Arwen Bunce
Research interests
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InterestsEthnography
Publications
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1.90Impact points
Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study.
BMC medical informatics and decision making. 02/2012; 12(1):6.
ABSTRACT: BACKGROUND: The purpose of this study was to identify recommended practices for computerized clinical decision support (CDS) development and implementation and for knowledge management (KM) processes in ambulatory clinics and community hospitals using commercial or locally developed system... [more] ABSTRACT: BACKGROUND: The purpose of this study was to identify recommended practices for computerized clinical decision support (CDS) development and implementation and for knowledge management (KM) processes in ambulatory clinics and community hospitals using commercial or locally developed systems in the U.S. METHODS: Guided by the Multiple Perspectives Framework, the authors conducted ethnographic field studies at two community hospitals and five ambulatory clinic organizations across the U.S. Using a Rapid Assessment Process, a multidisciplinary research team: gathered preliminary assessment data; conducted on-site interviews, observations, and field surveys; analyzed data using both template and grounded methods; and developed universal themes. A panel of experts produced recommended practices. RESULTS: The team identified ten themes related to CDS and KM. These include: 1) workflow; 2) knowledge management; 3) data as a foundation for CDS; 4) user computer interaction; 5) measurement and metrics; 6) governance; 7) translation for collaboration; 8) the meaning of CDS; 9) roles of special, essential people; and 10) communication, training, and support. Experts developed recommendations about each theme. The original Multiple Perspectives framework was modified to make explicit a new theoretical construct, that of Translational Interaction. CONCLUSIONS: These ten themes represent areas that need attention if a clinic or community hospital plans to implement and successfully utilize CDS. In addition, they have implications for workforce education, research, and national-level policy development. The Translational Interaction construct could guide future applied informatics research endeavors.
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3.97Impact points
Clinical decision support in small community practice settings: a case study.
Journal of the American Medical Informatics Association : JAMIA. 04/2011; 18(6):879-82.
Using an eight-dimensional model for studying socio-technical systems, a multidisciplinary team of investigators identified barriers and facilitators to clinical decision support (CDS) implementation in a community setting, the Mid-Valley Independent Physicians Association in the Salem, Oregon area.... [more] Using an eight-dimensional model for studying socio-technical systems, a multidisciplinary team of investigators identified barriers and facilitators to clinical decision support (CDS) implementation in a community setting, the Mid-Valley Independent Physicians Association in the Salem, Oregon area. The team used the Rapid Assessment Process, which included nine formal interviews with CDS stakeholders, and observation of 27 clinicians. The research team, which has studied 21 healthcare sites of various sizes over the past 12 years, believes this site is an excellent example of an organization which is using a commercially available electronic-health-record system with CDS well. The eight-dimensional model proved useful as an organizing structure for the evaluation.
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Studying the vendor perspective on clinical decision support.
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 01/2011; 2011:80-7.
In prior work, using a Rapid Assessment Process (RAP), we have investigated clinical decision support (CDS) in ambulatory clinics and hospitals. We realized that individuals in these settings provide only one perspective related to the CDS landscape, which also includes content vendors and electroni... [more] In prior work, using a Rapid Assessment Process (RAP), we have investigated clinical decision support (CDS) in ambulatory clinics and hospitals. We realized that individuals in these settings provide only one perspective related to the CDS landscape, which also includes content vendors and electronic health record (EHR) vendors. To discover content vendors' perspectives and their perceived challenges, we modified RAP for industrial settings. We describe how we employed RAP, and show its utility by describing two illustrative themes. We found that while the content vendors believe they provide unique much-needed services, the amount of labor involved in content development is underestimated by others. We also found that the content vendors believe their products are resources to be used by practitioners, so they are somewhat protected from liability issues. To promote adequate understanding about these issues, we recommend a "three way conversation" among content vendors, EHR vendors, and user organizations.
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Multiple perspectives on the meaning of clinical decision support.
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 01/2010; 2010:672-6.
Clinical Decision Support (CDS) is viewed as a means to improve safety and efficiency in health care. Yet the lack of a consensus around what is meant by CDS represents a barrier to effective design, use, and utilization of CDS tools. We conducted a multi-site qualitative inquiry to understand how d... [more] Clinical Decision Support (CDS) is viewed as a means to improve safety and efficiency in health care. Yet the lack of a consensus around what is meant by CDS represents a barrier to effective design, use, and utilization of CDS tools. We conducted a multi-site qualitative inquiry to understand how different people define and describe CDS. Using subjects' multiple perspectives we were able to gain new insights as to what stakeholders want CDS to achieve and how to achieve it; even at times when those perspectives are competing and conflicting.
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Multiple perspectives on the meaning of clinical decision support.
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 01/2010; 2010:1427-31.
Clinical Decision Support (CDS) is viewed as a means to improve safety and efficiency in health care. Yet the lack of consensus about what is meant by CDS represents a barrier to effective design, implementation, and utilization of CDS tools. We conducted a multi-site qualitative inquiry to understa... [more] Clinical Decision Support (CDS) is viewed as a means to improve safety and efficiency in health care. Yet the lack of consensus about what is meant by CDS represents a barrier to effective design, implementation, and utilization of CDS tools. We conducted a multi-site qualitative inquiry to understand how different people define and describe CDS. Using subjects' multiple perspectives we were able to gain new insights as to what stakeholders want CDS to achieve and how to achieve it even when those perspectives are competing and conflicting.
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1.39Impact points
Educating Youth About Health and Science Using a Partnership Between an Academic Medical Center and Community-based Science Museum.
Journal of community health. 05/2009;
Declining student interest and scholastic abilities in the sciences are concerns for the health professions. Additionally, the National Institutes of Health is committed to promoting more research on health behaviors among US youth, where one of the most striking contemporary issues is obesity. This... [more] Declining student interest and scholastic abilities in the sciences are concerns for the health professions. Additionally, the National Institutes of Health is committed to promoting more research on health behaviors among US youth, where one of the most striking contemporary issues is obesity. This paper reports findings on the impact of a partnership between Oregon Health and Science University (OHSU) and the Oregon Museum of Science and Industry linked to a 17-week exhibition of BodyWorlds3 and designed to inform rural underserved youth about science and health research. Self-administered survey measures included health knowledge, attitudes, intended health behaviors, and interest in the health professions. Four hundred four surveys (88% of participants) were included in analyses. Ninety percent or more found both the BodyWorlds (n = 404) and OHSU (n = 239) exhibits interesting. Dental care habits showed the highest level of intended behavior change (Dental = 45%, Exercise = 34%, Eating = 30%). Overall, females and middle school students were more likely than male and high school students, respectively, to state an intention to change exercise, eating and dental care habits. Females and high school students were more likely to have considered a career in health or science prior to their exhibit visit and, following the exhibit, were more likely to report that this intention had been reinforced. About 6% of those who had not previously considered a career in health or science (n = 225) reported being more likely to do so after viewing the exhibits. In conclusion, high quality experiential learning best created by community-academic partnerships appears to have the ability to stimulate interest and influence intentions to change health behaviors among middle and high school students.
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1.39Impact points
Educating the Public About Research Funded by the National Institutes of Health Using a Partnership Between an Academic Medical Center and Community-based Science Museum.
Journal of community health. 04/2009;
The NIH roadmap has among its goals, to promote studies designed to improve public understanding of biomedical and behavioral science, and to develop strategies for promoting collaborations between scientists and communities toward improving the public's health. Here, we report findings on the i... [more] The NIH roadmap has among its goals, to promote studies designed to improve public understanding of biomedical and behavioral science, and to develop strategies for promoting collaborations between scientists and communities toward improving the public's health. Here, we report findings on the impact of a partnership between the Oregon Health and Science University (OHSU) and the Oregon Museum of Science and Industry (OMSI) designed to inform the public about health research being conducted in Oregon, which was linked to a 17-week traveling exhibition of BodyWorlds3. Measures included the public's understanding of health knowledge, attitudes, intended health behaviors, and visitor experience in their interactions with OHSU experts/volunteers, which were collected using exit surveys administered verbally. Nine hundred fifty-three surveys were included in analyses. Among those who felt that health behavior change was relevant to them, 67.4% of smokers (n = 133) intended to change their smoking behavior, 58.6% (of 677) intended to change their eating habits, 60.3% (of 667) intended to change their exercise routine, and 47% (of 448) intended to change their dental care habits. Forty-six percent of these visited the OHSU research exhibits (n = 437), and responded to how the exhibit changed their understanding about and openness to participate in health research. Greater than 85% had a much improved understanding of NIH research at OHSU and >58% reported they would be willing to participate in future research studies at OHSU. In conclusion, research partnerships between academic institutions and community-based museums appear to be viable ways to inform the public about research, stimulate their interest as future participants, and possibly influence their intention to improve health behaviors.
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1.43Impact points
Factors affecting vasectomy acceptability in Tanzania.
International family planning perspectives. 04/2007; 33(1):13-21.
CONTEXT: Calls for increased inclusion of men in matters of reproductive health emphasize the need for research into vasectomy acceptability and decision making. Vasectomy is a safe, simple and effective method of contraception, but is underused worldwide. METHODS: Focus group discussions and in-dep... [more] CONTEXT: Calls for increased inclusion of men in matters of reproductive health emphasize the need for research into vasectomy acceptability and decision making. Vasectomy is a safe, simple and effective method of contraception, but is underused worldwide. METHODS: Focus group discussions and in-depth interviews were conducted with potential and actual sterilization clients and their partners in the Kigoma Region of Tanzania. Content analysis was used to search for emergent themes related to vasectomy decision making. RESULTS: Six themes emerged as overarching factors contributing to the vasectomy decision-making process: economics, spousal influence, religion, provider reputation and availability, uncertainty about the future, and poor vasectomy knowledge and understanding. There was substantial communication between partners regarding the vasectomy decision, and wives had a strong influence on the outcome; however, men and women agreed that husbands would resist vasectomy if wives initially raised the topic. Vasectomy acceptance is limited by the scarcity of skilled vasectomy providers and by the fact that men and women hold many of the same misunderstandings about vasectomy, including a fear of decreased sexual performance as a result of the procedure. CONCLUSIONS: Spousal discussions are important in the decision to get a vasectomy, but these discussions should be initiated by the male partner. Programs need to educate men about contraceptive options, including vasectomies. Detailed, culturally relevant knowledge of the barriers and facilitators individuals experience during their decision- making process will enable vasectomy promotion programs to more successfully target appropriate populations.
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1.05Impact points
Fear, hope and social desirability bias among women at high risk for HIV in West Africa.
The journal of family planning and reproductive health care / Faculty of Family Planning & Reproductive Health Care, Royal College of Obstetricians & Gynaecologists. 11/2005; 31(4):285-7.
BACKGROUND: Self-reports are widely used for measuring behaviour in HIV research and prevention, yet the accuracy of these measures has been shown to be questionable in many cases. Social desirability bias (SDB) is one of the key factors identified as affecting self-report accuracy. METHODS: Using i... [more] BACKGROUND: Self-reports are widely used for measuring behaviour in HIV research and prevention, yet the accuracy of these measures has been shown to be questionable in many cases. Social desirability bias (SDB) is one of the key factors identified as affecting self-report accuracy. METHODS: Using in-depth interviews, we examined SDB from the perspective of 60 women at high risk for HIV in two West African countries: Ghana and Nigeria. We solicited suggestions for reducing SDB in the context of HIV research and prevention, and asked for feedback regarding methods currently being employed to reduce SDB. RESULTS: Themes pertaining to fear and a desire to have a better life were pervasive throughout the data. Thematic structure was similar between sites and age groups, although younger women tended to be more concerned about the interview context. CONCLUSIONS: Vulnerability of a population should be considered when asking sensitive questions. Audio-computer-assisted self-interviews may not be appropriate for vulnerable populations in developing countries, particularly for older respondents.
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1.07Impact points
Examining the context of microbicide acceptability among married women and men in India.
Culture, health & sexuality. 8(4):351-69.
Married women in India are increasingly at risk of HIV, often due to their husbands' extramarital sexual behaviour. Topical microbicides may provide protection to women who are unable to negotiate condom use. During the formative phase of a study to develop measures related to microbicide accept... [more] Married women in India are increasingly at risk of HIV, often due to their husbands' extramarital sexual behaviour. Topical microbicides may provide protection to women who are unable to negotiate condom use. During the formative phase of a study to develop measures related to microbicide acceptability, we conducted in-depth interviews with 14 'high-risk' and 16 'low-risk' married women and 15 husbands. Some participants had recently completed a 2-week microbicide safety trial. A sequence of in-depth interviews with each participant explored the context of microbicide acceptability, including perceptions of couple harmony, vulnerability to HIV, sexual power, and ability to control life events. Women's perceptions of control and sexual power influenced attitudes towards microbicide use. HIV risk was most commonly associated with partner infidelity and easily detected, according to both men and women, by a lack of marital harmony. Despite this, high-risk women denied perceiving HIV risk until confronted with specific evidence of a husband's positive HIV or STI diagnosis. This study provides an in-depth examination of HIV risk for Indian married women, identifying potential determinants of microbicide use, and providing guidance for the development of psychometric scales to measure couple harmony, HIV risk perception, and sexual power and control.
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2.11Impact points
Uninsured patient opinions about a reduced-fee retainer program at academic health center clinics.
Journal of the American Board of Family Medicine : JABFM. 24(3):304-12.
Access Assured, an experimental program to deliver primary care to uninsured patients using a monthly retainer payment system, has been shown to provide a financially viable method of delivering primary care services to people without health insurance. This qualitative study was designed to assess p... [more] Access Assured, an experimental program to deliver primary care to uninsured patients using a monthly retainer payment system, has been shown to provide a financially viable method of delivering primary care services to people without health insurance. This qualitative study was designed to assess patient attitudes and concerns about this program and to identify ways to improve it. We conducted telephone interviews with 40 purposefully selected Access Assured members between May and June of 2009. This population was stratified to include a sample of 20 patients from those who had elected to renew enrollment in the program after their first 6-month enrollment period. The other 20 patients were selected from those enrollees who had not re-enrolled in the program after this initial period. The semistructured interviews were based on an original list of 19 standardized questions, which were asked of each participant. All interviews were audio taped. The interview tapes were transcribed verbatim and content analysis was conducted using immersion-crystallization methods. Content analysis identified 9 themes related to patient attitudes and concerns about this program. (1) Patients could not understand why they needed to remain enrolled if they were healthy. (2) Patients had variable levels of personal agency or responsibility for their own care. (3) Patients reported they had no choice and needed to enroll in the program to have access to care. (4) Patients liked that the program allowed them to choose their provider and see that provider with continuity from visit to visit. (5) Patients felt they were respected and treated the same as other patients. (6) Patients expressed appreciation for the program. (7) Patients had a range of comments about the quality of care and service they received. (8) Patients reported confusion about the rules of the program and often did not understand its terms and benefits. (9) Patients were under personal and family economic stress. Twenty of the subjects in our study had re-enrolled in Access Assured and 11 of the 20 patients who had not re-enrolled expressed an intention to do so. Our study population expressed gratitude and other positive opinions about the retainer-based program for uninsured patients in 2 academic family medicine clinics. Conversely, some were concerned about the perceived lack of choice related to enrollment. Significant gaps in patient understanding about the program were identified. Based on these results, we have made improvements to the program and plan to continue to offer this care model to uninsured patients in our practices.
Following (2)
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Carmit Mcmullen
Kaiser Permanente Center for Health Research -
Joshua Richardson
Weill Cornell Medical College
