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This paper describes the design and implementation of a client application for the Baylor College of Medicine Teen Health Clinics. The application is the front end to the Collaborative Social and Medical Services System (CSMSS) under development by Baylor's Medical Informatics and Computing Research Program [8]. The application provides distributed access to an underlying object oriented database system. A process driven and patient centered design will provide staff members with a complete set of services, including forms for data entry and viewing, query, and access management to facilitate efficient and effective delivery of services. Role-specific interfaces will be supplied for clerks, nurses, nurse practitioners, physicians, and social workers. The client application is being designed using object oriented methodologies and technologies with the C++ programming language, and will operate within a Microsoft Windows operating environment utilizing Object Linking and Embedding for application interoperability.

This paper describes the Collaborative Social and Medical Services System, a robust information infrastructure for integrated social and medical care. The Collaborative Social and Medical Services System design and architecture address the primary goals of creating a readily extensible social and ambulatory care system. Our initial step toward reaching this goal is the delivery of an application supporting the operations of the Baylor Teen Health Clinics. This paper discusses our protoype experiences, system architecture, components, and the standards we are addressing.

Clinical practice guidelines must be implemented effectively if they are to influence the behavior of clinicians. The authors describe a model for computer-based guideline implementation that identifies eight information management services needed to integrate guideline-based decision support with clinical workflow. Recommendation services determine appropriate activities in specific clinical circumstances. Documentation services involve data capture. Registration services integrate demographic and administrative data. Explanation services enhance the credibility of automated recommendations by providing supportive evidence and rating the quality of evidence. Calculation services measure time intervals, suggest medication dosages, and perform other computational tasks. Communication services employ standards for information transfer and provide data security. Effective presentation services facilitate understanding of complex data, clarify trends, and format written materials (including prescriptions) for patients. Aggregation services associate outcomes with specific guideline interventions. The authors provide examples of the eight services that make up the model from five evidence-based practice parameters developed by the American Academy of Pediatrics.

Objective

At our institution, traditional postpartum rounds were time consuming and inefficient with a low percentage (approximately 12%) of patients meeting the goal of being discharged by 11:00 am. A patient-centered collaborative care (PCCC) initiative was implemented to improve discharge efficiency, staff communication, and patient satisfaction. We investigated whether this paradigm shift to PCCC could improve clinical inefficiencies and timely discharge.

Methods

The PCCC rounding system was created by a representative group of physicians, residents, nurses, case managers, and social workers. An intervention study was conducted to examine the impact of PCCC during which physicians, residents, medical students, nurses, case managers, and social workers made rounds together. Efficiency data were collected for patients whose infants were delivered by the obstetric service for a 1-month period before and 6 months after implementing PCCC. Comparisons were made on the time of discharge and whether Foley catheter removal affected discharge time. χ2 test, Wilcoxon 2-sample test, and Pearson correlation coefficient were used where appropriate.

Results

Three hundred five patients were included in this analysis, of which 156 participated in traditional postpartum rounds and 149 in PCCC rounds. Discharge efficiency significantly improved with PCCC rounds, with 20.8% of patients being discharged by 11:00 am as compared to 11.5% for traditional postpartum rounds (P  =  .03). Early Foley catheter removal was significantly associated with time to discharge order (Pearson correlation coefficient, 0.22; P  =  .01) and discharge time (Pearson correlation coefficient, 0.28; P  =  .002).

Conclusions

Patient-centered collaborative care rounds improve the efficiency of postpartum care and discharge time.

Background

Enhancing service efficiency and quality has always been one of the most important factors to heighten competitiveness in the health care service industry. Thus, how to utilize information technology to reduce work load for staff and expeditiously improve work efficiency and healthcare service quality is presently the top priority for every healthcare institution. In this fast changing modern society, e-health care systems are currently the best possible way to achieve enhanced service efficiency and quality under the restraint of healthcare cost control. The electronic medical record system and the online appointment system are the core features in employing e-health care systems in the technology-based service encounters.

Methods

This study implemented the Service Encounters Evaluation Model, the European Customer Satisfaction Index, the Attribute Model and the Overall Affect Model for model inference. A total of 700 copies of questionnaires from two authoritative southern Taiwan medical centers providing the electronic medical record system and the online appointment system service were distributed, among which 590 valid copies were retrieved with a response rate of 84.3%. We then used SPSS 11.0 and the Linear Structural Relationship Model (LISREL 8.54) to analyze and evaluate the data.

Results

The findings are as follows: (1) Technology-based service encounters have a positive impact on service quality, but not patient satisfaction; (2) After experiencing technology-based service encounters, the cognition of the service quality has a positive effect on patient satisfaction; and (3) Network security contributes a positive moderating effect on service quality and patient satisfaction.

Conclusion

It revealed that the impact of electronic workflow (online appointment system service) on service quality was greater than electronic facilities (electronic medical record systems) in technology-based service encounters. Convenience and credibility are the most important factors of service quality in technology-based service encounters that patients demand. Due to the openness of networks, patients worry that transaction information could be intercepted; also, the credibility of the hospital involved is even a bigger concern, as patients have a strong sense of distrust. Therefore, in the operation of technology-based service encounters, along with providing network security, it is essential to build an atmosphere of psychological trust.

The major objective of this research is to examine whether or not medical students acquire values other than those related to traditional orientations to medical service. These values are approached in the context of the medical training of the student physician at a predominantly black medical college. The research setting is the Howard University College of Medicine in Washington, DC, one of the two black four-year medical colleges in the United States.

Specifically, the study examines whether or not socialization in medical school initiates the acquisition of a communal value system among students. A communal value system in this analysis consists of (1) community involvement and (2) an ideology emphasizing liberalism toward social change.

Methodologically, interviews (unstructured and focused), direct observation, and survey research are used in the data collection process. The research design also includes the use of a cross sectional method of analysis with longitudinal focus involving first, second, third, and fourth year students.

The findings suggest that this particular medical school reinforces, clarifies, or alters communal value orientations acquired prior to coming to medical school. Among students who do not change their communal value commitments after entering graduate training, the feeling is that the medical school reinforces prior dispositions. Among students who change as medical trainees, two tendencies are evident. Regarding community involvement, the majority of students develop a stronger interest as the result of their medical school experience. Concerning social change, students, in general, move from a liberal perspective to a more conservative position. The initial development of a communal value orientation is related to family socializing influences and racial identification factors.

It is concluded that the experiences at Howard University Medical College interact with previous student dispositions concerning a communal value orientation.

Existing communications standards represent person name, date, time, and other ubiquitous attributes in various incompatible formats. The electronic medical record requires convergence of diverse representational systems toward a single communications standard or a harmonized group of standards. The obstacles to convergence include disparities in semantic definition, syntax, and communications protocols. To facilitate harmonization of existing standards, the message standards developers subcommittee of the ANSI HISPP (American National Standards Institute Healthcare Informatics Standards Planning Panel) has defined a set of common data types to facilitate semantic convergence. The authors present the general method used to develop the common data types. The derivation of the person name common data type is presented in detail. A general semantic model of the person name attribute is developed from observations of international usage conventions. A superset of the person name formats of the ACR-NEMA, ASTM, HL7, NCPDP, MEDIX, and X-12 standards is taken as the provisional starting point for a common data type definition. The convergence superset is compared with the general semantic model. Highly specialized and/or infrequently encountered sub components of the general model are combined into component complexes, thereby defining mappings to less rigorous representations. The ANSI HISPP common data types are specified for use in a demonstration of a prototype object-oriented HL7-DICOM HIS/PACS interface (between hospital information systems and imaging systems) at the 1993 Annual Meeting of the Radiological Society of North America.

Objective

To present a collaboration process for creating a roadmap for the implementation of a strategy for integrated health and social care. The developed collaboration process includes multiple phases and uses electronic group decision support system technology (GDSS).

Method

A case study done in the South Karelia District of Social and Health Services in Finland during 2010–2011. An expert panel of 13 participants was used in the planning process of the strategy implementation. The participants were interviewed and observed during the case study.

Results

As a practical result, a roadmap for integrated health and social care strategy implementation has been developed. The strategic roadmap includes detailed plans of several projects which are needed for successful integration strategy implementation. As an academic result, a collaboration process to create such a roadmap has been developed.

Conclusions

The collaboration process and technology seem to suit the planning process well. The participants of the meetings were satisfied with the collaboration process and the GDSS technology. The strategic roadmap was accepted by the participants, which indicates satisfaction with the developed process.

The concentration of industry on modern relational databases has left many nonrelational and proprietary databases without support for integration with new technologies. Emerging interface tools and data-access methodologies can be applied with difficulty to medical record systems which have proprietary data representation. Users of such medical record systems usually must access the clinical content of such record systems with keyboard-intensive and time-consuming interfaces. COSTAR is a legacy ambulatory medical record system developed over 25 years ago that is still popular and extensively used at the Massachusetts General Hospital. We define a model for using middle layer services to extract and cache data from non-relational databases, and present an intuitive World-Wide Web interface to COSTAR. This model has been implemented and successfully piloted in the Internal Medicine Associates at Massachusetts General Hospital.

Images

Despite their demonstrated effectiveness, clinical decision support (CDS) systems are not widely used within the U.S. The Roadmap for National Action on Clinical Decision Support, published in June 2006 by the American Medical Informatics Association, identifies six strategic objectives for achieving widespread adoption of effective CDS capabilities. In this manuscript, we propose a Service-Oriented Architecture (SOA) for CDS that facilitates achievement of these six objectives. Within the proposed framework, CDS capabilities are implemented through the orchestration of independent software services whose interfaces are being standardized by Health Level 7 and the Object Management Group through their joint Healthcare Services Specification Project (HSSP). Core services within this framework include the HSSP Decision Support Service, the HSSP Common Terminology Service, and the HSSP Retrieve, Locate, and Update Service. Our experiences, and those of others, indicate that the proposed SOA approach to CDS could enable the widespread adoption of effective CDS within the U.S. health care system.

Summary Time Oriented Record (STOR) is a clinical information system operating at the University of California San Francisco Medical Center (UCSF). It provides two major services: on-line display of clinical information in the hospitals and clinics and an ambulatory medical record that partially replaces the traditional paper medical record for outpatient patient visits. In 1985 STOR was approved for clinic-wide implementation in the UCSF ambulatory care clinics. The implementation will be completed in September 1989. STOR captures clinical data directly from clinicians via hand written notations and ancillary data from other UCSF computers via a local area network. Development on STOR is continuing in order to meet the changing and diversified environment of inpatient and outpatient practices found in a university medical center.

A number of barriers exist which prevent the widespread integration of practice guidelines with electronic medical record systems. These include dependencies on clinical databases, as well as problems with converting existing guideline specifications into computable rules. We are developing the MBTA (Modeling Better Treatment Advice) practice guideline system which uses a distributed client-server architecture and an object-oriented data representation to support practice guidelines usable by different electronic medical record systems. We describe the structure and organization of MBTA, focusing on how an open systems design, combined with principles of guideline implementation, can be used to provide a general purpose guideline server for use by a variety of clinical workstations.

Purpose

Despite the substantial progress that has been made in the development of community-based service systems for seniors, effective linkages with the health care system remain elusive. Supportive service programs operating in naturally occurring retirement communities (NORCs) where large numbers of seniors reside have begun to address this critical gap in the health and social service system; however, linkages with the health care system are neither fluid nor systematic. To address this problem, two New York city-based funders established the NORC-Health Care Linkage Project to foster the development and testing of new models of collaborative and coordinated problem-solving between community-based social service providers and key health providers. This paper reports on an innovative evaluation design and implementation strategies that build organizational capacity while effectively assessing multiple levels of outcomes.

Conceptual framework

Randomized controlled designs which compare intervention communities with controls are unfeasible, unmanageable and inappropriate for many community-based initiatives that have multiple sites and varied goals and interventions. Theories of action (TOAs) refer to specification of the underlying assumptions about how a program is expected to get from conditions at baseline to a desired future. In this way, TOAs bridge strategic planning and evaluation. To be effective TOAs should be co-generated by evaluators and those being evaluated. Working collaboratively fosters ownership to the components of the theory and enables individual organizations to develop their own theories. Such collaboration between evaluators and practitioners builds organizational capacity for applied outcomes research and encourages evidence-based program planning.

Methods

All four funded linkage partnerships worked with the evaluation team to co-create action plans and logic maps that built upon TOAs articulated by the participating partnerships. Specific interventions focused on falls, discharge planning, depression, and, diabetes. Using a case study approach, process, impact and distal outcomes were tracked from 2002 to 2006 using tracking forms, client surveys, stakeholder interviews and period site visits. Intensive technical assistance enabled the participating sites to take an active role in data collection and analysis.

Findings

Findings suggest that internal capacity to collect, analyze and utilize data increased at all four participating partnerships, with the greatest improvement seen among the community-based organizations. Interventions were successfully implemented and comprehensively monitored. Theory-based predictions of multiple levels of outcomes were demonstrated across a number of domains, including improved shared care planning and continuity of care.

Discussion

Most published community health promotion programs have targeted a single disease and have been initiated ‘top-down,’ often with a university or consulting firm in charge. This innovative initiative aimed to build capacity for program design, implementation and evaluation within organizations so that participants could continue to apply the new skills after the funder and external consultants had gone back to their respective professional homes. This approach was successful in that participating organizations found value in tracking their own progress, both for accountability purposes but also for future programming.

Medical Databases deal with dynamic, heterogeneous and fuzzy data. The modeling of such complex domain demands powerful semantic data modeling methodologies. This paper describes GSM-Explorer a Case Tool that allows for the creation of relational databases using semantic data modeling techniques. GSM Explorer fully incorporates the Generic Semantic Data Model-GSM enabling knowledge engineers to model the application domain with the abstraction mechanisms of generalization/specialization, association and aggregation. The tool generates a structure that implements persistent database-objects through the automatic generation of customized SQL ANSI scripts that sustain the semantics defined in the higher lever. This paper emphasizes the system architecture and the mapping of the semantic model into relational tables. The present status of the project and its further developments are discussed in the Conclusions.

Background

The new forms of organization of healthcare services entail the development of new clinical practices that are grounded in collaboration. Despite recent advances in research on the subject of collaboration, there is still a need for a better understanding of collaborative processes and for conceptual tools to help healthcare professionals develop collaboration amongst themselves in complex systems. This study draws on D'Amour's structuration model of collaboration to analyze healthcare facilities offering perinatal services in four health regions in the province of Quebec. The objectives are to: 1) validate the indicators of the structuration model of collaboration; 2) evaluate interprofessional and interorganizational collaboration in four health regions; and 3) propose a typology of collaboration

Methods

A multiple-case research strategy was used. The cases were the healthcare facilities that offer perinatal services in four health regions in the province of Quebec (Canada). The data were collected through 33 semi-structured interviews with healthcare managers and professionals working in the four regions. Written material was also analyzed. The data were subjected to a "mixed" inductive-deductive analysis conducted in two main stages: an internal analysis of each case followed by a cross-sectional analysis of all the cases.

Results

The collaboration indicators were shown to be valid, although some changes were made to three of them. Analysis of the data showed great variation in the level of collaboration between the cases and on each dimension. The results suggest a three-level typology of collaboration based on the ten indicators: active collaboration, developing collaboration and potential collaboration.

Conclusion

The model and the typology make it possible to analyze collaboration and identify areas for improvement. Researchers can use the indicators to determine the intensity of collaboration and link it to clinical outcomes. Professionals and administrators can use the model to perform a diagnostic of collaboration and implement interventions to intensify it.

OBJECTIVES: This study evaluated the influence of features of community social environment and service system integration on service use, housing, and clinical outcomes among homeless people with serious mental illness. STUDY SETTING: A one-year observational outcome study was conducted of homeless people with serious mental illness at 18 sites. DATA SOURCES: Measures of community social environment (e.g., social capital) were based on local surveys and voting records. Housing affordability was assessed with housing survey data. Service system integration was assessed through interviews with key informants at each site to document interorganizational transactions. Standardized clinical measures were used to assess clinical and housing outcomes in face-to-face interviews. RESEARCH DESIGN: Structural equation modeling was used to determine the relationship between (1) characteristics of the social environment (social capital, housing affordability); (2) the level of integration of the service system for persons who are homeless in each community; (3) access to and use of services by individual clients; and (4) successful exit from homelessness or clinical improvement. PRINCIPAL FINDINGS: Social capital was associated with greater service systems integration, which was associated in turn with greater access to assistance from a public housing agency and to a greater probability of exiting from homelessness at 12 months. Housing affordability also predicted exit from homelessness. Neither environmental factors nor systems integration predicted outcomes for psychiatric problems, substance abuse, employment, physical health, or income support. CONCLUSION: Community social capital and service system integration are related through a series of direct and indirect pathways with better housing outcomes but not with superior clinical outcomes for homeless people with mental illness. Implications for designing improved service systems are discussed.

BACKGROUND

The Accreditation Council for Graduate Medical Education has suggested various methods for evaluation of practice-based learning and improvement competency, but data on implementation of these methods are limited.

OBJECTIVE

To compare medical record review and patient surveys on evaluating physician performance in preventive services in an outpatient resident clinic.

DESIGN

Within an ongoing quality improvement project, we collected baseline performance data on preventive services provided for patients at the University of Alabama at Birmingham (UAB) Internal Medicine Residents' ambulatory clinic.

PARTICIPANTS

Seventy internal medicine and medicine-pediatrics residents from the UAB Internal Medicine Residency program.

MEASUREMENTS

Resident- and clinic-level comparisons of aggregated patient survey and chart documentation rates of (1) screening for smoking status, (2) advising smokers to quit, (3) cholesterol screening, (4) mammography screening, and (5) pneumonia vaccination.

RESULTS

Six hundred and fifty-nine patient surveys and 761 charts were abstracted. At the clinic level, rates for screening of smoking status, recommending mammogram, and for cholesterol screening were similar (difference <5%) between the 2 methods. Higher rates for pneumonia vaccination (76% vs 67%) and advice to quit smoking (66% vs 52%) were seen on medical record review versus patient surveys. However, within-resident (N=70) comparison of 2 methods of estimating screening rates contained significant variability. The cost of medical record review was substantially higher ($107 vs $17/physician).

CONCLUSIONS

Medical record review and patient surveys provided similar rates for selected preventive health measures at the clinic level, with the exception of pneumonia vaccination and advising to quit smoking. A large variation among individual resident providers was noted.

This paper develops an approach to electronic data exchange of patient records from Ambulatory Encounter Systems (AESs). This approach assumes that the AES is based upon a standard data model. The data modeling standard used here is IDEFIX for Entity/Relationship (E/R) modeling. Each site that uses a relational database implementation of this standard data model (or a subset of it) can exchange very detailed patient data with other such sites using industry standard tools and without excessive programming efforts. This design is detailed below for a demonstration project between the research-oriented geriatric clinic at the Baltimore Veterans Affairs Medical Center (BVAMC) and the Laboratory for Healthcare Informatics (LHI) at the University of Maryland.

In debates over access to essential medical care, comparatively little attention has been paid to the provision of outpatient physiotherapy services. We examined physiotherapy utilization for musculoskeletal disorders (MSDs) among approximately 2,000 employees of a large, unionized, Ontario workplace. We obtained MSD-related physiotherapy claims and service data from the public Workplace Safety and Insurance Board, two private medical insurance carriers, a workplace special fund starting in 1995 and a workplace-contracted, on-site physiotherapy clinic starting in 1999. We observed substantial increases in overall physiotherapy utilization for MSDs: a median of 234 services per quarter for 1992–1994 to 1,281 for 1999–2002. With inclusive workplace provision policies, most physiotherapy utilization occurred on-site by 1999–2002 (70%). With a user-pay orientation to outpatient physiotherapy services increasing among working-age adults in Ontario, there is substantial potential for unequal access among those not privately insured or in workplaces with direct service provision.

This paper describes an innovation designed to improve discharge planning and, potentially, reduce the length of inpatient stays. Unlike other approaches, this one has been implemented within a Hospital Information System. The rationale is that reports integrating clinical and non-clinical data gathered upon admission can enable the Social Work Manager to assign staff more effectively, i.e., to the most difficult cases, and can enable staff to perform discharge planning more effectively, i.e., more pro-actively. The paper reviews the use of computers in social work and provides a critique, not of the models proposed, but of the implementations attempted to date. We contend that our approach will prove more successful than those other implementations because ours is based on an integrated and almost totally-electronic medical record keeping system, encompassing observations by both clinical and non-clinical staff.

The objective of the study was to develop and validate predictors of 30-day hospital readmission using readily available administrative data and to compare prediction models that use alternate comorbidity classifications. A retrospective cohort study was designed; the models were developed in a two-thirds random sample and validated in the remaining one-third sample. The study cohort consisted of 29,292 adults aged 65 or older who were admitted from July 2002 to June 2004 to any of seven acute care hospitals in the Dallas–Fort Worth metropolitan area affiliated with the Baylor Health Care System. Demographic variables (age, sex, race), health system variables (insurance, discharge location, medical vs surgical service), comorbidity (classified by the Elixhauser classification or the High-Risk Diagnoses in the Elderly Scale), and geographic variables (distance from patient's residence to hospital and median income) were assessed by estimating relative risk and risk difference for 30-day readmission. Population-attributable risk was calculated. Results showed that age 75 or older, male sex, African American race, medical vs surgical service, Medicare with no other insurance, discharge to a skilled nursing facility, and specific comorbidities predicted 30-day readmission. Models with demographic, health system, and either comorbidity classification covariates performed similarly, with modest discrimination (C statistic, 0.65) and acceptable calibration (Hosmer-Lemeshow χ2 = 6.08; P > 0.24). Models with demographic variables, health system variables, and number of comorbid conditions also performed adequately. Discharge to long-term care (relative risk, 1.94; 95% confidence interval, 1.80— 2.09) had the highest population-attributable risk of 30-day readmission (12.86%). A 25% threshold of predicted probability of 30-day readmission identified 4.1 % of patients ≥65 years old as priority patients for improved discharge planning. We conclude that elders with a high risk of 30-day hospital readmission can be identified early in their hospital course.

The author considers the University of Toronto's Health, illness and the Community course for undergraduate medical students, described in this issue by Wasylenki and associates (see pages 379 to 383). Social accountability in medical education demands a community orientation and hence an emphasis on outreach. Medical schools should expand their clinical service to the community, provide community-based residency placements and offer continuing medical education in rural and regional centres. Accountability also requires community involvement in planning and implementing research projects. Placing students in a community setting as part of the curriculum is praiseworthy, but it is not sufficient to ensure social accountability. What is needed now is a more comprehensive acceptance by faculties of medicine of the mandate of community-centred learning, together with well-targeted funding for education and research initiatives.

This paper describes a system that has been developed to support Telemedicine activities in Brazil, a country that has serious problems in the delivery of health services. The system is a part of the broader Tele-health Project that has been developed to make health services more accessible to the low-income population in the northeast region. The HealthNet system is based upon a pilot area that uses fetal and pediatric cardiology. This article describes both the system’s conceptual model, including the tele-diagnosis and second medical opinion services, as well as its architecture and development stages. The system model describes both collaborating tools used asynchronously, such as discussion forums, and synchronous tools, such as videoconference services. Web and free-of-charge tools are utilized for implementation, such as Java and MySQL database. Furthermore, an interface with Electronic Patient Record (EPR) systems using Extended Markup Language (XML) technology is also proposed. Finally, considerations concerning the development and implementation process are presented.

The Macromolecular Structure Database (MSD) group (http://www.ebi.ac.uk/msd/) continues to enhance the quality and consistency of macromolecular structure data in the Protein Data Bank (PDB) and to work towards the integration of various bioinformatics data resources. We have implemented a simple form-based interface that allows users to query the MSD directly. The MSD ‘atlas pages’ show all of the information in the MSD for a particular PDB entry. The group has designed new search interfaces aimed at specific areas of interest, such as the environment of ligands and the secondary structures of proteins. We have also implemented a novel search interface that begins to integrate separate MSD search services in a single graphical tool. We have worked closely with collaborators to build a new visualization tool that can present both structure and sequence data in a unified interface, and this data viewer is now used throughout the MSD services for the visualization and presentation of search results. Examples showcasing the functionality and power of these tools are available from tutorial webpages (http://www.ebi.ac.uk/msd-srv/docs/roadshow_tutorial/).

The persistent underuse of family planning services by inner-city, low-income, sexually active youth underscores the importance of testing innovative programs that maximize participation. Presented in this paper is an analysis of a Chicago public health clinic's special program for adolescents that originated from the staff's observations of the scheduling, educational, and support needs of teens seeking family planning services from a traditionally managed public health facility. Between December 1982, when the special program--the Teen Clinic--was implemented, and March 1985, more than 600 adolescents sought social support and contraceptive services--an 82 percent increase in new-patient registration compared with the enrollment before the program began. In contrast, two neighboring public health department facilities without special family planning programs for teens experienced either a small increase, 4 percent, or a modest decrease, 17 percent, in utilization by teenagers during the same period. The increased use of the study facility by teens, coupled with patients' self-reported nonuse of alternative sources of care and referral patterns, suggests that the new program was successful in recruiting sexually active teens who had previously been inadequately protected against pregnancy. The perceived institutional and interpersonal factors influencing 153 teens' initial and repeated use of the Teen Clinic, as measured by a structured survey, echo the findings of previous research. Strategies suggested by the study's findings for improving outreach and service delivery are described.