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Oregon Community Health Outreach Project

Subcontract with the NN/LM PNR


The home page for the OHSU/Hood River Community Health Outreach Project has recently debuted.

The goal of OHSU Libraries' Oregon Community Health Outreach Project is to train health professionals working with underserved and minority populations to access electronic sources of clinical information and patient education materials. The advent of electronic technologies, especially the World Wide Web, provides new sources of excellent materials available readily at a reasonable cost. Grant funds will be sought to: 1) train a target group of clinicians to use these sources; 2) make appropriate clinical and patient education software/consumer health databases available to them; 3) purchase access to the Internet and, where necessary, equipment needed for connectivity. Expected outcomes include the following: 1) information seeking behavior of providers will be changed to incorporate use of electronic resources as a routine part of patient care; 2) the unique role of librarians in training providers, resource development, team-building and enhancing patient care will be demonstrated; 3) interagency collaboration to meet the health care needs of a minority population will be improved; 4) a reproducible model for similar efforts in other medically underserved areas and with other minority populations will be created. The project will begin in September 1997 and last for 18 months. Clinicians serving the Hood River area will be targeted, with a focus on its Hispanic population.

Target Population:

The target population is health care providers in Hood River County, Oregon and their patients. Hood River County is located on the south shore of the Columbia River, about 60 miles from Portland. Hood River County covers 522 square miles and has a population of 18,589, according to 1995 figures.

Gender: 51% male, 49% female.

Age distribution: 0-4=8.7%; 5-17=19.2%; 18-34=21.9%; 35-49=23.9%; 50-64=13%; 65+=13.3%.

Persons of Hispanic origin account for approximately 20% of the population. Of these, the majority are of Mexican descent.

(These figures are from the Hood River County Health Department.)

Major towns in the county include Hood River and Cascade Locks. Hood River is designated by federal and state rural health service area designations as a Health Professional Shortage Area for migrant season farm workers. Cascade Locks is designated by the Office of Rural Health as an area of unmet need for the total population, as well as a Health Professional Shortage area for migrant season farm workers. Cascade Locks has been designated an area of unmet need by virtue of unavailablity of primary care personnel, travel time to nearest health care, health status indicators, comparative mortality rate, and low birth weight. Both Hood River and Cascade Locks have a higher percentage of population with incomes below the federal poverty level than the average percentage for Oregon.

Hood River County is a High Migrant Impact Area, according to the Oregon Health Division, with an estimated 14,285 migrant and seasonal farmworkers and dependents in the county at peak season, and an estimated 11,857 migrant and seasonal farmworkers in the county year round. Some of the agencies involved in this project also serve clients in the Columbia Gorge area adjacent to Hood River. In Oregon, these counties are: Wasco County (2381 sq. mi., 22737 pop.); Sherman (823 sq. mi., 1886 pop.); Gilliam (1204 sq. mi., 1861 pop.); Wheeler (1715 sq. mi., 1539 pop.). In Washington, these counties are: Skamania (1657 sq. mi., 1998 pop.), Klickitat (1873 sq. mi., 18231 pop.).

Hood River County, compared with other Oregon counties, is remarkable for high maternal risk factors such as percentage of mothers over 35 (13.2%), percentage of mothers with 4 or more live births (13.2%), percentage non-white (44.3%), and percentage with less than 12 years education (45%). These statistics do not include migrant season farm workers. The top five causes of death in the county include myocardial infarction, chronic ischemic heart disease, malignant neoplasms in the respiratory/intrathoracic organs, unintentional injuries, and bronchitis/emphysema/asthma.

There are approximately 34 physicians, 2 physician assistants, 1 nurse practitioner,126 nurses, 16 dentists, and 14 dental hygienists in Hood River County. There is one hospital in Hood River (32 beds), one county health department clinic, and one non-profit clinic (serving 18,398 visits per year).

There is no professional medical library service in Hood River County. Although all Oregon health professionals are eligible for free passwords allowing them to search Medline and other NLM databases through Oregon Health Sciences University, the information available there is generally not appropriate or specific to patient education needs. Further, relatively few of these professionals have taken advantage of obtaining personal passwords to OHSU's online information services. Finally, as evidenced in the needs assessment, there are significant barriers to accessing electronic information and patient education resources. These include not enough available equipment, inadequate training opportunities, and limited time to devote to searching for patient education material.

Identification of Need:

The intent of this project is to improve the capacity of Oregon providers to deliver quality care to their underserved patients. This target area has been selected by virtue of its status as a High Migrant Impact Area and because a substantial percentage of the permanent population recorded by the Bureau of the Census is of Hispanic origin.

There are financial, social and cultural barriers to health care for these residents, including poverty, language differences, cultural isolation, and lack of education. According to the New York Times, 1/30/97:

"Census data show that for the first time the poverty rate among Hispanic people in the U.S. has surpassed that of blacks. Hispanic residents now constitute nearly 24% of the country's poor, up 8 percentage points since 1985...Hispanic Americans...are the nation's fastest growing ethnic group....The Hispanic population is in danger of becoming an entrenched underclass, the working poor."

It is well documented that informed patients are more satisfied with their care, more likely to complete treatment and medication recommendations, experience reduced anxiety and, it is believed, experience better outcomes. Also they have an increased sense of ownership of their own health and healthcare decisions. Prevention efforts are likely to be more successful when directed at an informed community.

In the Hood River area, health care professionals are not able to identify and provide ample patient education information materials to an underserved population that has needs that are especially difficult to meet by virtue of language, educational and cultural factors. According to Keith Mueller, president of the National Rural Health Association:

"Recent immigrants to a rural community, speaking a native language other than English, pose a challenge to the health care delivery system.."(Nov/Dec 1996 issue, Journal of Rural Health)

In the needs assessment conducted for this application in April 1997, all respondents cited provider time and lack of Internet training as barriers to information access. Several also cited lack of equipment. In addition to these, significant barriers in the form of low literacy levels, language, discomfort with the healthcare system, poverty, and, especially for migrants, transiency make it difficult for providers to communicate effectively with their patients. ( See Appendix A, Needs Assessment) A recent survey (Medicine on the Net, Feb, 1997) of health care providers found that 70% of the physicians surveyed, and 8-15% of the nurses and pharmacists use the Internet, 30% of the entire group relies on it for patient education purposes, and more than 80% either agreed or strongly agreed that this is a very positive tool. Even if they weren't using it, they indicated that they wanted to. And further, none of the respondents had received any Internet training, which they felt they needed. They clamored for problem-specific bookmarks which would take them directly to information rather than general web sites requiring additional search time.

Goals/Objectives and Impact:

The intent of this project is to assist providers in delivering quality patient care by improving their access to electronic resources including patient education materials. The project may serve as a model for possible replication in other underserved, minority areas.

GOAL #1: Increase provider awareness and use of electronic sources with an emphasis on clinical and patient education materials.

Objective A: Train providers and key personnel at all participating agencies

-Basic Internet training onsite.

-Onsite training in identifying and using clinical and patient education materials available on the WWW, particularly use of the OHSU Patient Education Web page, and resources available through the U.S. Department of Health and Human Services Healthfinder Website.

-Onsite training in use of electronic databases for providing clinical and patient education material including Health Reference Center and MEDLINE.

Objective B: Make professional personnel available to provide ongoing, onsite support tailored to the specific needs of each agency and its providers.

Impact: -Ongoing involvement of personnel skilled in accessing information will be recognized as essential to the success and continued viability of projects that relate to the use of electronic information.

-The information seeking behavior of providers will be changed so that use of electronic resources is a routine part of care.

GOAL #2: Improve access to electronic sources of health information for providers who are without library and information services

Objective A: Provide enhanced connectivity/equipment

-Improve connectivity based on needs assessment

- Provide additional equipment based on needs assessment

Objective B: Improve resources

-Share expertise and resources of resource library and librarians in areas of technology and consumer health information/patient education materials

-Introduce PubMed for MEDLINE searches

-Continue to develop and enhance a Patient Education Web Page that provides an efficient means of linking to current, authoritative sites reviewed and selected by medical librarians

-Make Health Reference Center and other consumer health databases available

Impact: - Providers will be better able to access electronic resources.

-New databases will be available to providers.

- A resource will be created for use of providers that will have applicability beyond the project area (Patient Education Web Page).

GOAL #3: Strengthen the participation and visibility of medical librarians in the delivery of health care by demonstrating emerging roles for this professional group

Objective: - Demonstrate expertise of medical librarians in:

Selection and review of patient education WWW sites

Training providers in use of Internet/WWW

Facilitating delivery of health information to clinicians for improved patient care

Impact: -The contribution of medical librarians to patient care will enjoy improved recognition.

- The feasibility of an emerging role for librarians, clinical librarian for patient education, will be demonstrated.

-The role of librarians in team building among community agencies will be demonstrated.

GOAL #4: Enhance interagency collaboration for the improved health of the community.

Objective A: Hold regular meetings to facilitate cooperation among participating agencies

Objective B: Have principal investigator serve as liaison between agencies for purpose of identifying common problems and successful approaches to using electronic resources for clinical and patient education

Impact: -Interagency collaboration will set the stage for community sponsorship of patient education programs following the end of the grant period.

-A working community group will have been created that can collaborate in areas beyond patient education.


To address providersÕ time constraints and equipment needs, their inexperience with electronic

clinical reference resources, and their lack of suitable patient education materials, especially those geared to low literacy and Spanish speaking populations, we have designed the following approach.

Computer equipment and Internet access will be purchased and installed to address the needs cited in the needs assessment.

Three onsite training sessions will be provided to each agency. The first will address basic Internet navigation and search skills and identification of clinical resources. The second and third will focus on locating patient education resources on the World Wide Web and using Health Reference Center and other appropriate databases.

Electronic sources will provide an ability to quickly locate patient education materials, including those written in Spanish. Electronic sources of materials written by health care providers for use in their offices with patients will be featured. World Wide Web sites with patient education handouts, including Spanish language sites, will direct providers to vast amounts of patient education materials instantly accessible. A Web page developed to link providers to recommended patient education sites has already been developed by the Principal Investigator for this purpose. (See Appendix B). This Patient Education Web page will continue to be developed as part of this project.

To address the issue of low literacy and the scarcity of materials available written below an eighth grade level, we asked provider participants their suggestions. They recommended that they would, as needed, adapt the materials found to a low literacy format or, for patients who donÕt read, present the contents orally to patients in small groups or one-to-one sessions. Patients will receive much more information than they currently do. For patients who read, or those with family members who read, written material will provide reinforcement as the patient can refer back to the materials at home when necessary.

For technical support, participants will be able to call on their local Internet service provider for many quetions. In addition, staff at the OHSU Libraries will be available via a toll-free number to answer questions.

Intensive support aimed at helping providers actually use the electronic resources to which they have access is crucial to the long-term success of the project. It is widely recognized that simply delivering equipment and providing one-time training will not effect long term change in the information-seeking behavior of health professionals. The Principal Investigator will make site visits to each agency once a month. Her background as a clinician will enhance interaction with providers. Providers will be able to avail themselves of her expertise with regard to actual use and delivery of clinical and patient information, and address issues and questions specific to their individual needs. Additionally, the OHSU LibraryÕs professional reference staff will provide backup technical and search support. It is expected that over the course of the project, each provider will be able to experience firsthand how online access improves his or her ability to care for patients.

Overall project coordination will be accomplished through quarterly meetings of the agency directors, the Principal Investigator and the OHSU BICC Outreach Coordinator. In addition, the Principal Investigator will be able to monitor overall progress during monthly site visits.

The experience gained in implementing and fine tuning this project may serve to create a working model that could be easily replicated throughout the region and, in fact, the nation.

Evaluation Plan

The aims of the evaluation component are to:

1. Measure the use of the service and of the individual resources.

2. Measure acceptance of the service/system by health care providers.

3. Measure levels of awareness of the service on the part of the health care providers.

4. Measure the impact of the service on patients.

5. Evaluate the training intervention.

Step 1. Before each training session, all participants will be required to complete a pre-training questionnaire. The questions will be designed to assess a) attitude toward computers, b) skill level with computers, and c) awareness of consumer health resources in electronic form. Respondents will also be asked questions to identify their profession, age, sex, etc. They will be promised confidentiality: the evaluation specialist and data entry assistant will be the only individuals who see the forms. At the end of the training session, a class evaluation will be administered.

2. Step 2. After the training has taken place, health care providers who did not avail themselves of the training will be contacted by phone and asked the same questions.

3. Step 3. At the six month point, both trained and untrained providers will be contacted by telephone and asked a series of questions. The questions will be the same as in the initial assessment with the addition of feedback to the study team. The follow up calls will also offer an opportunity to ask some open-ended questions to gather suggestions from users.

Step 4. At the one year point, the same method outlined in Step 3 will be used to gather feedback from trained and untrained providers.

Data analysis: Questions will be designed on a Likert scale and quantitative data will be entered into a statistical software program (JMP from the SAS Institute). Analysis for Steps 1 and 2 will involve frequency counts and descriptive data, plus analysis of variance to determine differences in trained and untrained providers. Analysis for Steps 3 and 4 will look at changes over time as well as differences in groups. Qualitative data will be put into machine readable form and reviewed for patterns and helpful suggestions.

Reporting: Quarterly reports will be issued detailing the results of the analyses.

Groundwork has already been laid to establish a coalition of area agencies in the target area. At a March 1997 meeting in Hood River the OHSU project team met with five agency directors to explain project goals, to demonstrate use of Internet and electronic sources, and to solicit their ideas and participation. The project generated immediate support and a working group was formed.

Each of the participating agencies will function in a similar role. Each will insure that its providers will become proficient in using Internet/World Wide Web and other electronic resources to identify and generate materials appropriate to their unique clienteles. Some agencies have already developed working plans of how their provider staffs will make use of and deliver materials to their clients. (See Appendix C)

1. La Clinica del Carino
849 Pacific Ave.
Hood River, Oregon 97031
Contact person: Lorena Sprager, Health Promotion Manager

La Clinica del Carino is a non-profit clinic meeting health and dental needs of mainly low income patients from a five county area in Oregon and Washington.
La Clinica's clients are 53% Hispanic.
Role: see above.
Level of participation:All providers are expected to participate.
Statement of need: See Appendix A
Letter of support: See Appendix D

2. Next Door, Inc.
P.O.Box 661
Hood River, Oregon 97031
Contact person: Michael Mehling, Executive Director

Next Door, Inc., provides for unmet mental health needs and provides other education and support services to children and families. The agency serves a seven county area in Oregon and Washington.
Clients are approximately 30% Hispanic.
Role: see above.
Level of participation:All providers are expected to participate.
Statement of need: See Appendix A
Letter of support: See Appendix D

3. La Familia Sana, Inc.
212 Fourth St.
P.O. Box 1217
Hood River, Oregon 97031
Contact person: Eddie McKee, Executive Director

La Familia Sana's mission is to protect and promote the physical and mental well being of the Hispanic and other underserved communities in the Mid-Columbia region. Reducing domestic violence among families and violence among young people are priorities.
Clients are approximately 98% Hispanic.
Role: see above.
Level of participation: All providers are expected to participate.
Statement of need: See Appendix A
Letter of support: See Appendix D

4. Hood River County Health Department
1109 June Street
Hood River, Oregon 97031
Contact person: Ann Cathy, Director

The Hood River County Health Department provides public health, education and clinical services. Their service area includes all of Hood River County.
Clients are approximately 21% Hispanic.
Role: see above.
Level of participation: All providers are expected to participate.
Statement of need: See Appendix A
Letter of support: See Appendix D

5.Hood River Memorial Hospital
P.O. Box 149
Hood River, Oregon 97031
Contact person: Barbara Archer, Assistant Administrator

Hood River Memorial Hospital is a 32 bed Type B rural hospital serving a four county area in Oregon and Washington.
Clients are 8.9% Hispanic.
Role: see above.
Level of participation:All providers are expected to participate.
Statement of need: See Appendix A
Letter of support: See Appendix D

Oregon Health Sciences University
Biomedical Information Communication Center
P.O. Box 573
Portland, Oregon 97207
Contact: Margaret Connors, Consumer Health Resources Coordinator
Steve Teich, Outreach Coordinator

See below: Description of Facilities and Resources Available to the Project

Personnel and facilities

Margaret Connors, M.A.L.S., M.S.W., Principal Investigator, is Assistant Professor and Coordinator, Consumer Health Resources, at OHSU. Ms. Connors currently develops and directs consumer health information services for the university. Her professional experience includes 25 years in librarianship, college teaching, and clinical work.

Her background in patient education includes provision of patient education in inpatient and outpatient settings, reviewing and selecting patient education materials, presenting workshops on patient education resources and serving on hospital patient education committees. For this project, Ms. Connors will be responsible for selecting appropriate WWW sites, databases and other electronic resources and for training providers in the use of online patient education resources. She will facilitate quarterly meetings of the contact people from participating agencies. Ms. Connors will also make regular site visits to provide ongoing support and assessment.

Steve Teich, M.L.S., is Coordinator for Outreach Services for the BICC. He has been involved in outreach for 18 years at OHSU, working both with librarians and end-users. He coordinates support for OHSU information services to all 42 rural hospitals in the state, as well as eight clinics. He is also responsible for providing training to off-campus health professionals with regard to OHSU online services and the Internet. For this project, Mr. Teich will be responsible for providing introductory Internet training at each site. He will be available to provide technical support on an as-needed basis. He will also attend the quarterly meetings of the contact people from participating agencies.

Joan S. Ash, Ph.D., M.L.S., M.B.A. is Associate Professor, Library and Medical Informatics in the Biomedical Information Communication Center. Dr. Ash holds joint appointments in the Library and the Division of Medical Informatics and Outcomes Research, School of Medicine.

In addition, she is an adjunct faculty member in the School of Business Administration, Portland State University, holding an appointment as Instructor. While a practicing librarian and then IAIMS Coordinator, she has been involved in outreach activities emanating from the Yale Medical Library and the OHSU Libraries. She served as Project Manager for the National Library of Medicine-funded grant for the Oregon Health Information Network. Her Ph.D. is in Systems Science: Business Administration, with her dissertation research focused on the diffusion of information technology innovations in health care. The proposed consumer health project involves diffusion of an innovation throughout five agencies and is therefore of special interest to her. Her role on the project will be to design and implement evaluation protocols measuring use, acceptance, awareness, and impact of the proposed service.

Description of Facilities and Resources Available to the Project

Facilities and Resources/OHSU

Oregon Health Sciences University, a public institution, has a four-part mission of education, research, patient care, and community service. It is the state's only academic institution dedicated to the education of health professionals and biomedical researchers and has many collaborative programs with educational institutions, research centers, hospitals, health agencies and businesses throughout Oregon.

Biomedical Information Communication Center

The Biomedical Information Communication Center at OHSU houses the information services of the university. The BICC was designed to support the provision of excellent, cost effective health care in Oregon by making information services and technology available to all those who contribute to the health of its citizens. The BICC program consolidates the activities of the health sciences libraries including consumer health information resources, audiovisuals, teleconferencing and distance learning.

The OHSU Library houses over 219,000 volumes, including over 75,000 monographs, and currently subscribes to over 2,300 medical, nursing, dental and allied health journals. Medical librarians skilled in reference, Internet training and HTML training are available. Standard library services available to all students, staff and faculty include reference, circulation, interlibrary loan, photocopy service, database searching, and instruction in end user searching. The library catalog is in electronic form and available on public microcomputers throughout the Library. People using the Library also have access to the Ovid end user database searching systems featuring the full MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, PsychInfo (Pyschological Abstracts online), HealthStar, Current Contents and AIDSline.

OHSU's Consumer Health Resources Center provides access to consumer health information for patients and members of the community. Resources include a consumer health reference collection, Infotrac's Health Reference Center, and access to selected World Wide Web sites on consumer health information through OHSU's Patient Education Web Page (See Appendix B). Health Reference Center is an electronic database containing 500 pamphlets, 1600+ short handouts on medical topics written by health providers for patients, and hundreds of articles from consumer health and medical journals, many full-text. Consumer Health Resources Center services include a phone-in/mail out service and a walk-in library at one of our family practice clinics.

The BICC offers access to OHSU Information Services, a set of electronic information services and databases, available in two ways: on the campus electronic network and via modem. These services can be accessed by faculty and staff on their office workstations, by students and others from home via modem, and on public access computers in the BICC building. Thus, all OHSU faculty, staff, students and Oregon health care professionals are able to have E-mail accounts and access to database searching, the Internet and other electronic services.

Providing assistance and support for these information services is a "help desk." Staffed by BICC personnel with expertise in computing, library services, networking and telecommunications, these staff support users at OHSU and off-campus with both telephone and walk-in help.

Information Technology Group (ITG)

ITG oversees the computing and network infrastructure on campus and is responsible for clinical, educational, research and administrative computing.

Faculty and staff on the campus electronic network use the "OHSU Workstation," a set of core applications and services, including a word processing program, a calendar/scheduling system, E-mail, and access to information services, which runs on a variety of platforms. Full support for the World Wide Web was added to network services in May 1996. All converted workstations can access Web browser software and any department or individual can have a home page.

Facilities and Resources/Agencies

La Clinica del Carino
12 PCs with Internet access, 1 CD-Rom, 1 Laser printer
Conference room
No training room
No library

Next Door
5 PCs (3 with Internet access) with printers, 3 CD-Roms
Conference room
No training room
Small professional library(unstaffed)

La Familia Sana
1 PC with Internet access and printer, 1 CD-Rom
Conference room
No training room
No library

Hood River County Health Dept.
4 PCs with Internet access, no CD-Rom, 1 Laser printer
No library

Hood River Memorial Hospital
6 PCs with Internet access, 2 CD-Roms, l Laser printer
Conference room
Training room
Small education department library



Other Funding