The Cochrane Library (second quarter 2009). We focused on literature published from January 1, 234S Medical Care Research and Review Supplement to 67(5) 1994 to July 1, 2009. Details of the search methodology are available from the corresponding author. Data Abstraction At least two authors reviewed and abstracted all articles independently. Discussion:Improving Communication with Patients and Providers Using Health Information TechnologyWe evaluated the quality of the studies using the SQUIRE (Standard for Quality Improvement Rep­ orting Excellence) guidelines (available at http://www.squire-statement.org/), which provide a structure for evaluating QI interventions in a systematic manner (Ogrinc et al., 2008). We used a consensus scoring system in which higher scores on the guidelines indicated more thorough description of the QI intervention and its results. Key Informant Interviews We conducted in-depth interviews with five key informants who are experts in health care services for Asian Americans in underresourced settings. Underresourced settings were defined as settings where the majority of patients had incomes at 100% to 200% of the poverty level or lower and had either Medicaid insurance or were uninsured or underinsured. A list of key informants can be obtained from the corresponding author. Interview protocols were developed, and key topics for discussion were identified. Using the questionnaire, the first author conducted audio-taped telephone interviews with all key informants. Analysis was conducted by two reviewers (QNM and CFG) and consisted of listening to each interview, reviewing notes, and discussions between the reviewers. Salient topics and emerging themes were identified and reported. Results of the Literature Search We found no papers that described interventions conducted among Asian Americans. We found two intervention studies that included very small numbers of Asian Americans in the sample (approximately 30 patients in each study) but did not report results stratified by race/ethnicity. One trial that examined the effectiveness of home blood pressure monitoring and web-based communication included 29 Asian American patients among a total of 778 patients (Green et al., 2008). Discussion:Improving Communication with Patients and Providers Using Health Information TechnologyThis study found that home blood pressure monitoring with feedback from a pharmacist improved blood pressure control among hypertensive patients. Another study (Prochaska, Zabinski, Calfas, Sallis, & Patrick, 2000) using an interactive technology to target behavioral change (nutrition and physical activity) also included small numbers of Asian Americans (n = 33, 12% of study sample). This study found that the technology could be incorporated into the clinical setting and was acceptable to patients. The small number of Asian Americans in these studies and the lack of analyses stratified by race limit our ability to draw conclusions from their results. The lack of intervention studies conducted among Asian Americans highlights the need for more research in this area. Ngo-Metzger et al. 235S Until then, we have to make inferences on how to improve provider–patient communication based on research conducted in non–Asian American populations. Interventions to Improve Provider–Patient Communication in Non–Asian American Populations A review of provider–patient communication interventions yielded six studies (seven articles) focusing on patient activation and empowerment to increase participation during office visits, though none of these studies included Asian Americans (Butow, Dunn, Tattersall, & Jones, 1994; Cegala, Marinelli, & Post, 2000; Cegala, McClure, Marinelli, & Post, 2000; Frederikson & Bull, 1995; Jacobson et al., 1999; McCann & Weinman, 1996; McGee, 1998). These interventions can be divided into two categories: low intensity or high intensity. Low-intensity interventions usually involved a one-page leaflet that was given to patients immediately before the office visit (Butow et al., 1994; Frederikson & Bull, 1995; Jacobson et al., 1999; McCann & Weinman, 1996). The leaflets encouraged patients to write down specific questions and concerns to ask their providers during the subsequent visit. Most of the trials were small studies that involved approximately 100 to 150 patients recruited from one physician’s practice. Discussion:Improving Communication with Patients and Providers Using Health Information TechnologyThe findings are summarized in Table 1. The largest, most effective study using this low-intensity method focused on increasing pneumococcal vaccination among older patients (Jacobson et al., 1999). This study included 433 patients and found that a one-page, low-literacy education leaflet significantly increased discussion about the vaccines and vaccination rates. High-intensity interventions generally involved more intense patient coaching. These interventions included either a patient workbook to be completed prior to their visit or previsit face-to-face training with a health educator (Cegala, Marinelli, et al., 2000; Cegala, McClure, et al., 2000; McGee, 1998). These interventions significantly increased the number of questions that patients asked during the visit, patient compliance, and recall of information. However, the effects were seen only among nonHispanic White patients, with no effects on African Americans. These findings illustrate that a strategy that works in one patient population may not work in another and that effective intervention strategies must be tailored to the target population’s needs and preferences (Post, Cegala, & Marinelli, 2001). Results of Key Informant Interviews We interviewed key informants who provide care to low-income, LEP Asian Americans in safety net settings, such as federally qualified community health centers (FQHCs), small private practices, and public hospitals. We also interviewed the Executive Director of the Association of Asian Pacific Community Health Organizations (AAPCHO), a national network of 28 community health centers providing services to more than 360,000 primarily low-income Asian American patients throughout the United States. Currently, many community health centers that serve Asian American 236S One physician’s office in the United Kingdom Discussion:Improving Communication with Patients and Providers Using Health Information TechnologyButow et al. 142 first-time cancer One oncologist at teaching (1994) consultation hospital in Excluded: nonAustralia English speaking Frederikson 80 patients and Bull No demographics (1995) given Surgery patients Setting Findings/Results Quasi-experimental design, random assignment of patients Physician blinded to patient’s group status Intervention single-page leaflet, encourage patients to think about problem and what physicians can do, tell concerns, instructed to listen, and ask questions Control: no leaflet Randomized trial, physician and patient blinded This intervention occurred in a public hospital Yes Intervention patients did Patients can fill out not ask more questions the question sheet in the Not tested in a study but a promising strategy Can be, not Challenge would Outcome was a single tested in be for front physician’s rating of the minorities office staff will communication of visits remember to give Experimental group’s to patient. ratings by the physician Does not guarantee was higher than the that patient will control group’s ratings actually follow Limitation of study advice of leaflet, statistically significant may be hard if using chi-square, no patient is passive control variables or rushed Discussion about the Randomized controlled Ambulatory 433 patients: 93% vaccine was four trial care clinic African American, times as likely in the Patients in the intervention of a 900-bed 69% female, 65% intervention group as group were given a public teaching Purchase . 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