PATIENT PROFILE: A PRACTICE MANAGEMENT SYSTEM DEVELOPED USING AN OFF-THE-SHELF RELATIONAL DATABASE PROGRAM. T. Yackel 1 , B. Slater 2 ; 1 Oregon Health Sciences University, Portland, OR; 2 George Washington University Medical Center, Washington, DC STATEMENT OF PROBLEM OR QUESTION: The George Washington University Department of Health Care Sciences is part of a multi-specialty faculty practice with departmentally centralized paper medical records. An internal study revealed that patient chart availability at the time of care was as low as 66%. The use of electronic resources to obtain patient specific information was limited to laboratory results retrieval and patient scheduling. Laboratory results were available online only for tests drawn in the past 60 days. OBJECTIVES OF PROGRAM/INTERVENTION: 1) Improve availability of patient information at the time of care. 2) Implement an electronic disease management system for patients with HIV and diabetes mellitus. 3) Accomplish these objectives in a short period of time with little funding. DESCRIPTION OF PROGRAM/INTERVENTION: Using an off-the-shelf relational database product, Access 97 (Microsoft, Redmond, WA), we implemented an advanced clinical information system over a six-month period. The program was written during spare evenings and weekends by the authors, neither of whom have had formal training in database programming. The system includes sophisticated features such as a problem list linked to ICD-9 codes; a prescription manager that provides drug-drug interaction checking and patient-specific formulary information; templates for HIV and diabetes disease management; automatic importing of laboratory information with longitudinal views, including results from the past 3 years for HbA1C, PSA, cholesterol, HIV viral loads, and CD4 counts; a reminder system; the ability to import dictations; user-level security and encryption of data; and an easy-to-use interface. FINDINGS TO DATE: Patient Profile has been in continuous use since June 1998 by a group of 3-5 users and has required little maintenance. The availability of the system exceeds 99%. Due to the program's simplicity, low-cost, and popularity among care providers, it became a prototype for a practice-wide electronic medical record project. KEY LESSONS LEARNED: Using commercially available tools, clinicians with minimal experience in computer programming can develop and implement their own practice management systems for a fraction of the cost of commercial products. Because these programs are infinitively customizable, they may serve the specific needs of providers better than a system purchased from a vendor. All students were mailed a questionnaire requesting they rate the importance of various factors in choosing a residency program using a 5 point Likert scale (1 = not important, 3 = somewhat important, and 5 = very important). Underrepresented minority (URM) applicants were defined as African American, Latino, or Native American. RESULTS: Response rate was 36% (1005/2820), 55% were men, 30% were married and 61% self-rated in the top 25% of their class. The factors most important to all applicants were good housestaff morale (mean SD= 4.54 0.72), the academic reputation of the program (4.46 0.78), a positive interview experience (4.10 0.99), variety of clinical experiences by residents (4.05 0.72) and location near spouse/significant other (4.04 1.43). URM applicants (N=92 or 9%) were significantly more likely to identify ethnic diversity of the patients ( CONCLUSION: Applicants rate location and program-related factors as most important in influencing their decision to chose a particular Internal Medicine Residency Program. However, URM applicants also place significant importance on the ethnic diversity of patients, housestaff and faculty, and the support provided to ethnic minorities within the academic environment. Residencies must place an emphasis on improving these factors if they wish to recruit highly qualified minority applicants. Although there is some literature on violence in the medical workplace, little has been written about threats physicians experience on the job. Our study examines the epidemiology of threats to resident physicians in internal medicine by patients, their families, and non-physician staff. METHODS: We implemented a mass-administered survey to internal medicine residents in two large urban training programs. One program is in a public county hospital which serves predominately uninsured patients. The other is in a private, tertiary care, academic medical center whose patient base is predominately insured by Medicare or managed care entities. We defined a threat as an actual or implied action intended to harm or torment someone. The survey measures the frequency, type and setting of threats. It examines the support structures residents use to deal with threats. We also assess resident attitudes towards receiving threats, particularly as they relate to patient care. RESULTS: Our preliminary data analysis shows 24 of 69 (34.8%) residents at the public hospital and 15 of 40 (37.5%) of residents at the private hospital have experienced one or more threats (total number of threats 66, mean 1.7). The threats were most commonly from patients assigned to that resident (47%), 16% from patients they covered on call, 19% from family members of patients, and 18% from other non-physician staff. Eighty five percent of the threats were verbal in nature and 15% were physical. The location of the threat occurrence was usually on the wards (70%). The remainder occurred in the emergency department (24%), and 6% occurred in outpatient clinics. Residents reported that the threats made them feel angry, nervous, afraid, and helpless. Approximately three-quarters of residents (74%) sought some support for these episodes. This support came from a variety of sources including peers, family, attending physicians, and security. Of residents reporting a threat, one in five (21%) said the experience impacted on the care of the patient involved, while only 2 of 39 (5%) said the experience impacted on how they care for other patients. Eleven of 39 (28%) said that following the threat they are more likely to avoid certain situations at work to feel more safe. Residents strongly disagreed with the statement that being threatened by a patient or their family members is a part of their job. CONCLUSION: Residents commonly experience threats from patients, their family members and non-physician staff in the workplace. The prevalence of threats was similar at both a public and private hospital. The most common reactions residents reported to these experiences include negative emotions and an impact on their care of the involved patient. An in-house support system needs to be developed to prevent and handle threats residents experience in the workplace. Residency programs have used support groups and Balint groups to address some of the stresses faced by trainees. We developed a monthly, faculty facilitated, hourlong session for residents on a ward or coronary care unit rotation. The goal of this session was to promote an opportunity and a safe environment for residents to explore clinical issues that had an impact on the feelings, attitudes, and challenges of becoming a physician. In each session, ground rules for safety were reiterated, as was the voluntary nature of this session. The group was held during one half of a scheduled attending rounds session in the third week of the month. The teaching attending (different from the facilitator) was welcome to participate. METHODS: We developed a confidential and anonymous survey given to all medicine and medicine pediatrics residents at the end of the 1999-2000 academic year. The survey was designed to access resident attitudes towards participation, their acceptance of this discussion format and any potential behavior change as a result of participation in those groups. RESULTS: Overall response rate was 75% (65% medicine and 35% medicine pediatrics). 62% of respondents were under age 30; 27% were age 30-35. 62% of respondents were female. Residents had attended an average of 1.6 sessions on the wards, and 1.1 sessions in the CCU. 90% of respondents indicated the timing was appropriate. Residents rated their comfort in these discussions with fellow residents on a 1 (low comfort) to 5 (high comfort) scale, with the mean response of 3.83. Residents were asked the following: The issues discussed in the balance groups are ones you may have thought about or discussed in the past. As a result of the discussions this past year, please rate your current activity from 1 (less activity) to 3 (same activity) to 5 (more activity) in: self reflection (mean response = 4.41), discussions with peers (mean response = 4.33) and discussions with family and friends (mean response = 4.17). CONCLUSION: Balance groups in this Internal Medicine residency training program were well received regarding their timing, and the comfort felt among participants. Importantly, residents indicated that they continued to reflect privately and with peers, family, and friends. Timing and attendance are significant barriers to successful groups; we found that scheduling this during a regular educational session, reinforcing appropriate ground rules and the voluntary nature of this session were important to its success. We recognize that some groups are longitudinal and benefit from the increased trust gained by the group. We chose to focus on the small group of each ward or unit team, and planned this discussion later in the month when some group identity and cohesion was more likely to have taken place.